Paul Krugman: Can It Happen Here?

What are the chances that we'll actually get guaranteed health care for all?:

Can It Happen Here?, by Paul Krugman, Commentary, NY Times: The draft Democratic Party platform that was sent out last week puts health care reform front and center. “If one thing came through in the platform hearings,” says the document, “it was that Democrats are united around a commitment to provide every American access to affordable, comprehensive health care.”

Can Democrats deliver on that commitment? ... For one thing, we know that it’s economically feasible: every wealthy country except the United States already has some form of guaranteed health care. The ... risk of losing your insurance, the risk that you won’t be able to afford necessary care, the chance that you’ll be financially ruined by medical costs ... would be considered unthinkable in any other advanced nation.

The politics of guaranteed care are also easy, at least in one sense: if the Democrats do manage to establish a system of universal coverage, the nation will love it.

I know ... some pundits claim that the United States has a uniquely individualistic culture, and that Americans won’t accept any system that makes health care a collective responsibility. Those who say this, however, seem to forget that we already have ... Medicare. It’s a program that collects money from every worker’s paycheck and uses it to pay the medical bills of everyone 65 and older. And it’s immensely popular.

There’s every reason to believe that a program that extends universal coverage to the nonelderly would soon become equally popular. Consider ... Massachusetts, which passed a state-level plan for universal coverage two years ago.

The Massachusetts plan has come in for a lot of criticism. ... And its costs are ... higher than expected, mainly because ... there were more people without insurance than anyone realized.

Yet recent polls show overwhelming support for the plan — support that has grown stronger ... despite the new system’s teething troubles. Once a system of universal health coverage exists, it seems, people want to keep it.

So why be nervous about the prospects for reform? Because it’s hard to get universal care established in the first place. There are, I’d argue, three big hurdles.

First, the Democrats have to win the election ... by enough to face down Republicans, who are still, 42 years after Medicare went into operation, denouncing “socialized medicine.”

Second, they have to overcome the public’s fear of change.

Some health care reformers wanted the Democrats to endorse a single-payer, Medicare-type system for all. On the sheer economic merits, they’re right: single-payer would be more efficient than a system that preserves a role for private insurance companies.

But it’s better to have an imperfect universal health care plan than none at all — and the only way to get a universal health care plan ... is to inoculate it against Harry-and-Louise-type claims that people will be forced into plans “designed by government bureaucrats.” So the Democratic platform emphasizes ... that Americans “should have the option of keeping the coverage they have or choosing from a wide array of health insurance plans, including many private health insurance options and a public plan.” We’ll see if that’s enough.

The final hurdle facing health care reform is the risk that the next president and Congress will lose focus. There will be many problems crying out for solutions, from a weak economy to foreign policy crises. It will be easy and tempting to put health care on the back burner...— and then forget about it.

So I’m nervous. The history of the pursuit of universal health care in America is one of missed chances, of political opportunities frittered away. Let’s hope that this time is different. ...

Comments

[hari]

If Paul has read the Draft and claims it's feasible this time around...I'm sure it will be enacted as a priority. It's unlikely GOP will put up a fight like before - simply because the country won't support GOP tactics.

Good luck!

[MattY]

Paul is a little premature in declaring Massachusetts a success. Their costs for this are rising about 10% per year, the federal government already pays for half and it is under severe pressure to keep expenses down. Then, we are into a longer downturn that will raise costs by moving more people into the subsidized portion of the system. Massachusetts is trying to close a 1.3 billion dollar deficit, about half due to this new program. And they have caused shortages and price hikes.

Economists on this subject are so far removed from the medical industry that they cannot even agree on what constitutes the industry definition. Hence, once they get started, then their task, as in Massachusetts, the effort becomes almost entirely limiting the original definition of medicine to ration the stuff.

[Bob]

In 2001 Harry lost his job, and healthcare. Louise couldn't afford the premiums on her plan with just one salary. In 2003 Louise contracted cancer. The medical bills forced them out of their home. Louise died in 2005. Harry, out of work and in deep debt couldn't afford the apartment they'd been in and is living on the street.

And George Bush is having a heckuva good time in Bejing.

[anne]

"[Krugman] is a little premature in declaring Massachusetts a success. Their costs for this are rising about 10% per year, the federal government already pays for half and it is under severe pressure to keep expenses down. Then, we are into a longer downturn that will raise costs by moving more people into the subsidized portion of the system. Massachusetts is trying to close a 1.3 billion dollar deficit, about half due to this new program. And they have caused shortages and price hikes."

Reference?

[Cost is the Problem]

Simply continuing the current system with different payers will not solve the basic cost spiral. Capitalism does not work without effective competition, and current rules restrict competition to the point where the cost system is dysfunctional.

Other countries actively manage their national health care systems to keep costs reasonable. That is why they can cover their entire population for what we spend per capita on public care now. Spending twice as much public money, and rapidly rising, is simply not sustainable.

[Noni Mausa]

MattY says...Paul is a little premature in declaring Massachusetts a success. Their costs for this are rising about 10% per year...

Is anyone having a look at the effect of this Massachusetts health coverage is having on the success of business in the state, particularly medium and small businesses? Is it possible that one of the reasons the costs are rising in the state's system is that people are leaving (or small businesses are eliminating) the health coverage supplied by the business?

Researchers might look at changes in hiring and job hunting patterns which may have been affected by the Massachusetts plan.

Anecdotally, I've heard from many friends in the United States whose work careers have been influenced by the healthcare or lack of it available from employers.

On the one hand, an employer with good health insurance, although this is an expense to them, may have an advantage by being able to keep people, and keep them at lower wages, who otherwise might be tempted to look for new employment.

On the other hand, employers have a strong motivation to avoid hiring people with even a rather benign health concerns, because those people will affect the affordability of the entire health plan the employer purchases. They may lose out on valuable staff for this reason.

Universal health coverage removes all these considerations, allowing employees more choice in the workplace and allowing employers one less headache. What's not to like?

Anyone know if these factors are being studied?

Noni

[Noni Mausa]

MattY says...Paul is a little premature in declaring Massachusetts a success. Their costs for this are rising about 10% per year...

Is anyone having a look at the effect of this Massachusetts health coverage is having on the success of business in the state, particularly medium and small businesses? Is it possible that one of the reasons the costs are rising in the state's system is that people are leaving (or small businesses are eliminating) the health coverage supplied by the business?

Researchers might look at changes in hiring and job hunting patterns which may have been affected by the Massachusetts plan.

Anecdotally, I've heard from many friends in the United States whose work careers have been influenced by the healthcare or lack of it available from employers.

On the one hand, an employer with good health insurance, although this is an expense to them, may have an advantage by being able to keep people, and keep them at lower wages, who otherwise might be tempted to look for new employment.

On the other hand, employers have a strong motivation to avoid hiring people with even a rather benign health concerns, because those people will affect the affordability of the entire health plan the employer purchases. They may lose out on valuable staff for this reason.

Universal health coverage removes all these considerations, allowing employees more choice in the workplace and allowing employers one less headache. What's not to like?

