Paul Krugman: Health Care Destruction

The McCain health care plan has a reverse Robin Hood effect in that it takes health care insurance away from those who need it the most and gives it to those who are healthiest and most able to afford coverage:

Health Care Destruction, by Paul Krugman, Commentary, NY Times: ...Conservative Republicans still hate Medicare, and would kill it if they could... (that’s what the 1995 shutdown of the government was all about). But so far they haven’t been able to pull that off.

So John McCain wants to destroy the health insurance of non-elderly Americans instead.

Most Americans under 65 currently get health insurance through their employers. That’s largely because the tax code favors such insurance ... as long as the ... plan ...[is] available to all employees, regardless of ... the state of their health.

This system does a fairly effective job of protecting those it reaches, but it leaves many Americans out in the cold. Workers whose employers don’t offer coverage are forced to seek individual health insurance, often in vain. For one thing, insurance companies offering “nongroup” coverage generally refuse to cover anyone with a pre-existing medical condition. And individual insurance is very expensive, because insurers spend large sums weeding out “high-risk” applicants — that is, anyone ... likely to actually need the insurance.

So what should be done? Barack Obama offers incremental reform... His plan falls short of universal coverage, but it would sharply reduce the number of uninsured.

Mr. McCain, on the other hand, wants to blow up the current system, by eliminating the tax break for employer-provided insurance. And he doesn’t offer a workable alternative.

Without the tax break, many employers would drop their current health plans. Several recent nonpartisan studies estimate that ... around 20 million Americans ... would lose their health insurance.

As compensation, the McCain plan would give people a tax credit — $2,500 for an individual, $5,000 for a family — that could be used to buy health insurance... At the same time, Mr. McCain would deregulate insurance, leaving insurance companies free to deny coverage to those with health problems — and his proposal for a “high-risk pool” for hard cases would provide little help.

So what would happen?

The ... total number of uninsured Americans might decline marginally under the McCain plan — although many more Americans would be without insurance than under the Obama plan.

But the people gaining insurance would be those who need it least: relatively healthy Americans with high incomes. Why? Because insurance companies want to cover only healthy people, and ... only those able to pay a lot in addition to their tax credit would be able to afford coverage (remember, it’s a $5,000 credit, but the average family policy actually costs more than $12,000).

Meanwhile, the people losing insurance would be those who need it most: lower-income workers who wouldn’t be able to afford individual insurance even with the tax credit, and Americans with health problems whom insurance companies won’t cover.

And in the process of comforting the comfortable while afflicting the afflicted, the McCain plan would also lead to a huge, expensive increase in bureaucracy: insurers selling individual health plans spend 29 percent of the premiums they receive on administration, largely ... to screen applicants. This compares with costs of 12 percent for group plans and just 3 percent for Medicare.

In short, the McCain plan makes no sense at all, unless you have faith that the magic of the marketplace can solve all problems. And Mr. McCain does: a much-quoted article published under his name declares that “Opening up the health insurance market to more vigorous nationwide competition, as we have done over the last decade in banking, would provide more choices of innovative products less burdened by the worst excesses of state-based regulation.”

I agree: the McCain plan would do for health care what deregulation has done for banking. And I’m terrified.

Comments

[Cyrille]

A tax credit is a stupid "solution", on top of being unaffordable.

On these shores, healthcare is run by the Government, with much lower administrative costs on top of having everyone covered. But then we don't (yet) have the religion that the solution to any problem is a tax cut.

May it stay that way.

[Gegner]

I used to sell insurance for people who didn't need it and let me tell you, that's a pretty small group. I didn't sell a lot of policies because most folks preferred a plan that let them seek healthcare when they felt they needed it.

The 'catastrophic' coverage I was selling only suited self employed young men without families.

If you have children, you need insurance.

Mr. Krugman is right, the McCain plan is a disaster waiting to happen.

[Linda]

HSAs are irrelevant for anyone whose income, health status, and family situation make the cost prohibitive. I continue to be incredulous about these plans that completely ignore the large number of people who, despite working full-time, cannot afford the required expenses/"savings" accounts. Sometimes I wish everyone who sees such things as an Answer could be forced to live at or slightly below median income level for a year. (Hint: You wouldn't necessarily go to work in a suit and if you did, you'd probably buy it at places like Ross or Sears.)

The "best plan" would be a plan that makes it possible for everyone to see their doctor when necessary.

[Noni Mausa]

The price of US health insurance boggles my mind. $12k per year for a commodity that when needed you might not even be able to use? And you can't find out ahead of time for certain if you'll be able to use it? And using it disqualifies you from buying it again?

From up here north of the border, the whole system looks as nutso as the Lilliputian "big-enders" and "little-enders".

Noni

[bakho]

Does anyone know the origin of the McCain plan? McCain is obviously not a health care expert. Which lobbyists wrote this?

This proposal would probably speed the enactment of single payer, because it would get rid insurance through your job for too many people. However, it would cause a lot of pain for a lot of people first.

[Real Person from the Real World]

So far all of the above comments are sensible. Soon the Republican and libertarian types will discover this thread and start ranting about how medical care ought to be rationed because there just isn't enough of it to go 'round, that grandma/pa ought to just die and get it over with, and how they should not be forced to pay into a system that will reward obese couch potatoes for their human failings.

I still feel that universal health care is the way to go, but BO has had to back down from that. The love of accumulation, may get some of the younger guys, who think they are immortal, to try to fight for HSAs. Even older Republicans who are on medicare, will vote for the Republicans, because that is what they are: "Democrats are tax and spend", limousine liberals, and in that view, just as bad as Republicans. Never mind that a lot of us are in the middle: too old too be healthy anymore, but too young to get medicare supplemental insurance.

A few months back, it was remarked that people seem to have fewer friends or connections outside family. Perhaps that is where it's at now. Who cares about someone who works at perma temp jobs, and lives alone in a condo or rent by the month? This society is falling apart at the seams.

[Individual Policy Holder]

I have no desire to take away employers' tax breaks, but can someone explain to me why I don't receive a tax break on my own individual plan that I've paid for over the past 15 years?

Every year at tax time I feel ripped off. Can't we simply make my policy deductible as well?

[Both]

So give those who buy their own insurance a tax credit, but keep the employer deduction also. Those who buy their own insurance need some relief, as insurance is getting pricey. National health care for basic services might be best, but it seems like it is a long way away. People need help now.

[save_the_rustbelt]

"Does anyone know the origin of the McCain plan? McCain is obviously not a health care expert. Which lobbyists wrote this?"

This is a cut and paste version of several proposals floating around for a long time, nothing terribly original.

I'm not a McCain supporter, but Krugman's breathless hysteria is getting a little hard to take.

[Robinia]

Doctrine and ideology have replaced truth here. McCain is peddling a "revealed truth" that, unfortunately, many seem to believe. We are beginning to reap the effects of that irrational belief in pseudo-economics. We must try hard to speak truth louder and more convincingly.

There is a world of evidence about what works in providing health care to populations with good outcomes (including good epidemological prevention of contagious diseases, which respect no wealth measure) and have a reasonable-sized chunk of GDP used to provide service. Why would we invent something so stupid instead? Crony capitalism and blind faith in ideologies that demonstrably don't work can be the only answers.

[Ninja Zombie]

Linda: "The "best plan" would be a plan that makes it possible for everyone to see their doctor when necessary."