Anyone know if these factors are being studied?

Noni

[save_the_rustbelt]

"single-payer would be more efficient than a system that preserves a role for private insurance companies."

That's a very broad statement from someone who knows very little about operating a health care system, and flies in the face of much of our experience with Medicare.

Reference?

[Sarah]

An often overlooked aspect of this is the effect lack of universal coverage has on the formation of small businesses and a competitive market. Under the current, employer-based system, few of the older, experienced and successful executives who one would expect to find starting small businesses are willing to take the necessary risks for a start-up, since those risks include not just ordinary business risks, but the added health risk to both the executive and his or her family entailed in doing without or making do with a less comprehensive health care plan and the added business risk of having to spend precious start-up funds on expensive coverage-- or accept lower quality (or more desperate) personnel who are willing to work for a company with no or inadequate health coverage. This results in start-ups being disproportionately founded by younger, less-experienced executives who do not yet have a family and are willing to accept greater risks, or less successful executives who have lost a job and cannot easily find a replacement.

For a country that prizes entrepreneurship so highly it is surprising that this is so seldom remarked on-- the more so because I often hear lack of health care coverage cited as a reason not to risk trying a promising business idea. People are keenly aware of this on a personal level, but it seems we have not made the connection to the wider world that shows lack of universal health coverage to be an obstacle to a healthy and competitive business climate.

[Real Person from the Real World]

Well, the Republican whine against universal health care is circulating via email. I got one cautionary tale about a student from a communist country complete with old bullet wound from fighting the commies, telling a story about how you catch "wild pigs" - by putting out free corn, then piece by piece, sections of a fence that they get used to, step by step. The point being, that socialism is a trap where you get used to "free".

This came from a medicare beneficiary with some company supplied supplemental health benefits. He'll complain about cuts in the company paid portion of his health benefits, and never mind that as a catholic who trained in his youth for religious orders (altho he eventually married), that most religious orders are socialist and everything is held in common. The big fear is TAXATION. Americans have never liked taxation, from the time of the Boston Tea Party on.

This is the problem. ALL the cautionary whining about how the COST will go up but care will be limited, or YOU will have to shell out your hard earned pay for someone else who smoked and was obese and is now dying of diabetes and lung cancer. The logic seems inexorable (costs go up, you have to pay for "scarce" resources), and trickle down from the wealthy getting creative works.

After years of inflation in the 60's and 70's all everyone understands or believes in, is cost going up, and up and up. That's what they see with food and gas. When it comes to taxation, no one stops to think some CEO from a student loan or mortgage company ought to pay higher taxes. Contractors, mechanics, all believe they have the God given right to charge what they charge to keep their living standard up. What's an extra lawn cut? Buy a cheaper faucet to install, but charge full rate. Foreign vendors vending H1b visa serfs with commodity skills and an 8 page resume (2 pages from outside the US) for the same or nearly the same hourly rates as a US citizen with a 3 page resume.

Well, money makes the world go 'round. We need to get past the fears it generates.

[ddt]

PK: Democratic platform emphasizes "Americans “should have the option of keeping the coverage they have or choosing from a wide array of health insurance plans, including many private health insurance options and a public plan.”"

Bad, bad idea. Single-payer tax-funded is the only way to really do universal care. If you don't have the guts to put a couple insurance companies out of business, don't even bother. The insurance system itself drives up prices - that's what you should be trying to get rid of.

[ken melvin]

Universal, single payer, is the only kind of health care that makes sense. A system under which if you get sick or lose your job you lose your health care is beyond cynical, it's sadistic. Most people aren't going to have to retire on and will be depending solely on Social Security. For a good many of these Americans, illness will have taken their home by the time the reach retirement age. For any country that willingly wasted upwards of a $trillion in Iraq????

[swells]

Here is what I worry about in regards to universal health care. Look at the explosion of health care spending since Medicare went into effect. It consumes a larger and larger portion of our budget, both publicly and privately. If universal health care is extended to the population as a whole, why is it reasonable to think this trend will get better instead of being exacerbated? From the current trends, it would seem that what can be extrapolated is a health care delivery system that eats even more resources than today. What limits that which is "free" other than eventual bankruptcy?

I haven't seen any inclination in this country to make the hard choices that would be required to constrain health care spending to some reasonable percentage of the available resources. We don't do that. We put things on the never-never.

[anne]

"Look at the explosion of health care spending since Medicare went into effect. It consumes a larger and larger portion of our budget, both publicly and privately."

Where, where, where, where, where? Huh?

[evagrius]

"Look at the explosion of health care spending since Medicare went into effect. It consumes a larger and larger portion of our budget, both publicly and privately."

Actually the problem is Medicare fraud perpetrated by private "providers".

Universal health care will only work if there are no private, profit-oriented entities involved.

[Ken]

"[Krugman] is a little premature in declaring Massachusetts a success. Their costs for this are rising about 10% per year, the federal government already pays for half and it is under severe pressure to keep expenses down. Then, we are into a longer downturn that will raise costs by moving more people into the subsidized portion of the system. Massachusetts is trying to close a 1.3 billion dollar deficit, about half due to this new program. And they have caused shortages and price hikes."

arent everyone's insurance rates rising at 10% a year?

[swells]

anne, I can probably find the data you ask for. I will attempt to do so and post it. But, in the interim, I would just say that we weren't having this discussion in the early 1960's so it seems reasonable to assume the cost of health care wasn't as big a portion of our budget then. If it had been, then the discussion would have been occurring then.

Is that an unreasonable assumption?

[anne]

"Look at the explosion of health care spending since Medicare went into effect. It consumes a larger and larger portion of our budget, both publicly and privately."

This is meaningless.

[save_the_rustbelt]

I was just having coffee with my honey baby (aka the world's greatest nurse) and I asked her about the efficiency of government health care programs. Besides being a terrific clinician she is an expert in medical records especially RAPs/MDS.

When she finished laughing she said the government cannot run an efficient health care program.

We started rattling off government program issues and came up with his brief list.

Quiz:

How many of these can you explain without any reference help?

ICD-9
CPT
PQRI
RAPs / MDS
RUGs
DRG
DMERC
HCPCS
HCFA-1500
RAC
Secondary
SCHIP
NPDB
HIPDB
IQRS
NPIS
ESRD
MACED
PRRB

Answer and a few thousand more can be found at:

http://www.cms.hhs.gov/apps/acronyms/

Be careful what you wish for.

[OhNoNotAgain]

Swells,

Like Anne, my questions would be:

1) References ?

and rhetorical:

2) What portion of any increase can be directly attributed to lack of negotiation power on Medicare's part ?

3) What portion of any increase can be directly attributed to increased pharmaceutical prescriptions and costs ?

4) What are Medicare's administration costs compared to a private insurance company's ?

Answering those questions should give us a better idea of whether universal insurance would be a better idea.

[anne]

"When she finished laughing she said the government cannot run an efficient health care program."

Rubbish, but keep trying.

[swells]

Anne, one reference here:

In The Aggregate Effects of Health Insurance: Evidence from the Introduction of Medicare (NBER Working Paper No. 11619), NBER researcher Amy Finkelstein challenges the belief that the spread of health insurance played only a small role in contributing to the dramatic rise in health care spending over the last half century. In a related study prepared with colleague Robin McKnight (NBER Working Paper No. 11609), Finkelstein asks: What Did Medicare Do (And Was It Worth It)?

At an annual cost of $260 billion, Medicare is one of the largest health insurance programs in the world. Providing nearly universal health insurance to the elderly as well as many disabled, Medicare accounts for about 17 percent of U.S. health expenditures, one-eighth of the federal budget, and 2 percent of gross domestic production. Medicare's introduction in 1965 was, and remains to date, the single largest change in health insurance coverage in U.S. history.

Finkelstein estimates that the introduction of Medicare was associated with a 23 percent increase in total hospital expenditures (for all ages) between 1965 and 1970, with even larger effects if her analysis is extended through 1975. Extrapolating from these estimates, Finkelstein speculates that the overall spread of health insurance between 1950 and 1990 may be able to explain at least 40 percent of that period's dramatic rise in real per capita health spending.

This conclusion differs markedly from the conventional thinking among economists that the spread of health insurance can explain only a small portion of the rise in health spending. This belief is based on the results of the

Rand Health Insurance Experiment (HIE), one of the largest randomized, individual-level social experiments ever conducted in the United States. The HIE compared the spending of individuals randomly assigned to different health insurance plans. Based on these comparisons, the estimated impact of health insurance on hospital spending was at least five times smaller than Finkelstein's estimates of the impact of Medicare on hospital spending.

Finkelstein suggests that the reason for the apparent discrepancy is that market-wide changes in health insurance - such as the introduction of Medicare - may alter the nature and practice of medical care in ways that experiments affecting the health insurance of isolated individuals will not. As a result, the impact on health spending of market-wide changes in health insurance may be disproportionately larger than what the estimates from individuals' changes in health insurance would suggest. For example, unlike an isolated individual's change in health insurance, market wide changes in health insurance may increase market demand for health care enough to make it worthwhile for hospitals to incur the fixed cost of adopting a new technology. Consistent with this, Finkelstein presents suggestive evidence that the introduction of Medicare was associated with faster adoption of then-new cardiac technologies.

Such evidence of the considerable impact of Medicare on the health care sector naturally raises the question of what benefits Medicare produced for health care consumers. Finkelstein and McKnight investigate this question, noting. two potential benefits that public health insurance might provide to the elderly:: better health and risk- reduction.

The period after Medicare's introduction, for example, was one of declining elderly mortality. However, using several different empirical strategies, the authors estimate that the introduction of Medicare had no discernible impact on elderly mortality in its first ten years in operation. They present evidence suggesting instead that, prior to Medicare, elderly individuals with life- threatening, treatable health conditions (such as pneumonia) sought care even if they lacked insurance, as long as they had legal access to hospitals.

Even absent measurable health benefits, Medicare's introduction of Medicare may still may have benefited the elderly by reducing their risk of large out-of-pocket medical expenditures. The authors document that prior to the introduction of Medicare, the elderly faced a risk of very large out- of- pocket medical expenditures. Tthe introduction of Medicare was associated with a substantial (about 40 percent) reduction in out-of-pocket spending for those who had been in the top quarter of the out- of- pocket spending distribution, the authors estimate.

Finkelstein and McKnight conduct a cost-benefit analysis comparing the insurance value of the reduction in the risk of large out- of- pocket medical expenditures provided by Medicare with the costs of the program. They estimate that even in the apparent absence of health benefits, the insurance value of Medicare alone is enough to cover between 45 percent and 75 percent of the its costs. In addition, the authors caution that Medicare may well have had health benefits that their analysis cannot detect, such as improvements in health status, even without mortality improvements. Moreover, given the evidence that the introduction of Medicare was associated with more rapid adoption of new cardiac technologies, in the long run Medicare's impact on elderly mortality may be much larger than the ten-year impact they examine.

This reference came from:

http://www.nber.org/digest/apr06/w11609.html

[swells]

There is also a chart at

http://freedomkeys.com/medigraph3.jpg

I don't know how accurate the data is. The source is rather virulently opposed to "socialized medicine" so the accuracy of the data should be rigorously examined for bias I would think. I'll try to do a bit of that and post what I find.

[swells]

anne said

Look at the explosion of health care spending since Medicare went into effect. It consumes a larger and larger portion of our budget, both publicly and privately."

This is meaningless.

Anne, this sort of statement doesn't seem to strike you as meaningless when we talk about the explosion in the budget for the military. Why would it be meaningless in the context of health care?

I guess my basic point is this. Governments run education. Education has really big problems. Governments run defense. Our self-defense capabilities have really big problems (not the least of which is it being used inappropriately). Governments run infrastructure like highways and air traffic. Our infrastructure has multi-billion if not trillion dollar problems.

All I'm asking is why we should believe that governments will do a great job with health care in a universal health care system? The evidence in respect to the competence of government just doesn't seem to jibe well with the claims from my perspective.

[swells]

This article from the National Coalistion for Health Care would also seem to document the proposition that governmentally provided health care is resulting in larger percentages of the budget being spent on health care.

This organization is very much in favor of universal health care it would appear.

http://www.nchc.org/facts/Economy/effects_on_the_federal_budget.pdf

[Noni Mausa]

swells asked: Look at the explosion of health care spending since Medicare went into effect. It consumes a larger and larger portion of our budget, both publicly and privately. If universal health care is extended to the population as a whole, why is it reasonable to think this trend will get better instead of being exacerbated?

"Phone A Canadian!" [soon to be a bumper sticker]

As I understand it, Medicare was hamstrung in several ways at the outset, including restrictions on its ability to bargain over costs.

Single-payer, however, has huge bargaining power. Witness the difference in drug costs, for the identical product from identical manufacturers, between the US and Canada, which does regulate the costs of drugs.

Regular readers here know I love individual experiences as a way to gain insight on economic issues. But sometimes you can't see the ocean if you're focused on one wave. This is one such case -- when you step back and compare costs and outcomes in health among the G8 and other prosperous nations, there is no missing the USA. Most of these countries, with their universal health care, pay in gross costs about $3000 per capita for health care. The USA pays double that, and has less healthy citizens.

Where does the other $3000 per capita go to? I could be polite or rude here, but suffice it to say that it doesn't go to health care.

Noni

[swells]

Anne, try this link. I would think the data here is pretty good. In particular, look at the chart on page 6. It indicates that health care spending in 1960 was 5.2% of GDP. In 2005, that percentage was 16%. That would seem to comport with my statement that spending on health care has exploded since the introduction of medicare in 1965.

http://www.kff.org/insurance/upload/7670.pdf

[evagrius]

"We started rattling off government program issues and came up with his brief list...."

The reason for all those programs is very simple; there is no unified approach to health care. t's all been a piece meal patchwork effort with the result being rather large and unwieldy and prone to incompetence and fraud among other things.