What makes you think there are enough doctors (more precisely, doctor-hours) for this?

Considering that our medical system currently works at nearly full capacity (most doctors already do 60 hours weeks), I fail to see how any variation of your best plan is even physically possible. Could you explain?

says...

"Considering that our medical system currently works at nearly full capacity (most doctors already do 60 hours weeks), I fail to see how any variation of your best plan is even physically possible."

The problem with having a reasonable health care insurance system in America as opposed to every other developed country in the world is that having universal health care insurance in America would mean having all doctors work at least 500 hours a week. Longer, depending on the specialty.

Clear enough answer?

[anne]

"I'm not a McCain supporter, but Krugman's breathless hysteria is getting a little hard to take."

Then please set down a reasonable Republican universal health care insurance proposal.

[The above comment on the threat of working our doctors to the death was by me. I am terribly worried about such things.]

[More]

Er, train more doctors. There is a shortage.

[ddt]

the free market solution would be to train and import more doctors. Of course the AMA white-collar union is directly opposed to any increase in the number of doctors or foreign competition.

"If U.S. trade negotiators approached the highly paid professions in the same way they approached the auto industry, then they would actively be trying to uncover all the factors that prevent direct competition between U.S. professionals and their counterparts in the developing world, and then construct trade agreements that eliminated these barriers. They would be asking hospitals, law firms, and universities what is preventing them from doubling, tripling, or quadrupling the number of doctors, lawyers, and economists from developing countries working in their institutions. They would also be asking the trade negotiators from Mexico, India, or China what obstacles prevent them from sending hundreds of thousands of highly skilled professionals to the United States.

This does not happen. In fact, the exact opposite happens. In 1997 Congress tightened the licensing rules for foreign doctors entering the country because of concerns by the American Medical Association and other doctors' organizations that the inflow of foreign doctors was driving down their salaries. As a result, the number of foreign medical residents allowed to enter the country each year was cut in half. 3

3 For a discussion of the debate over the impact of foreign doctors on the wages of U.S. physicians, see "Caught in the Middle," Washington Post, March 19, 1996, "A.M.A. and Colleges Assert There is a Surfeit of Doctors," New York Times, March 1, 1997, and "U.S. to Pay Hospitals Not to Train Doctors, Easing Glut," New York Times, February 15, 1997. The success of the 1997 policy changes in restricting the inflow of foreign doctors was noted five years later. See “Fewer Foreign Doctors Seek U.S. Training,” Washington Post, September 4, 2002, and “Test Tied to Slip in Foreign Applicants for Medical Residences,” New York Times, September 4, 2002."

Dean Baker
http://www.conservativenannystate.org/cns.html#2

[TigerPaw]

Combine a single-payer system with tort reform and doctors would spend less time covering their rear-ends, filling out forms, etc. That should free up a fair bit of their time.

Not to mention the elimination of the large insurance company staffs dedicated to saying "no" by one method or another. Then they could do something useful for the country instead.

[anne]

http://www.pnhp.org/news/2008/october/commonwealth_fund_on.php

October 2, 2008

Commonwealth Fund on Candidates' Proposals *

So these are the "choices for America." We currently have 46 million people who are uninsured. After ten years of McCain's plan, we would have 65 million uninsured, but ten years of Obama's plan would leave only 33 million people without insurance. Only 33 million!?

* http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=707948

[anne]

http://www.pnhp.org/news/2008/october/medical_causes_of_ho.php

October 6, 2008

Get Sick, Get Out: The Medical Causes of Home Mortgage Foreclosures
By Christopher Tarver Robertson, Richard Egelhof, & Michael Hoke

In recent years, there has been national alarm about the rising rate of home foreclosures, which now strike one in every 92 households in America, and which contribute to even broader macroeconomic effects.

These factors — loose lending, irresponsible borrowers, a flat real estate market, and rising interest rates — have together become the "standard account" of home foreclosure.

Policymakers and scholars may be surprised to learn that even in the midst of this spike, one of the largest causes of home foreclosures was none of the above. We studied homeowners going through foreclosure in four states and found that medical crises contribute to half of all home foreclosure filings. If these patterns hold nationwide, medical causes may put as many as 1.5 million Americans in jeopardy of losing their homes each year.

Half of all respondents (49%) indicated that their foreclosure was caused in part by a medical problem, including illness or injuries (32%), unmanageable medical bills (23%), lost work due to a medical problem (27%), or caring for sick family members (14%). We also examined objective indicia of medical disruptions in the previous two years, including those respondents paying more than $2,000 of medical bills out of pocket (37%), those losing two or more weeks of work because of injury or illness (30%), those currently disabled and unable to work (8%), and those who used their home equity to pay medical bills (13%). Altogether, we found that about 7 in 10 of our respondents either self-reported a medical cause of foreclosure, or experienced one of these indicia of medical disruptions in the years before foreclosure.

Altogether, these findings suggest that the standard account of mortgage foreclosure is missing a large portion of the story. Mortgage foreclosures are not just the results of bad loans, bad properties, or bad borrowers. Instead, many mortgage foreclosures are the result of unpredictable medical disruptions that impact both the incomes and the expenses of family finances.

* http://works.bepress.com/cgi/viewcontent.cgi?article=1001&context=christopher_robertson

[save_the_rustbelt]

I just spent six days with health care finance adn quality experts from all fifty states so I am feeling a little brain dizzy.

If we do not approach health care reform carefully we will rediscover the law of unintended consequences.

Every federal government reform or innovation has had some negative fall out.

Krugman does not like Obama's incremental approach, but I think it is far better than trying to create a single payer plan in a short period of time.

[anne]

http://jhppl.dukejournals.org/cgi/content/abstract/33/5/979?etoc

October, 2008

Health Care Financing Reforms in Germany: The Case for Rethinking the Evolutionary Approach to Reforms
By Percivil M. Carrera, Karen K. Siemens, and John Bridges

Health care reform has been a perpetual issue in German politics since reunification. Reform initially focused on restructuring the health care system of the former East Germany. It has subsequently focused on questioning whether the financing of the German social health insurance (SHI) system is sustainable, in light of economic malaise that characterized the 1990s and heightened global competition. In this article, we document twelve significant attempts to reform health care financing in Germany and critically appraise them according to the principles of solidarity and subsidiarity on which SHI systems were built. While the reforms in the aggregate offered the prospect of addressing the challenges faced by the system, the modest results of the reforms and remaining deficiencies of the system underscore the limitations of the evolutionary approach to reforms. This suggests that reformers should consider a more revolutionary approach.

Concluding

An appraisal of health care financing reforms in Germany since reunification offers three lessons. First, while evolutionary reforms may be more politically feasible than radical reforms, evolutionary reforms are inadequate in addressing the issue of the sustainability of health care financing. Second, the impact of evolutionary reforms can be substantial when they extend and build on and not contradict or undermine previous measures. Finally, the biggest challenge to health care financing reform is the aversion to take the revolutionary route.

[This study suggests that revolutionary rather than evolutionary change may be most proper in moving to health care insurance, similarly the recent experiences in Taiwan and Switzerland suggest the same.]

[ken melvin]

STR - and all along i thought you were a man for change.

[Ninja Zombie]

Tigerpaw: "Combine a single-payer system with tort reform and doctors would spend less time covering their rear-ends, filling out forms, etc. That should free up a fair bit of their time."