Please look at the Medicaid program- there so many different programs for so many different eligibility groups that it's really quite difficult to figure out under which program a Medicaid beneficiary falls under.

[evagrius]

That would seem to comport with my statement that spending on health care has exploded since the introduction of medicare in 1965.

Not a logical conclusion. Other countries have had similar programs such as medicare for the entire population without the "explosion".

I put part of the medicare cost on the ease of possible fraud.

[swells]

evagrius, how to respond. Spending has exploded since the introduction of Medicare. I take that as a fact, I don't reach it as the conclusion of some chain of dedcutions. So, in that sense it is true that I haven't reached a logical conclusion. Maybe it is simple coincidence that event Y followed event X. That is a logical possibility.

However, it is also a logical possiblity that the explosion of spending is the result of some causal connection. I don't pretend to be an economist nor do I pretend to know how to tease out what the relationship might be.

As a prudent person, in the face of not knowing whether it is or is not causally connected, I have to look more broadly afield. Does the US system of government do things efficiently in the general case? As far as I can tell, not when it comes to education, not when it comes to the military, not when it comes to infrastructure, not when it comes to the environment. I simply ask, why should I believe the US system of government will do things efficiently in the case of health care?

I see some evidence that makes such a hope tenable in Obama's candidacy with his emphasis on having real and productive discussions and arguments that aren't so much about winning as they are about discovery.

On the other hand, there is a lot of the politics of know-nothingness in our past and in our current politics. That makes me extremely cautious about giving the US system of government yet one more bludgeon with which to beat us into insensibility.

[hari]

@ Swell -

Just because gov has proven to be the problem - in other sectors - is no justification to allow current healthcare situation to get worse -> with some +40M without any healthcare (mostly poor working class)?

Inside EU your ideas would be considered not only *dumb* but outright *stupid* - Why?

Because the state has a political responsibility to protect the health and welfare of its sovereign citizens - the taxpayer! The costs are not relevant criteria when its comes down to the health and welfare of the citizens....

Why don't you ask that cost factor when dealing with the escalating military-industrial cost of the national budget?

And that's where we find ourselves on parallel but different political highways, my dear Swell!

Back to your preaching on Morality - what's the moral obligation of the state to the citizen?

[anne]

Swells:

Excellent.... I will reply.

[save_the_rustbelt]

"Rubbish, but keep trying."

Anne, work in the health care system for 35 years and then get back to me.

By the way, did you pass the quiz?

[me]

"When she finished laughing she said the government cannot run an efficient health care program."

Doctors disagree:

"The Doctors' Revolt

Doctors, the traditional advocates for the medical status quo, are increasingly in favor of major reforms to the U.S. health-care system.

Roger Bybee | July 1, 2008 | web only



Doctors have historically been the watchdogs of the U.S. medical system, with the American Medical Association scaring New Dealers into dropping national health coverage from the Social Security Act and then the AMA shredding Harry Truman's reform efforts in the late 1940s. But a new poll and other significant indicators suggest that doctors are turning against the health-insurance firms that increasingly dominate American health care.

The latest sign is a poll published recently in the Annals of Internal Medicine showing that 59 percent of U.S. doctors support a "single payer" plan that essentially eliminates the central role of private insurers. Most industrial societies -- including nations as diverse as Taiwan, France, and Canada -- have adopted universal health systems that provide health care to all citizens and permit them free choice of their doctors and hospitals. These plans are typically funded by a mix of general tax revenues and payroll taxes, and essential health-care is administered by nonprofit government agencies rather than private insurers.

The new poll, conducted by Indiana University's Center for Health Policy and Professionalism Research, shows a sharp 10 percent spike in the number of doctors supporting national insurance: 59 percent in 2007 compared to 49 percent five years earlier. This indicates that more physicians are eager for systematic changes, said Toledo physician Dr. Johnathon Ross, past president of Physicians for a National Health Program.

http://www.prospect.org/cs/articles?article=the_doctors_revolt

[me]

Why is "socialized medicine" OK for Dick Cheney and not me?

Just ask yourself this question, would Dick Cheney be alive if he had my health care plan at my income level? Good luck with that.

[swells]

hari, I am pretty shocked when you say "Because the state has a political responsibility to protect the health and welfare of its sovereign citizens - the taxpayer! The costs are not relevant criteria when its comes down to the health and welfare of the citizens...."

What parallel universe do you occupy where resources are unconstrained and hence there exists no need for budgeting or allocation of resources?

[hari]

Your guys remind me of a prehistoric homosapien - may be from the neanderthal period or wahtnot....arguing about the fundamentals of universal healthcare...as absolute idiotic and (theoretical) academics!

Why not come to Old Europe and learn a few facts of life...and fundamentally about the morality of the state and the citizen.

You know what I'm upto...because if you continue to debate the esoterics of your current HMO and whatnots - you'll never get to the goal of universal care.

Mental retardation is also a factor built on socalled free market capitalist ideology - which is afterall about to sink into a more regulated and may be a bit more wholesome entity to protect its citizens and its wealth.

[cm]

"Cost explosions" and frauds come largely from the private profit motive involved.

Paying doctors by diagnostic codes, by ordering diagnostic routines on expensive equipment, by drug prescription etc., then it is difficult to imagine how this would not distort incentives to (1) to focus on the highest billable stuff, and (2) getting "creative" and finding ways how to charge more of the stuff (whether performed on a patient or not).

And there are the follow-up effects of equipment and drug manufacturers "educating" doctors how to "take advantage" of all the new (and expensive) stuff.

[swells]

me, do you really hold out Dick Cheney still being alive as a reason FOR his type of health plan? I can only respond that it would have been an entirely better thing had his ticker ticked its last tock decades ago.

[cm]

swells: We live in a universe where the resources for all kinds of things, from national "defense" to rescuing "financial entrepreneurship" and securing the profitability of politicians' buddies' businesses are pretty much unconstrained, as long as it does not come to the welfare of the general population.

[swells]

hari, we aren't talking about health care in Europe. While European soil has been drenched in blood spilt wastefully for most of the last 1000 years, it would appear the European's have gotten their act together at least somewhat better over the last few decades.

We are talking about health care reform in the US.

Before you condemn my position as academic idiocy, you really need to take into account the monumental stupidity of most US citizens and our system that rewards politicians with the post of panderer in chief if they succeed.

If you are willing to ship us enough more intelligent citizens to tip the political balance, then please do wo and then we can discuss universal health care in that context.

[swells]

cm, I agree wholeheartedly. At root, my position is that universal health care would be a fantastic system to have if our system weren't so brain dead and corrupt.

I don't see how it behooves me to ACT as if the stupidity isn't really stupid or to ACT as if the system weren't corrupt.

People keep making the mistake of thinking things are okay here in the US. They profoundly are not.

[Julio]

swells:
I haven't seen any inclination in this country to make the hard choices that would be required to constrain health care spending to some reasonable percentage of the available resources.

Nor will there be such an inclination, in this quarter at least, while the tradeoff is between treatment for my mother versus more profit for our insurer.

Universal care, or in some way getting the insurance companies out of the spending decision, is a prerequisite to such a discussion.

[swells]

Julio, your point is well-taken. Oddly enough, treatment for MY mother is what got me most interested in this. Over 300K was spent on her in the last 9 months of her life. I loved my mother but it probably shouldn't have been spent. Her quality of life for those last 9 months was atrocious. The money should have gone to something else, like pre-natal care or making sure young kids have a decent chance to get an education.

[anne]

http://www.nytimes.com/2008/08/11/opinion/11krugman.html?ref=opinion&pagewanted=print

August 11, 2008

Can It Happen Here?
By PAUL KRUGMAN

One more thing: if we do get real health care reform, a lot of people will owe a debt of gratitude to none other than John Edwards. When Mr. Edwards dropped out of the presidential race, I credited him with making universal health care a "possible dream for the next administration." Mr. Edwards's political career is over — but perhaps he and his family can take some solace from the fact that his party is still trying to make that dream come true.

[Right.]

[cm]

swells: The problem I see with the reasoning "X% of all cost is incurred at the end of life" is that it places the focus wrongly. The most desperate of circumstances, which are rife with social mores of "family values" and not leaving family members out to die, are simply where providers can charge most shamelessly.

The same level of care that the elderly or terminal patients receive can probably be provided at far lower cost when you take out the inflated profits and extortionary components of the charges. Of course, that's close to impossible in a system based on private profit and private "competition".

[Callahan]

Does it stand a chance? Probably a snowball's chance in hell, until ... we are out of Iraq, and we have created some meaningful, well paying jobs by re-building our crumbling third world infrastructure. Which means it could be a loooooooooooooooooooooong time.

[Patrick]

I'm Canadian. Our health system is a mess too, but in a different way. Most people get pretty good basic care. The problem is mostly with expensive and complex procedures for boomers with lifestyle induced health problems: the system simply can't afford to pay for all that heart disease and cancer. There's also a problem with things like hip replacements for octogenarians - in a public system it's hard to justify the expense. The problem is that we can't have a rational debate about the limits of what is possible.

A hybrid system that provides basic, preventative, and emergency care to all (esp. kids and pregnant women), rations care for lifestyle induced disease, and allows people to buy insurance and/or pay for the rest is probably the way to go.

[im1dc]

My idea of Word Perfect: "Can It Happen Here?, by Paul Krugman"

Every word, sentence, paragraph, thought and idea in Our Professor Krugman's Editorial is perfect and I could not agree more wholeheartedly.

Thank you Professor. I hope Obama and his people are listening.

Personally, speaking from my gut feeling without any data, analysis or studies but with some recent history upon which to guide me on these issues, I believe if Obama picked Hillary Clinton as his VP choice National Universal Heatlh Care stands a much greater chance of becoming a done deal and Obama's odds of being elected improve 100%.

Obama has not yet convinced me that he is not simply playing politics with National Universal Health Insurance to get elected. I want to see substance behind his rhetoric and Hillary as VP and point person on Health Care would be substantial substance.

[swells]

CM, I don't buy it. The entirety of my mom's costs were paid by medicare, which sets rates of compensation and within which rates providers provide what they provide. Where were the extortionate profits, etc. in that scenario? That was already a government negotiated scenario.

In a universe of unconstrained resources, it would be the case that people simply get whatever they need. In the universe we inhabit, 300K spent on my mom at the bitter end of her life is 300K that isn't available to be spent elsewhere.

[Dickeylee]

So why should John Edwards career be over as we know it? The Republican candidate for president dumped his wife, who was in very poor health after an auto accident, and married his current wife just 30 days after his divorce. He was "fooling" around with his new cheerleader girlfriend while his wife was back home recovering from yet another surgury.
That this all took place back in the late 70's/early 80's makes it all OK now? Can't wait to hear what Newt has to say about this!

[anne]

Swells, thank you for taking the trouble to be completely precise and referenced. I knew of Amy Finkelstein's writing, but would not have remembered reading her unless reminded. I have a problem in being unable to fairly discuss the writing, so I am not sure how to reply properly.

I am appreciative, but thinking whether this is more I can fairly add in this unusual circumstance.

[ken melvin]

Swells - How much did Medicare pay? The bills the hospitals send out are about four times what Medicare actually pays.

[swells]

anne, no problem. I can't make heads or tails of the situation conclusively either. That just leaves me in a position of confusion. First, it does make basic sense to me that health care is important. Second, it makes sense to me that health care ought to, in some sense, treated like a utility. So ubiquitously needed that there should be a large role for government to play in it's delivery.

Third, I can't help being distrustful of whether it will be properly delivered or not given our government's track record on the other things it's heavily involved in.

Thanks for your reply.

[anne]

http://papers.ssrn.com/sol3/papers.cfm?abstract_id=804255

September, 2005

What Did Medicare Do (and Was It Worth It)?
By Amy Finkelstein and Robin Mcknight

Abstract:

We study the impact of the introduction of one of the major pillars of the social insurance system in the United States: the introduction of Medicare in 1965. Our results suggest that, in its first 10 years, the establishment of universal health insurance for the elderly had no discernible impact on their mortality. However, we find that the introduction of Medicare was associated with a substantial reduction in the elderly's exposure to out of pocket medical expenditure risk. Specifically, we estimate that Medicare's introduction is associated with a forty percent decline in out of pocket spending for the top quartile of the out of pocket spending distribution. A stylized expected utility framework suggests that the welfare gains from such reductions in risk exposure alone may be sufficient to cover between half and three-quarters of the costs of the Medicare program. These findings underscore the importance of considering the direct insurance benefits from public health insurance programs, in addition to any indirect benefits from an effect on health. *

* http://economistsview.typepad.com/economistsview/2007/02/amy_finkelstein.html

[swells]

ken melman, I don't know precisely. From the paperwork I saw, the actual payments from medicare were over 300K but how much over I don't know. I don't think I saw all of it. There were several longish ICU stays, a whole lot of home health care (mostly palliative which seems absolutely required to me) and radiation, chemo and more over 9 months or so.

I quit my job at the time to take care of her so I saw most of what went on in detail but my focus wasn't exactly on precise accountings. Mostly I was trying to take care of the woman who taught me to read when I was three and then spent money she and my step-dad could ill afford to make sure I had encyclopedia's etc. anytime I wanted to know how something worked or what it was.