Having doctors spend less time on paperwork and not performing "lawsuit protection" procedures might help. But why is it necessary to do this via a single-payer system?

"Not to mention the elimination of the large insurance company staffs dedicated to saying "no" by one method or another. Then they could do something useful for the country instead."

If there is no mechanism for saying "no", then the amount of medical procedures demanded will go up (1). Where will the extra doctor-hours and other resources necessary to perform these procedures come from?

(1) The RAND study suggests a 30% increase in medical procedures performed with no increase in health outcomes.

[Alex Tolley]

STR: "Krugman does not like Obama's incremental approach, but I think it is far better than trying to create a single payer plan in a short period of time."

Why? "Revolutionary" changes have worked very well in countries that tried it.

I think it speaks to the power of perceptions that even when other H/C delivery systems are proven to have better outcomes than the US, are cheaper, more universal, more fair, that when given the choice after careful examination, Americans prefer the Canadian system, that despite all this, I still hear that any other system than our current one would be:

1. government dictated, socialism
2. giving something to poor people for nothing.

I think we really need to use the message of advertising - repeating the message with enough frequency so that the ideas about universal H/C delivery can take root.

[donna]

Yup, you want a free market, let's have more doctors, then. Either make it a free market and let more people hang out there shingle, or stop pretending it is one.

[anne]

"If there is no mechanism for saying 'no,' then the amount of medical procedures demanded will go up."

Watch me being terrified, as patients are left to die in the streets because they finally have health care insurance. OMG.

[Robert Edele]

The problem with tax credits is that you need to have enough taxes to offset, otherwise they're useless. Only the middle class and rich can benefit from them, and it's the poor that need it the most.

As far as doctors being overworked, I'm very curious as to how that situation has developed. I thought that the US had one of the highest ratios of doctors to population in the world. In any case, either relaxing requirements or providing free medical schooling would go a long way towards increasing the number of doctors, should that be seen as desireable.

[save_the_rustbelt]

I'm all in favor of reform and change. I've seen the problems at the service level.

My problem is that reformers deal in billions, but at the service level we have to deal with individual transactions and services.

We are already driving providers away from primary care, we must move carefully that we do not create a worse problem, as I hear is happening in Mass.

I don't want to throw the baby out with the bath water.

[save_the_rustbelt]

Alex:

If this were 1960 a transition to a single payer plan would be fairly easy.

We are, however, way down the road, and from the operational level this wouldn't be so easy, not to mention billions of dollars committed based on the current model, and thousands of decisions, that suddenly will be "wrong" under a new model.

[Jay]

Government healthcare in the U.S. covers far less than 100% of the population, yet U.S. socialized medicine per-capita (using 300 million as the base) is more expensive than in most other nations.
I suggest we take a look at the monopolies that the AMA has successfully lobbied for.

[anne]

Technical problems in revolutionary change are a given and important, more so are changes in employment for administrative support staff in health care, but we are not even committed to a philosophy of change, we have not even decided whether health care insurance must be universal with every person required to have insurance. A revolutionary change in philosophy, allows for coming to terms with subsidiary problems while we are not politically considering revolutionary change beyond the change that has been so far accepted in Massachusetts.

[Ninja Zombie]

Anne: "Watch me being terrified, as patients are left to die in the streets because they finally have health care insurance. OMG."

Way to miss the point Anne. I have no doubt we could play all sorts of fun games with *financial services*, such as health care insurance. We could probably provide everyone in the US with financial services.

But that's not what I'm asking; I'd like to know where the extra *medical services* will come from. Will they simply be taken from some, and given to others? So far, no one here has provided an answer.

Another question: if socialized medical insurance is a solution to scarcity of medical resources, is a socialized oil distribution system (such as what they have in other countries, e.g. Iran) the solution to scarcity of oil? If not, why not?

[anne]

"Another question: if socialized medical insurance is a solution to scarcity of medical resources, is a socialized oil distribution system (such as what they have in other countries, e.g. Iran) the solution to scarcity of oil? If not, why not?"

Simply notice the nuttiness of the language and understand the idea is to destroy the possibility of a reasonable American political discussion. Me, I am all for universal health care insurance in Iran too.

[jfb2252]

Health care is about 15% of GDP. Maybe 15 million workers, since average salary is higher than usual? If administrative costs were cut to Medicare levels, ~3%, from 12% (group) or 30% (individual), perhaps 3-4 million would become unemployed. Roll the change out over five years, in groups of states with ~60million population. Provide unemployment payments and retraining.

[Ninja Zombie]

Anne: "Simply notice the nuttiness of the language..."

I agree: it is nutty to believe that playing games with financial services will make a scarce resource more plentiful.

By the way, you still have not explained where the extra medical services will come from. Shall I assume that all you will be doing is taking from some, and giving to others?

[paine]

krugman with wings on his feet

mccain/pail as the peerless
corporate lobby party ticket

the anti lobby mavericks

a thief crying thief in the night

[anne]

The assumption is we are near a shortage of health care resources or doctors, nurses and technicians in particular. What I will ask about to begin with is a comparison of doctor, nurse, technician-population ratios in a number of developed countries. I have no idea what such ratios are, and how much detail about them there may be, but I have no initial reason to assume that we are near shortages or have shortages that are not easily correctable in short and long term ways.

I have not actually seen my doctor in several office visits which were handled properly by a nurse and technician (though I later waved at my buddy in passing along). Massachusetts evidently has excessive-needless use of emergency centers right now, which may be taxing certain professional staff needlessly, but there is no reason the problem cannot be easily lessened and resolved.

[anne]

There are continual reports of access problems in Massachusetts for patients, but I have never heard of problem directly beyond wanting to have access to a particular highly sought after specialist, but there is an old joke there. The idea has always been to be a doctor who is impossible to get to see. There is no difference now from what I remember as a child, when my parents would use a magic word to see who they wanted when they wanted.

I am not the least concerned with access given universal health care insurance, not before there is evidence of such a problem in France or Germany or Australia or Japan or Sweden or Spain.

[Patricia Shannon]

Ninja Zombie says...

Where will the extra doctor-hours and other resources necessary to perform these procedures come from?

We could execute the CEOs & other members of the plutocracy responsible for defrauding our financial system into bankruptcy. Then the medical resources that they were using would be available for others.

[paine]

any one who don't want single payer is an arse

any one who thinks our health sector
don't need
mark up cap and trade
is a fool
big pharma flack
a med eqipment and supply sales man
or a ..... f_ _ _ ing doctor

[Ninja Zombie]

Anne: "The assumption is we are near a shortage of health care resources or doctors, nurses and technicians in particular."

Not quite, the assumption is that we are at capacity.

Doctors:

http://www.bls.gov/oco/ocos074.htm

Over 1/3 of doctors work > 60 hours/week, and only 8% work part time. How do you propose to get doctors to work even more hours?

Nursing shortage:

http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm

This isn't even controversial, although it is easier to remedy than the shortage of doctors.

"have shortages that are not easily correctable in short and long term ways."

It certainly can be corrected in the long term: allow the licensing of more medical schools and expand existing ones (most medical schools are full).

In the short term, the use of nurse practitioners can be expanded, and many drugs (e.g., birth control) can be made non-prescription.

But socialized medicine is not necessary for any of this, nor will it help. The RAND experiment and similar studies suggest it will not affect health levels significantly.