[Patricia Shannon]

I don't have a link for this. It is from an e-mail from an officer of our company, which writes software for for detecting medical insurance fraud.
A single-payer plan should make it easier to detect medical payment fraud.
FBI: LA hospitals used homeless in medical fraud
By SHAYA TAYEFE MOHAJER
LOS ANGELES (AP) — For hundreds of homeless people, posing as phony hospital patients provided them a clean bed and cash. For the hospitals that processed them, it meant a full patient-load and a paycheck from the government.
Now some of those allegedly involved in what authorities say was a massive scheme have been charged with billing government programs for millions of dollars in unnecessary health services.
A hospital CEO was arrested Wednesday after federal agents raided three medical centers. City attorney Rocky Delgadillo's office has also sued the hospitals, saying they used homeless people as "human pawns."
Hospitals in Los Angeles and Orange counties submitted phony Medicare and Medi-Cal bills for hundreds, perhaps thousands, of homeless patients — including drug addicts and the mentally ill — recruited from downtown's Skid Row, state and federal authorities allege.
While treating minor problems that did not require hospitalization, such as dehydration, exhaustion or yeast infections, the hospitals allegedly kept homeless patients in beds for as long as three days and charged the government for the stays.
Search warrants were served Wednesday at City of Angels Medical Center, Los Angeles Metropolitan Medical Center and Tustin Hospital and Medical Center, the FBI said.
Agents arrested Rudra Sabaratnam, CEO of City of Angels hospital, and Estill Mitts, operator of a Skid Row health assessment center, FBI spokeswoman Laura Eimiller said. They were in federal custody and were scheduled to be arraigned Monday.
A 21-count indictment unsealed Wednesday charged both men with conspiring to receive and take kickbacks for patient referrals and to commit health care fraud. Sabaratnam also was charged with paying kickbacks and Mitts was charged with money laundering and tax evasion.
If convicted, Sabaratnam could face 50 years in federal prison, and Mitts could face 140 years, authorities said.
Bond for Mitts was set at $25,000. He was expected to be released Wednesday night to home detention, said Thom Mrozek, a spokesman for the U.S. attorney's office. Sabaratnam's bond hearing was set for Thursday.
Sabaratnam's lawyer Dominic Cantalupo, and Mitts' lawyer John Vandevelde did not immediately return calls seeking comment.
U.S. Attorney Thomas O'Brien said he expects additional charges in the case.
"This is one of several major medical fraud investigations that are ongoing," he said. "There's too much money being illegally stripped from public health care programs and the potential impact to those with a legitimate need is too great to let such fraud escape federal prosecution."
The city attorney's office said it filed a lawsuit against the corporate owners of the three hospitals — along with Sabaratnam, several doctors and others — in connection with the alleged scheme.
The investigation began in 2006 as Los Angeles police looked into reports that hospitals were dumping homeless patients on Skid Row streets.
Representatives of the hospitals did not immediately respond to calls seeking comment. Los Angeles Metropolitan and the Tustin hospital are owned by Pacific Health Corp., and Los Angeles-based Intercare Health Systems owns City of Angels.
Associated Press writer Robert Jablon contributed to this report.

[Patricia Shannon]

http://www.tennessean.com/apps/pbcs.dll/article?AID=/20080807/NEWS07/808070400

Emergency room waiting time rises
By MIKE STOBBE • Associated Press • August 7, 2008

ATLANTA — The average time that hospital emergency room patients wait to see a doctor has grown from about 38 minutes to almost an hour over the past decade, according to new federal statistics released Wednesday.

The increase is due to supply and demand, said Dr. Stephen Pitts, the lead author of the report by the Centers for Disease Control and Prevention.

"There are more people arriving at the ERs. And there are fewer ERs," said Pitts, an associate professor of emergency medicine at Atlanta's Emory University.

Overall, about 119 million visits were made to U.S. emergency rooms in 2006, up from 90 million in 1996 — a 32 percent increase.

Meanwhile, the number of hospital emergency departments dropped to fewer than 4,600, from nearly 4,900, according to American Hospital Association statistics.

Another reason for crowding is that patients who are admitted to the hospital end up waiting in the ER because of the limited number of hospital beds, Pitts said.

A shortage of surgical specialists also contributes. So does the difficulty many patients have in getting appointments to doctor's offices — which causes some to turn to emergency departments, experts said.

"It takes me a month to get an appointment for my own doctor, and I'm a physician, for God's sake," said Dr. Ricardo Martinez, an Atlanta emergency physician. He is executive vice president of Schumacher Group, an organization that manages about 140 hospital emergency departments.
Average is near 1 hour

The amount of time a patient waits before seeing a physician in an ER has been rising steadily, from 38 minutes in 1997, to 47 minutes in 2004, to 56 minutes in 2006.

Pitts added that 56 minutes may be the average, but it's not typical: The average was skewed to nearly an hour because of some very long waits. "Half of people had waiting times of 31 minutes or less," Pitts noted.

Researchers also found that there had not been any recent increases in the number of patients arriving by ambulance, or in the number of cases considered to be true emergencies.

Half of hospital admissions in 2006 came through emergency departments, up from 36 percent in 1996.

The results are based on a national survey of 362 hospital emergency departments.

[Patricia Shannon]

swells says...

Anne, try this link. I would think the data here is pretty good. In particular, look at the chart on page 6. It indicates that health care spending in 1960 was 5.2% of GDP. In 2005, that percentage was 16%. That would seem to comport with my statement that spending on health care has exploded since the introduction of medicare in 1965.

Since the population is aging, we would expect this.

[anne]

http://krugman.blogs.nytimes.com/2008/03/28/runaway-health-care-costs-were-1/

March 28, 2008

Runaway Health Care Costs — We're #1!
By Paul Krugman

Health Care Spending (Percentage of GDP) *

US...

1970... 7.0
2004... 15.3

Canada...

1970... 7.0
2004... 9.9

Germany...

1970... 6.2
2004... 10.6

UK...

1970... 4.5
2004... 8.1

* http://www.cms.hhs.gov/TheChartSeries/downloads/Chartbook_2007_pdf.pdf

[anne]

http://krugman.blogs.nytimes.com/2008/03/28/runaway-health-care-costs-were-1/

March 28, 2008

Runaway Health Care Costs — We're #1!
By Paul Krugman

The real problem lies in health care costs.

I am, of course, a big proponent of health care reform. But is there any reason to think that reform would curb the growth of costs?

Well, I was browsing some of the charts at CMS, * and thought I'd share some information from Chart 2.1. ** This table shows health care spending as a percentage of GDP in some major countries, 35 years ago and recently:

[Chart] We're #1!

Everybody knows that the US spends much more on health care than anyone else, without getting better results. Everyone also knows that health spending has outpaced GDP growth everywhere, thanks to medical progress. What I didn't realize was just how clearly the evidence shows that the rising trend is steepest in the US. We have the biggest increase as well as the highest level. We're #1!

What this suggests is that a more integrated system wouldn't just achieve a one-time saving, but also flatten the upward trend....