Basically, socialized medical insurance is expansion of the government for it's own sake. If you consider that to be intrinsically good, then make that argument. But don't pretend it has anything to do with health.

[kthomas]

Yo, Ninja. We already know what you oppose.

How about telling us what you'd do to get 40+ million Americans back on the insurance rolls? Waiting...

[save_the_rustbelt]

"This (nursing shortage) isn't even controversial, although it is easier to remedy than the shortage of doctors."

Well, we have been talking about the nursing shortage for 20 years and haven't made a dent. In fact, the situation is getting worse. The boomers are exhausted and looking to retire or do something different, if they are not already.

The hours are lousy, the pay is good but not spectacular, injuries are common, the emotional stress is gut wrenching, and the respect level is very low.

Try working Christmas eve and Christmas day, lots of fun.

[paine]

"Basically, socialized medical insurance is expansion of the government for it's own sake"

if i understand what you're driving at...

basically ninja
its just like your polcy Rx
for almost anything :

expansion of freemart goonery....
for its own sake

[Alex Tolley]

STR: "If this were 1960 a transition to a single payer plan would be fairly easy."

The Swiss managed a massive change in 1994. The arguments for and against were much the same and no doubt many tried the "it's too much change" tactic. Nevertheless, they got rapid change that works, even if it is not as good as elsewhere.

swiss h/c system: http://www.civitas.org.uk/pdf/Switzerland.pdf

news item: http://www.pittsburghlive.com/x/pittsburghtrib/s_427691.html

[paine]

"We could execute the CEOs & other members of the plutocracy responsible for defrauding our financial system into bankruptcy. Then the medical resources that they were using would be available for others"

pat s
you win the chiffon pie

[paine]

speaking of nurses i understand we have 100's of thousands trained but otherwise employed
why ???

a big chunk claim
the job conditions suck

[Ninja Zombie]

Save_the_rustbelt: "Well, we have been talking about the nursing shortage for 20 years and haven't made a dent."

It hasn't really been a priority. Perhaps it should be, but politicians are more concerned with playing games in the financial services industry.

In any case, by "easier", I didn't mean "easy". A nurse needs 2-4 years training, a doctor needs about 10. The doctor's training is harder, too. Training more nurses is both faster and cheaper than training more doctors.

Reducing the stigma around male nurses might also be useful.

kthomas: "How about telling us what you'd do to get 40+ million Americans back on the insurance rolls? Waiting..."

I don't care about increasing the market for certain financial services. Why should I?

I do, however, have a socialist plan to increase the *health* of all Americans. It's vastly cheaper and more effective than any proposed health insurance schemes I've ever heard of: socialized gym memberships and a tax on fatties.

[anne]

When a critic begins tossing about socialist this and socialist that, the reason is to destroy conversation let alone to destroy any form of social planning. Such is the game that has been so well learned by those who prefer to be socially destructive.

Me, I am all for the sort of medicine that has been socialized for the likes of fortunate me though, medicine which I have been enjoying all through my life.

[anne]

"I do, however, have a socialist plan to increase the *health* of all Americans. It's vastly cheaper and more effective than any proposed health insurance schemes I've ever heard of: socialized gym memberships and a tax on fatties."

Notice the intense impossible rottenness, and truly understand.

[Robert Edele]

Why does a doctor need 10 years of training?

[Ninja Zombie]

Anne: "Notice the intense impossible rottenness, and truly understand."

Are you about to start quoting Hamlet and calling me Ninja Truck?

The truth is "impossibly rotten" sometimes. The difference in life expectancy between the US and Sweden is 2 years. Walking 30 minutes/day will add 3 years to your life. My health plan will improve health far more than yours, and is cheaper as well.

[Julio]

So how's this:

We put all the HMO claim evaluators in charge of regulating Wall Street. And the Wall Street regulators in charge of controlling access to health care.

I'm all for family values.

[paine]

" .... a doctor needs about 10 "
so the pipe line is long
after a very brief lag 4-8 years
beyond the date when the nurses hit optimal rate
we're up to otimal new doc flow rate
no big deal here

" The doctor's training is harder, too "

ninja

we ration doc entry
the 4-6 year gauntlet
post b.a./b.s.
is largely an affectation

you're a hopeless elite freak
if you think this is much of a problem
in it's self

---i bet you know your iq and sats
do u put great stock in them ??----

i'm sure you've consider the system
under cost and supply pressure
might brake down the tasks
now monopolized by the doc/nurse cult
u know assign some of it
to machines
and other parts to specialized techs

[paine]

"Are you about to start quoting Hamlet and calling me Ninja Truck? "

oaf tries toe dancing

[paine]

anne
any one who thinks rying socialist gives leverage
must talk mostly to insurance agents and accountants

[anne]

"I do, however, have a socialist plan to increase the *health* of all Americans. It's vastly cheaper and more effective than any proposed health insurance schemes I've ever heard of: socialized gym memberships and a tax on fatties."

Notice carefully the language and understand how truly cruel, how truly destructive, how truly beyond conscience such a comment is. Definitive rottenness.

[anne]

Paine:

any one who thinks crying socialist gives leverage
must talk mostly to insurance agents and accountants

[Cleverly subversive.]

[anne]

Paine:

any one who thinks crying socialist gives leverage
must talk mostly to insurance agents and accountants

[Cleverly subversive.]

[TigerPaw]

> Why does a doctor need 10 years of training?

To learn about anatomy, diseases, medicines, surgery, diagnosis, patient care ... then perform as an intern for a few years to practice before going out on your own. It takes quite a while because the field isn't a small one. Mind you becoming a high-end physicist doesn't happen in 2 years either, nor in 4.

I don't think you really want someone that took a few courses at a local community college.

[Ninja Zombie]

Paine: "so the pipe line is long after a very brief lag 4-8 years
beyond the date when the nurses hit optimal rate we're up to otimal new doc flow rate no big deal here"

It's worse than that. Medical schools are all full. Before you can train more doctors, you need to build more medical schools.

Paine: "i'm sure you've consider the system under cost and supply pressure might brake down the tasks now monopolized by the doc/nurse cult u know assign some of it to machines and other parts to specialized techs "

A great idea, which could help dramatically. Nurses + machine learning systems can already do some parts of triage/diagnosis just as well as doctors. Unfortunately, current regulations (and the risk of lawsuits) make this illegal. Perhaps we need some...deregulation?

In any case, this is completely orthogonal to the issue of socialized medicine. Once we fix the supply issue, prices will come down anyway. No need for socialized medicine, or whatever anne wants to call it.

[anne]

"No need for socialized medicine...."

Simply notice the language, and understand the intent.

[anne]

http://www.pnhp.org/news/2008/july/why_not_the_best_re.php

July 17, 2008

Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008

Overview

Prepared for the Commonwealth Fund Commission on a High Performance Health System, the National Scorecard on U.S. Health System Performance, 2008, updates the 2006 Scorecard, the first comprehensive means of measuring and monitoring health care outcomes, quality, access, efficiency, and equity in the United States. * The 2008 Scorecard, which presents trends for each dimension of health system performance and for individual indicators, confirms that the U.S. health system continues to fall far short of what is attainable, especially given the resources invested. Across 37 core indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with U.S. and international performance benchmarks. Overall, performance did not improve from 2006 to 2008. Access to health care significantly declined, while health system efficiency remained low. Quality metrics that have been the focus of national campaigns or public reporting efforts did show gains.

* http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=692682

[anne]

http://www.pnhp.org/news/2008/july/why_not_the_best_re.php

July 17, 2008

Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008

Executive Summary

Every family wants the best care for an ill or injured family member. Most are grateful for the care and attention received. Yet, evidence in the National Scorecard on U.S. Health System Performance, 2008, shows that care typically falls far short of what is achievable. Quality of care is highly variable, and opportunities are routinely missed to prevent disease, disability, hospitalization, and mortality. Across 37 indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with benchmarks of best performance achieved internationally and within the United States.

Even more troubling, the U.S. health system is on the wrong track. Overall, performance has not improved since the first National Scorecard was issued in 2006. Of greatest concern, access to health care has significantly declined. As of 2007, more than 75 million adults—42 percent of all adults ages 19 to 64—were either uninsured during the year or underinsured, up from 35 percent in 2003. At the same time, the U.S. failed to keep pace with gains in health outcomes achieved by the leading countries. The U.S. now ranks last out of 19 countries on a measure of mortality amenable to medical care, falling from 15th as other countries raised the bar on performance. Up to 101,000 fewer people would die prematurely if the U.S. could achieve leading, benchmark country rates.

The exception to this overall trend occurred for quality metrics that have been the focus of national campaigns or public reporting. For example, a key patient safety measure—hospital standardized mortality ratios (HSMRs)—improved by 19 percent from 2000-2002 to 2004-2006. This sustained improvement followed widespread availability of risk-adjusted measures coupled with several high-profile local and national programs to improve hospital safety and reduce mortality. Hospitals are showing measurable improvement on basic treatment guidelines for which data are collected and reported nationally on federal Web sites. Rates of control of two common chronic conditions, diabetes and high blood pressure, have also improved significantly. These measures are publicly reported by health plans, and physician groups are increasingly rewarded for results in improving treatment of these conditions.

The U.S. spends twice per capita what other major industrialized countries spend on health care, and costs continue to rise faster than income. We are headed toward $1 of every $5 of national income going toward health care. We should expect a better return on this investment.

Performance on measures of health system efficiency remains especially low, with the U.S. scoring 53 out of 100 on measures gauging inappropriate, wasteful, or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology. Lowering insurance administrative costs alone could save up to $100 billion a year at the lowest country rates.

National leadership is urgently needed to yield greater value for the resources devoted to health care.

The National Scorecard

The National Scorecard includes 37 indicators in five dimensions of health system performance: healthy lives, quality, access, efficiency, and equity. U.S. average performance is compared with benchmarks drawn from the top 10 percent of U.S. states, regions, health plans, hospitals, or other providers or top-performing countries, with a maximum possible score of 100. If average U.S. performance came close to the top rates achieved at home or internationally, then average scores would approach 100.

In 2008, the U.S. as a whole scored only 65, compared with a score of 67 in 2006—well below the achievable benchmarks. Average scores on each of the five dimensions ranged from a low of 53 for efficiency to 72 for healthy lives.

On those indicators for which trend data exist, performance compared with benchmarks more often worsened than improved, primarily because of declines in national rates between the 2006 and 2008 Scorecards. Overall, national scores declined for 41 percent of indicators, while one-third (35%) improved, and the rest exhibited no change (or were not updated). Exhibit 2 lists indicators and summarizes scores and benchmark rates.

As observed in the first Scorecard, the bottom group of hospitals, health plans, or geographic regions is often well behind even average rates, with as much as a fivefold spread between top and bottom rates. On key indicators, a 50 percent improvement or more would be required to achieve benchmark levels.

Scorecard Highlights and Key Findings

The U.S. continues to perform far below what is achievable, with wide gaps between average and benchmark performance across dimensions. Despite some encouraging pockets of improvement, the country as a whole has failed to keep pace with levels of performance attained by leading nations, delivery systems, states, and regions. Following are major highlights from the Scorecard by performance dimension:

Healthy Lives: Average Score 72

Preventable mortality: The U.S. fell to last place among 19 industrialized nations on mortality amenable to health care—deaths that might have been prevented with timely and effective care. Although the U.S. rate improved by 4 percent between 1997-1998 and 2002-2003 (from 115 to 110 deaths per 100,000), rates improved by 16 percent on average in other nations, leaving the U.S. further behind.

Activity limitations: More than one of every six working-age adults (18%) reported being unable to work or carry out everyday activities because of health problems in 2006—up from 15 percent in 2004. This increase points to the need for better prevention and management of chronic diseases to enhance quality of life and capacity to work, especially among younger adults as they age.
Quality: Average Score 71

Effective care: Control of diabetes and high blood pressure improved markedly from 1999-2000 to 2003-2004 for adults, according to physical exams conducted on a nationally representative sample. Among adults with diabetes, rates of at least fair control of blood sugar increased from 79 percent to 88 percent from 1999-2000 to 2003-2004. Among adults with hypertension, rates of control of high blood pressure increased from 31 percent to 41 percent over the same time period. Yet, a 30 to 60 percentage point difference remains between top- and bottom performing health plans. Hospitals' adherence to treatment standards for heart attack, heart failure, and pneumonia also improved from 2004 to 2006, but with a persistent gap between leading and lagging hospital groups. Delivery rates for basic preventive care failed to improve: as of 2005, only half of adults received all recommended preventive care.

Coordinated care: Heart failure patients were more likely to receive hospital discharge instructions in 2006 (68%) than in 2004 (50%), but rates varied widely between top and bottom hospital groups (from 94% to 36%). Hospitalizations increased among nursing home residents from 2000 to 2004, as did rehospitalizations for patients discharged to skilled nursing facilities—signaling a need to improve long-term care and transitions between health care providers.

Safe care: One key indicator of patient safety—hospital standardized mortality ratios—improved significantly since the first Scorecard, with a 19 percent decline. Safety risks, however, remain high as one-third of adults with health problems reported mistakes in their care in 2007. Drug safety is of particular concern. Rates of visits to physicians or emergency departments for adverse drug effects increased by one-third between 2001 and 2004.

Patient-centered, timely care: In 2007, as in 2005, less than half of U.S. adults with health problems were able to get a rapid appointment with a physician when they were sick. They also were the most likely among adults in seven countries surveyed to report difficulty obtaining health care after hours without going to the emergency department, and this rate increased from 61 percent to 73 percent since 2005. Within the U.S., there is wide variation among hospitals in terms of patient reports of how well staff responded to their needs.

Access: Average Score 58

Insurance and access: As of 2007, 75 million working-age adults (42%) were either uninsured or underinsured, a sharp increase from 61 million (35%) in 2003. More than one-third (37%) of all U.S. adults reported going without needed care because of costs in 2007, versus only 5 percent in the benchmark country.

Affordable care: As insurance premiums rose faster than wages, the share of nonelderly adults living in a state where group health insurance premiums averaged less than 15 percent of household income dropped sharply, from 58 percent in 2003 to 25 percent in 2005. By 2007, two of five adults (41%) reported they had medical debt or problems with medical bills, up from 34 percent in 2005.

Efficiency: Average Score 53

Inappropriate, wasteful, or fragmented care: In 2007, as in 2005, U.S. patients were much more likely—three to four times the benchmark rate—than patients in other countries to report having had duplicate tests or that medical records or test results were not available at the time of their appointment.