* Centers for Medicare & Medicaid Services

** http://www.cms.hhs.gov/TheChartSeries/downloads/Chartbook_2007_pdf.pdf

[anne]

http://www.cbpp.org/3-5-08bud.htm

March 6, 2008

Federal Spending, 2001 Through 2008: Defense Is a Rapidly Growing Share of the Budget, While Domestic Appropriations Have Shrunk
By Richard Kogan

Domestic Discretionary Funding Is a Shrinking Share of Total Program Costs

Share of Total
2001
2008
Change

Defense & security
21.7%
29.2%
+7.5%

Social Security, Medicare/caid
45.9%
43.5%
-2.4%

Domestic Discretionary Funding Has Been Growing More Slowly Than Any Other Set of Programs

(Average annual rate of growth, from 2001 through 2008)
nominal
real
real per person

Defense & security
12.0%
9.1%
8.1%

Social Security, Medicare/caid
6.5%
3.8%
2.8%

Domestic Discretionary Funding is a Shrinking Percentage of the Economy

(% of GDP)
2001
2008
Change

Defense & security
3.6%
5.6%
+2.0%

Social Security, Medicare/caid
7.7%
8.4%
+0.7%

[Presently, we evidently can surely and easily afford Medicare-Medicaid.]

[swells]

Patricia Shannon, unless I'm mistaken, the demographic is such that any real explosion from the aging of the population should be still to come, not already water under the bridge. So, how does it follow that we should expect the growth in health care spending that we've seen to date from the population aging. People born in 1946 are 62 now.

Not saying youu are wrong, just don't understand why "we should expect this" is really the true cause of the explosion in health care spending.

[swells]

anne, thanks for the data. I do have a question. Given that the US is a smallish percentage of the world population and uses a much larger share of the world's resources, why would you think the trend toward spending more on the military industrial complex will reverse?

Doesn't it seem that the converse is true? That in order to "protect" our relative position in the world as consumers that spending on the military industrial complex will increase? How many US citizens do you know that will be "oka" with our standard of living regressing to the mean? I think that is what you are counting on in terms of decreasing funding to the military industrial complex and directing that money toward discretionary spending on health and other social services.

[kharris]

Swells,

Just from the point of view of fair discussion, it doesn't make sense to pull up instances of what you view to be poor management by the state and declare that state management is bad. Most of the problem with mortgages has so far been in the private sector - and the GSEs' troubles are growing at least partly out of the "private" motive of profit. Being unhappy with road maintenance is all well and good, but our road system is mostly public, and mostly carries millions of vehicles every day at or above posted speed-limits. If all we are going to do is slang each other with anecdotes, we can do that all day without learning a thing except what the other side's bias might be.

Same problem with rusty's list of acronyms. The private firm I work for now and the ones I've worked for in the past have managed to grow their own thickets for opague language. Those thickets may not be good for the company, but they are largely unimportant to the client. I don't need to know what the majority of the terms on Rusty's list mean. A long list doesn't mean bad service, and service is what I care about.

It keeps getting said, and keeps getting ignored - the rest of the rich countries can manage universal health care at lower cost than we can manage selective health care. Results in the other countries are often better. Carrying on about how bad the US system is doesn't change that. If the goal is the provision of health care when and where it is needed, why should I care how many indecipherable strings of letters are involved?

[anne]

Swells:

"Given that the US is a smallish percentage of the world population and uses a much larger share of the world's resources, why would you think the trend toward spending more on the military industrial complex will reverse?"

We are already assured the coming President-Congress will be spending relatively more on defense, and this will create a cost problem that Paul Krugman did not address. How affordable health care reform is considered will likely be a significant problem, especially so if insurance is not required.

[anne]

"We are already assured the coming President-Congress will be spending relatively more on defense, and this will create a cost problem that Paul Krugman did not address."

I write that defense spending will be relatively more, even should Barack Obama be President and should a Democratic Congress be elected, because Obama has pledged to maintain defense program spending levels, increase the numbers of our forces, and substitute Afghanistan for Iraq while limiting spending for Iraq as such will be troublesome.

Also, Obama has promised a raft of tax cuts and even when proposing a tax increase on oil company profits promises in turn a tax subsidy from the proceeds for consumers. Sort of creative financing all the way down.

[swells]

kharris, thanks for your reply. Well, yes, the roads do transport millions of people at the speed limit, to the tune, if T. Boone Pickens is to be believed, of 700 billion per year going overseas. I remember the oil crisis of the early 70's. My question is just this. If governments are so good at management and planning, why are we still depending on millions of people going over roads every day with really nary a plan in sight for effective mass transit?

If evidence of mismanagement doesn't qualify as evidence of mismanagement, what does? Should I assume that the people who got us in the mortgage mess really did a good job and give them more power over the mortgage system? I think not. I think the mortgage crisis pretty effectively demonstrated that they shouldn't be running the mortgage system. Why? Because they screwed it up. Take the GSEs. Someone, I don't remember who, made the point that the existence of the GSEs squeezed out other market participants and crowded them into niches where abuse could flourish. I don't know if that's true but the hypothesis should at least be taken seriously. Maybe the government giving the GSEs that much power over the mortgage market had a little something to do with niche players inventing sub-primes and marketing them as they did.

I don't know that providing health care "when and where it's needed" is a good goal or not. It could be. It could also put such a squeeze on resources that education, already seriously problematic, might collapse. Maybe a better goal would be providing health care when the investment makes economic sense might be a better goal, even a more noble one from the perspective of the whole.

I like getting the things I want too but I feel this funny obligation to ask myself whether my getting what I want when I want it is entirely a good thing and under what circumstances my getting what I want is sensible.

[swells]

anne, point taken. I, as you know, am an Obama supporter but I have been very concerned by his position on the FISA bill and I see his tax the oil companies and give gifts to the middle class as a pander move myself. It's worrisome to me.

[robert recht]

Hardly know where to begin. First, for you who fear the public will resist change to Medicare for all. polls have shown the opposite - about 70% to 30% in favor of government financed healthcare. Then there's fear of "losing" Tell me, what if we do== we only go back to the system we have, right? AND remember this, it's NOT necessary to get 80 or 90% of the vote in congress to pass HR 676, (Medicare for all, sponsor: Rep John Conyers, Mi.-- about 55 or 60% will win. ( we also need a president who won't veto it ( so that means a Democrat ) We must get a bigger majority in the senate to overcome the 60% rule. A few Republicans may defect too-it's election time you know and they know what the polls say too!

The Republicans will use smear and fear tactics as usual along with the insurers. The insurers are as popular as cancer, are fighting each other for a decreasing market share and are vulnerable. Let the Republicans do their thing. With healthcare such a major, major issue, they run great risk on their own to further discredit their party.
Counter info on the internet can help to counter this along with educating the public on what they gain with HR 676. What's to lose by trying? NOT MUCH !
Press forware with the internet info campaign and into about how HR 676 is financed witthout raising taxes for everyone below $300,000 family income, emphasize the success of Medicare for 43 yrs, what premiums will be for businesses and individuals which are a fraction of what we pay now. Benefits even better ( by far ) than a congressman and senator; no deductibles, co-pays, denials, cancellations or price raises for an individual, or rejection for any pre-existing condition.
And how an individual can contact his/her congressmen and/or senator for free-as well as the president to demand HR 676 be passed into law. FREE Call: 1-866-338 1015.
Then let's see if the polls are borne out, that the American public are ready for Medicare for all. WITH NO INSURANCE COMPANIES TO MAKE THEIR LIFE MISERABLE. MEDICARE FOR ALL, JUST LIKE THE GREAT MEDICARE THEIR PARENTS AND GRANDPARENTS HAVE ACCEPTED SO WELL!! BUT MUCH IMPROVED OVER ORIGINAL MEDICARE.
With a little luck and perseverance and a positive attitude, we can win this one possibly easier than you think.THE HEALTHCARE ISSUE HAS FINALLY RISEN TO CRITICAL MASS after 20 years. That's why victory is so possible.