Avoidable hospitalizations: Average rates of hospital readmissions within 30 days remained high, at 18 percent in both 2003 and 2005. Rates in the highest regions were 50 percent higher than in the lowest regions. Rates of hospitalizations for preventable conditions decreased somewhat from 2002-2003 to 2004-2005, but continued to vary two- to fourfold across hospital regions and states.

Variation in quality and costs: Among Medicare patients treated for heart attacks, hip fractures, or colon cancer, a high proportion of regions with the lowest mortality rates also had lower total costs, indicating that it is possible to save lives and lower costs through more effective, efficient systems. The total costs of caring for patients with chronic disease varied twofold across regions.

Administrative costs: U.S. health insurance administrative costs as a share of total health spending are 30 percent to 70 percent higher than in countries with mixed private/public insurance systems and three times higher than in countries with the lowest rates.

Information systems: U.S. primary care physicians' use of electronic medical records (EMRs) increased from 17 percent to 28 percent from 2001 to 2006. Still, the U.S. lags far behind leading countries, where EMRs are now used by nearly all physicians (98%) to improve care.

Equity: Average Score 71

Disparities: Compared with their white, higherincome, or insured counterparts, minorities, lowincome, or uninsured adults and children were generally more likely to wait when sick, to encounter delays and poorly coordinated care, and to have untreated dental caries, uncontrolled chronic disease, avoidable hospitalizations, and worse outcomes. They were also less likely to receive preventive care or have an accessible source of primary care.

Reducing gaps: Among blacks and Hispanics, it would require a 19 percent to 25 percent decrease in the risk of poor health outcomes and inadequate or inefficient care to reach parity with whites. Gaps for uninsured and low-income populations are still wider: it would require a 34 percent to 39 percent improvement on indicators of health care access, quality, and efficiency to achieve equity with insured and higher-income populations.

Systgem Capacity to Innovate and Improve: Not Scored

The capacity to innovate and improve is fundamental to a high-performing health care system. It includes:

a care system that supports a skilled and motivated health care workforce, with an emphasis on primary care and population health;

a culture of quality improvement and continuous learning that promotes and rewards recognition of opportunities to reduce errors and improve outcomes; and

investment in public health initiatives, research, and information necessary to inform, guide, and drive health care decisions and improvement.

On all three aspects, the U.S. currently under-invests in the capacity of the health system to innovate and improve. U.S. payment systems undervalue primary care and fail to support providers' efforts to manage and coordinate care. Studies indicate that health care teams and well-organized work processes can achieve significant gains in quality and safety with more efficient use of resources. Yet, health professionals are rarely trained to work in teams, and larger organized delivery systems that employ multidisciplinary health professionals are not the norm. There is little investment in spreading best practices, and incentives are rarely designed to reward or support improved quality and greater efficiency. In an era of rapid medical advances, national investment in research regarding clinical and cost-effectiveness—what works well for which patients and when—has failed to keep pace to inform health care decision-making.

Summary and Implications

Potential for Improvement

Overall, the National Scorecard on U.S. Health System Performance, 2008, finds that the U.S. is losing ground in providing access to care and has uneven health care quality. The Scorecard also finds broad evidence of inefficient and inequitable care. Average U.S. performance would have to improve by more than 50 percent across multiple indicators to reach benchmark levels of performance.

Closing performance gaps would bring real benefits in terms of health, patient experiences, and savings. For example:

Up to 101,000 fewer people would die prematurely each year from causes amenable to health care if the U.S. achieved the lower mortality rates of leading countries.

Thirty-seven million more adults would have an accessible primary care provider, and 70 million more adults would receive all recommended preventive care.

The Medicare program could potentially save at least $12 billion a year by reducing readmissions or by reducing hospitalizations for preventable conditions.

Reducing health insurance administrative costs to the average level of countries with mixed private/public insurance systems (Germany, the Netherlands, and Switzerland) would free up $51 billion, or more than half the cost of providing comprehensive coverage to all the uninsured in the U.S. Reaching benchmarks of the best countries would save an estimated $102 billion per year.

Studies further document the cost in lives and lost productivity from the nation's failure to provide secure health insurance to all. Based on areas within the U.S. that achieve superior outcomes at lower costs, it should be possible to close gaps in health care quality and access, and to reduce costs significantly.

Several implications for policy emerge from the Scorecard findings:

What Receives Attention Gets Improved

Notably, all of the quality indicators showing significant improvement have been targets of national and collaborative efforts to improve, informed by data with measurable benchmarks and indicators reached by consensus. Conversely, there was failure to improve in areas such as mental health care, primary care, hospital readmission rates, or adverse drug events for which focused efforts to assess and improve at the community or facility level are lacking. Further, the continued failure to adopt interoperable health information technology makes it difficult to generate the information necessary to document performance and monitor improvement efforts.

Better Primary Care and Care Coordination Hold Potential for Improved Outcomes at Lower Costs

Hospital readmission rates and rates of potentially preventable hospitalizations for ambulatory care-sensitive conditions remain high and variable across the country, as do total costs for the chronically ill. Studies indicate that it is possible to prevent hospitalization or rehospitalizations with better primary care, discharge planning, and follow-up care—an integrated, systems approach to care.

Multiple indicators highlight the fact that the U.S. has a weak primary care foundation. Investing in primary care with enhanced capacity to provide patients with round-the-clock access, manage chronic conditions, and coordinate care will be key steps in moving to more organized care systems.

However, current payment incentives for hospitals, physicians, and nursing homes do not support coordination of care or efficient use of expensive, specialized care. Information also fails to flow with patients across sites of care due to lack of health information technology and information exchange systems. These inefficiencies require innovative payment policies as well as care delivery approaches to improve outcomes for patients and use resources more efficiently.

Aiming Higher

The 2008 National Scorecard documents the human and economic costs of failing to address the problems in our health system. Recent analysis suggests it could be possible to insure everyone and achieve significant savings with improved value over the next decade. Health care expenditures are projected to double to $4 trillion, or 20 percent of national income, over the next decade, and millions more U.S. residents are on a path to becoming uninsured or underinsured, absent new policies. We need to change directions, starting with the recognition that access to care, health care quality, and efficiency are interrelated.

Aiming higher and moving on a more positive path will require strategies targeting the multiple sources of poor health system performance. These strategies include:

universal and well-designed coverage that ensures affordable access and continuity of care, with low administrative costs;

incentives aligned to promote higher quality and more efficient care;

care that is designed and organized around the patient, not providers or insurers;

widespread implementation of health information technology with information exchange;

explicit national goals to meet and exceed benchmarks and monitor performance; and

national policies that promote private-public collaboration and high performance.

Rising costs put families, businesses, and public budgets under stress, pulling down living standards for middle- as well as low-income families. New national policies that take a coherent, whole-system, population view are essential for the nation's future health and economic security.

[paine]

ninja's right anne
orthogonality between production and provision exists

but our claim
is about provision eh anne ???

single payer is about provision
not production

as to de regulation he he he
i think its a long settled point
much existing regulation
is contrary to social welfare
all rags exist in a second best frame work

fortunately the last 40 years
of discovery in our all too euclidian
science has allowed us to presume
pareto improvement follows
from careful market intervention

for new regs
its about objectives
that are embeded precisely and effectively
in their mechanism design

for existing reg
its about review
its about
the real results
the unintended consequences
--at least unintended so far
as motives in the design stage
reached into public discourse ---

[paine]

"I don't think you really want someone that took a few courses at a local community college"
a few courses???

depends what they're examining me for

most of us submit ourselves
to a large scale
diagnostic organization
nowadays
gen-prac docs
ought be
as anachronistic
as the village black smith

[Patricia Shannon]

http://news.yahoo.com/s/hsn/20080930/hl_hsn/seniorsinpoorareasmorelikelytodieaftersurgery;_ylt=AvCMghWveRtCTwMzCYlO8jnVJRIF

Mon Sep 29, 11:46 PM ET

MONDAY, Sept. 29 (HealthDay News) -- Elderly Americans who live in low-income ZIP codes are more likely to die after surgery than those who live in higher-income ZIP codes, according to new research.

The study analyzed death rates among more than one million older adults who had one of six common high-risk heart or cancer surgeries between 1999 and 2003.

The risk of death was between 17 percent and 39 percent higher for patients in low-income ZIP codes, mainly because the quality of care is lower at hospitals in lower socioeconomic areas, the study authors said.

In fact, all patients (regardless of income) who had surgery at hospitals in the poorest areas were more likely to die, while all patients who had surgery at hospitals in the richest areas were less likely to die.

[save_the_rustbelt]

"Why does a doctor need 10 years of training?"

Do you want a good doctor or a mediocre doctor?

Board certified spine surgeon:

4 years bachelors, heavy on science
4 years medical school (classroom + clinical)
1 year internship, very intensive clinical
3 years orthopaedic surgery residency, very intensive
1 year spine surgery fellowship, ultra intensive

[save_the_rustbelt]

gen-prac docs
ought be
as anachronistic
as the village black smith

Gen practice docs are the gatekeepers to most of the system, their breadth of diagnostic skills is truly amazing, giving the variety of chief complaints they see on a daily basis.

[save_the_rustbelt]

"speaking of nurses i understand we have 100's of thousands trained but otherwise employed
why ???"

Did you ever work Christmas day on the dementia unit?

Nurses burn out at an astounding rate.

My wife, aka the world's greatest nurse, gave up working full time before she was 40, the physical and emotional demands were just too much.

She continues as an angel of mercy on a limited part time schedule, but will not be able to do the work much longer. She has carpal tunnel, varicose veins and arthritis in her hands. A high price paid by a living saint.

[Larry]

It's great to talk about something other than the crisis...

Making a better health care system means curing these flaws:

- Only 85% have insurance. Wouldn't it be better if everyone did?
- Costs are 14% of GDP now and are increasing much faster than GDP with the rate likely to further increase with the boomer retirement cycle. Reasons:
-- Because the insurance company or the taxpayer pays our health care bills, our incentives as consumers are screwed up. We have less incentive to take care of ourselves, and no incentive to pay attention to the costs of the care we receive.
-- Guys like well-respected economist Robin Hanson estimate that 50% of health care spending is pure waste. Part of that waste is "defensive medicine" to protect against litigation.
Wouldn't it be better if health care costs were declining as % of GDP, like food, rent, and most other costs other than buying a house, sending your kid to college and government?
- Supply is highly constrained and while doctors are highly paid, they and their not-so-well-paid helpers are massively overworked with poorer quality as one result. Wouldn't it be better if health care people had normal lives like you and me?
- Creating a new drug requires $1b or so of investment. US consumers subsidize the rest of the world. If they stop, where do the billions come from? Maybe others will step up? Maybe it's OK not to have new drugs??? Wouldn't it be better if drug development costs were spread more evenly?
- Changing jobs means losing your insurance. This locks lots of people into jobs that no longer fit them and means those who leave anyway are taking a crapshoot. Wouldn't it be better if your health care didn't change drastically when you change jobs?
- Each of us consumes something like half of our lifetime amount of health care services in the last 6 months of our lives. Our quality of life during that period is often quite rotten. Wouldn't it be better if we just died?
- Young, healthy, poor people massively subsidize old, sick, rich people. Wouldn't it be better if rich people subsidized poor people?
- People who make no effort to take care of themselves get the rest of us to pay for their care. Wouldn't it be better if they took some responsibility for the way they live?
- Paying for chronic conditions via insurance makes no sense. Insurance protects against the unknown. You don't know whether your house will burn down or someone will crash into your car. Heart patients know they'll need statins forever. Wouldn't it be better if bills for diabetes, AIDS and other chronic conditions got paid some other way?

McCain's plan doesn't address all of this, but it's not just a Medicare killer (it doesn't really do much of anything about Medicare.)

- He helps the uninsured by allowing national marketing, which means that more affordable (albeit less comprehensive) plans will be available everywhere.
- He helps control costs by getting consumers to pay attention to them.
- He encourages consumers to pay attention to cost by supporting HSA's. Bureacracy is the only other line of defense. Sound good?
- He engages consumers in the battle to attack waste. McCain also supports restrictions on litigation.
- He supports drug reimportation to lower drug prices.
- He kills the tax reasons for worker lock-in. That's a good thing. In real companies benefits are one of the ways to attract and retain people. If they dump medical, they could give the money to those workers at zero net cost. (McCain should require them to do this.) If they did, that would end lock-in and give most workers a net financial benefit because of the tax credit.And lower income workers would do better than the rest because most of them would pay no income taxes on the extra (the bottom half today pay almost no income taxes.)
- He reduces today's weird cross-subsidy gets less by letting young, healthy, poor people buy insurance that is appropriate to their situation in life.
- He creates a high-risk pool to handle those with poor health. This part definitely needs some work.

@Linda - "I continue to be incredulous about these plans that completely ignore the large number of people who, despite working full-time, cannot afford the required expenses/"savings" accounts."

McCain offers tax credits to help them. Today they have nothing...

@Both - "National health care for basic services"

I don't see basic services as the issue. Most people can pay for earaches and sprained ankles and the overhead would be a lot less if we did. That's a long way from dialysis and heart surgery.

@save_the_rustbelt - "Krugman's breathless hysteria is getting a little hard to take."

That's his shtick! I was so glad when he stopped writing about his BDS 6 months or so ago. He's a brilliant guy, but so often he just loses it.

@anne - "please set down a reasonable Republican universal health care insurance proposal."

Working on it...

"working our doctors to the death"

Agree.

"Massachusetts."

Romney and his Dem buds pulled off something pretty cool there. Too bad it costs so much...National insurance marketing would help.

"I have no initial reason to assume that we are near shortages or have shortages that are not easily correctable in short and long term ways."

Visit a hospital, silly. Their hours are nuts. France has a different approach. They pay docs something like 25% of what US docs get. Sound like a plan?

@ddt - "foreign competition."

Medical tourism is going gangbusters...

@Robert Edele - "The problem with tax credits is that you need to have enough taxes to offset"

No. McCain makes them refundable.

@Jay - "U.S. socialized medicine per-capita (using 300 million as the base) is more expensive than in most other nations."

Medicare (universal care for seniors) is far more expensive than in other countries and would be even with reimportation.
I suggest we take a look at the monopolies that the AMA has successfully lobbied for.

@Patricia Shannon - "execute the CEOs & other members of the plutocracy"

At last a joke on this blog. It is a joke, right?

[Patricia Shannon]

Larry says...

if they took some responsibility for the way they live?

Do you were hats and sunblockers every time you go outside for more than a few minutes, to protect your eyes and skin from the sun? If not, it's your fault if you get skin cancer, I guess.