[ken melvin]

Seems some are inclined to blame government for everything that didn't turn out quite right even when government wasn't making the decisions. This, a sin of omission?

[Patricia Shannon]

Thanks to those who mentioned the war, and its financial costs.
The current and previous war have resulted in many badly wounded veterans. People who would have died preciously, are now living. Many have permanent disabilities. This is part of the increase in medical costs.
I'm sure someone (Anne?) can find specifics.

[Patricia Shannon]

Swells, the average medical costs start increasing before people reach 62. That is part of the reason people over 45 have a harder time getting a job.

[ilsm]

Socialized medicine is what the VA runs and Americans are going into the Army with the assurance that if they are disbaled they get socialized medicine for life.

Socialized medicine cannot be that bad, Americans risk their lives for it!

[Patricia Shannon]

oops
"People who would have died preciously"

should have been

"People who would have died previously"

[jim]

Let us put in place a plan that holds health spending to 8% of GNP or less and does not allow individuals to spend their own funds on care. I want to watch the resulting circus.

[swells]

Patricia, I could be wrong but your explanation (people are getting older) for the explosion in health care costs since the inception of medicare just seems too facile to me. For one thing, even taking your age of 45 at face value then your premise would only explain increases in or after 1991. (17 years ago given that the baby boomer bulge couldn't really start before 1946) But the trend of explosive increases was well established before that going back to 1971 if not earlier.

[Patricia Shannon]

Swells, I didn't say that aging demographics caused all the increase. In fact, I posted a comment about increased medical costs from the war. I also posted one about fraud. I rarely make absolute statements, because absolute statements are usually wrong, especially about topics that are interesting to discuss.

Maybe I missed it, but the only reference that I saw that supported your claim was the one from a source that you admitted was suspect. Citing figures from 20 or 30 years apart doesn't tell us the time distribution of the change.

I'm not saying Medicare did or did not have an effect on the rate of medical costs. I would guess that it contributed to the increase in costs, and that this extra care contributed to the increase in life expectancy and healthy life span.

Another factor in increasing medical costs is costly medical advances. In some instances these are good. Eg., many people today have survived or prevented heart attackes that would have killed them in the past, and are leading active lives. On the other hand, there are people with Alzheimers and comas who are kept alive beyond what seems to be humane limits. and the drug industry is a whole story in itself.

[swells]

Patricia, your points are taken. What I'm trying to do is to get at an answer to a seemingly simple question that isn't simple at all; i.e., is it likely that the government will be able to effectively administer a system of universal health care and provide such services at a cost we can live with.

I actually did provide some other references that were in pretty good agreement with the one that seemed explicitly polemic on the issue.

Another one I've found since is here: http://www.cato.org/pubs/pas/pa-613.pdf

It's an examination of "universal health care systems" from around the world and seems to me to be pretty well-reasoned and researched. It seems all the health care systems that are reasonably analogous to be pertinent to the situation here in the US are experiencing huge funding and provision of service problems that are projected to worsen.

My basic concerns are that the government isn't particularly good at providing services and that we can't really afford all the health care we "need". I'm trying to figure out if those concerns are reasonable or not.

Thanks for your reply.

[Patricia Shannon]

Well, I have to admit that although I think of myself as pretty altruistic, I'm not willing to be a sacrificial goat - to die from lack of health care in order to preserve the riches of Paris Hilton :)

[Jrossi]

I am a family physician. Patrick's comments make sense. A hybrid system makes sense.
Some posters essentially have the position that universal HC (gov run or otherwise) would be a nightmare. This might be correct. The issue is whether the nightmare would be worse or better than the current nightmare. I happen to believe it would be better, but cannot prove this assertion. Certainly Canada and most western Europeans have a system better than our disgraceful situation here, but extrapolation is always uncertain. To some extent HC reform is a shot in the dark, and some players would clearly get screwed(people with Cadillac insurance, HI Companies, drug companies,some physician specialists). The working classes would benefit immensely.
Some posters essentially have the position than universal HC is a panacea. This is wrong. HC will always be a struggle. People will always want more than the society will want to provide. Re-read Patrick's post. Revamping the payment scheme for MDs and other providers (hospitals, nursing homes, etc.) is necessary to avoid severe cost over-runs, brutal rationing, or both.

[Jrossi]

save the rustbelt: I have worked at Kaiser in California, in private practice, for a hospital-owned group in MN, and for the State of Washington. WA-state provided the best care (by miles and miles), Kaiser the next best, then private practice, and hospital-group(corporate, non-profit) care the worst. The corporate medicine group was so focused on money that almost nothing else mattered. The goal was to maximize income--shitty medicine was fine, as long as lawsuits were avoided. I have had numerous doctor friends with precisely the same experience--in Napa Calfornia, Eureka CA, Shawano WI, Milwaukee WI, Springfield MO, Eugene OR. There is a huge incentive to provide income-generating care (especially radiology scans), needed or not. This is the reality when the business types get doctors by the short hairs (admittedly with the complicity of some the the docs).
Is government run medicine inefficient? Absolutely. But no more than the private sector. And, in my experience, it puts pt care over corporate profits and does a better job at providing quality care.

[Patricia Shannon]

Jrossi,
Thank you for taking the time to give us some facts from someone who's been there.

I'm sure that decent doctors are very frustrated at the current situation of lack of medical care for the poor. My eye surgeon was obviously distressed for me that I was not able to afford a cataract operation until I was on the very boundary of being legally blind (and it was the luck of the timing of the job market that made it possible). He obviously feels bad for me that I only had one eye fixed. However, I feel happy and grateful to have one good eye now, so that I am able to drive and work.

[Real Person from the Real World]

From ABOVE
"In a universe of unconstrained resources, it would be the case that people simply get whatever they need. In the universe we inhabit, 300K spent on my mom at the bitter end of her life is 300K that isn't available to be spent elsewhere."

BS. What are you supposed to do, throw someone in a hole and wait for them to croak? Furthermore, we do learn from everything. If nothing else, your mother's death provided learning for those involved. Money should not be the complete arbitrare of what you spend in a civilized society.

[Patricia Shannon]

Well, there are limits. Is a medical treatment that prolongs life by 3 months while having severe side effects, and costing a tremendous amount of money, really reasonable?

If I were in a "locked in" state, where the person is conscious but unable to move or communicate, I would consider it torture to be kept alive artificially in a state of horrible boredom.

[Patricia Shannon]

Real Person from the Real World

Money should not be the complete arbitrare of what you spend in a civilized society.

To prevent misunderstanding, I was not disagreeing with you.
I see the word "complete" in your sentence. I was giving possible examples of why the word was needed and used in that sentence.