Are you a vegetarian? If not, then it's your fault if you get heart disease or several different forms of cancer.

Women who don't wear pointy-toed high-heels at work get put down by men. So it's the women's fault if they need bunion operations.

@Linda - "I continue to be incredulous about these plans that completely ignore the large number of people who, despite working full-time, cannot afford the required expenses/"savings" accounts."

McCain offers tax credits to help them. Today they have nothing...

@Both - "National health care for basic services"

I don't see basic services as the issue. Most people can pay for earaches and sprained ankles and the overhead would be a lot less if we did. That's a long way from dialysis and heart surgery.

@Robert Edele - "The problem with tax credits is that you need to have enough taxes to offset"

No. McCain makes them refundable.

If you don't know that many people can't afford to pay the money up front, regardless of how much they might get back, you are too ignorant to pay attention to.

If you don't know that a lot of people don't go to the doctor when they have earaches and sprained ankles, because they can't afford to, you are too ignorant to pay attention to.

says...

why not speak to fidel.he has been able to train

a surfeit of medical personnel,enough to lend them

to other countries.with his proximity

medical tourism could be a win/win development

[rufus]

Larry says...

"- He helps the uninsured by allowing national marketing, which means that more affordable (albeit less comprehensive) plans will be available everywhere."

I didn't realize that when McCain voted against extending healthcare coverage to children it was because he wants to 'help the uninsured'.

http://www.senate.gov/legislative/LIS/roll_call_lists
/roll_call_vote_cfm.cfm?congress=110&session=1&vote=00307

"- He helps control costs by getting consumers to pay attention to them."

'Silly, silly' us, all along the problem was that we were simply not paying attention to costs...that will surely make them go down.

I probably should have started this post with that infamous quote of someone I'm guessing you would highly regard,
"There you go again..." (1980 Ronald Reagan: A rebuttle offered in response to President Carter's call for improved healthcare coverage).

Funny when I heard Palin try to slip that into one of her speeches(debating points), it didn't have the same ring. Maybe after a few more acting lessons she'll be able to pull it off.

[Larry]

@Patricia Shannon - "Do you were hats and sunblockers every time you go outside for more than a few minutes, to protect your eyes and skin from the sun? If not, it's your fault if you get skin cancer, I guess."

There's no such thing as a risk-free life. But do you think we truly play no part in our own health and health care? Don't you think we can establish some reasonable norms and reward those who follow them?

"If you don't know that many people can't afford to pay the money up front, regardless of how much they might get back, you are too ignorant to pay attention to."

There are lots of people who can't afford health care and taxpayers should help them out. Nor do I favor debtors' prison.

@rufus - "I didn't realize that when McCain voted against extending healthcare coverage to children it was because he wants to 'help the uninsured'."

He voted against the bill that was so labeled. Most of what it did had nothing to do with that.

"'Silly, silly' us, all along the problem was that we were simply not paying attention to costs...that will surely make them go down."

You can make the argument that we're getting what we pay for. It would be nice if you did. Hanson's work indicates that administrative costs aren't the problem but that there is a big problem. I don't mean to say that if only consumers were paying attention there would be no problem. But accelerating costs make it impossible to achieve your equity goals. I've seen doctors take shotgun approaches to my own care at great expense and zero benefit. I care, but only abstractly, because somebody else is paying. If I was signing the check, my concern would no longer be abstract.

[rufus]

"You can make the argument that we're getting what we pay for. It would be nice if you did."

No, I don't believe one can make that argument so long as for profit insurance companies are in the loop inflating all costs (ie product, service, transaction).

Why shouldn't healthcare or the insurance to provide it be nationalized and made nonprofit? Our schools and churches are nonprofit. Mind, Body and Spirit.

[Icarus]

KThomas,

Here's a small idea...

Let's have healthcare insurance for $50/month. It won't cover everything, but should cover basic (inexpensive) primary care. Broken bones, pneumonia, immunization, prenatal care, etc.

But, more expensive treatments will be not covered, and there will be some sad stories.

We demand that every 'citizen' or 'worker' in the US pay the $50/month, even if they earn minimum wage. It is a cost of living in the US. Of course, you can pay for more.

We then have to reset expectations of medical care/coverage. You don't have a 'right' to hundreds of thousands of dollars in treatment. Some will die, even on the proverbial street. But, more people will live healthier.

We adjust tort law such that doctors are not penalized for refusing treatment for those who are not covered.

Ultimately, we need a healthier attitude towards death. We cannot afford to stave it off at all costs. We instead focus on preventative care, education, and set expectations accordingly. If you smoke for 40 years, and need expensive healthcare...well, you better have insurance. If not, you will wheeze to death, literally.
But, everyone is covered for inexpensive care, and hence, we create a system where people don't wait until emergency care is required to see a doctor.

And, if you're illegal...you remain in the cracks of this system.

[Ninja Zombie]

Patricia: "Do you were hats and sunblockers every time you go outside for more than a few minutes, to protect your eyes and skin from the sun? If not, it's your fault if you get skin cancer, I guess."

Are you seriously comparing the small increase in risk due to sun exposure to the very large increases in risk due to smoking, obesity and lack of exercise?

If you can pinch more than an inch, you are fat. It's your fault. And it will hurt your health.

Patricia: "Women who don't wear pointy-toed high-heels at work get put down by men. So it's the women's fault if they need bunion operations."

Yes, men are responsible for all the problems in the world, such as women looking down on other women who's fashion sense isn't up to snuff. Seriously, guys besides Tarantino noticing women's footwear seems extremely unlikely to me.

But I'm doing my part: I mock women who do wear stupid shoes. That way, where I work, women will be mocked no matter what they do, so they might as well be comfortable.

[anne]

"If you can pinch more than an inch, you are fat. It's your fault. And it will hurt your health."

Interesting the rottenness, interesting the contagion of rottenness, but no surprise there. Do continue with the rottenness, though.

[Jrossi]

A few comments from a family doc: It takes 4 years of college, 4 years of med school, and 3 years of residency to become an internist, pediatrician or family doc. Is this too long? I'm not sure, but I know I didn't feel over-prepared in July 1989 when I left the mother ship. Diagnosis and treatment are complicated. It takes about as long in other Anglophone countries.
There is a doctor shortage in primary care. We're having one of our docs retire in December. It will take at least a year to replace him, if we can replace him. Expand medical education now. But it will cost, both directly and indirectly. Remember that only about 22% of each HC dollar goes to docs, so there is a cost multiplier effect of about 5 for everything a doc orders.
Also, bright young college grads are not exactly beating the doors down to become family docs (or nurses for that matter). The work-effort trade-off is better in other specialties.
Expect the primary care doc shortage to get worse before it gets better. Interestingly, general surgery is also facing a shortage. Good money, high prestige, but an absolutely brutal lifestyle. Keep your appendices holy.

[Patricia Shannon]

http://online.wsj.com/article/SB122315505846605217.html?mod=special_page_campaign2008_mostpop

OCTOBER 6, 2008 By LAURA MECKLER
John McCain would pay for his health plan with major reductions to Medicare and Medicaid, a top aide said, in a move that independent analysts estimate could result in cuts of $1.3 trillion over 10 years to the government programs.

The Republican presidential nominee has said little about the proposed cuts, but they are needed to keep his health-care plan "budget neutral," as he has promised. The McCain campaign hasn't given a specific figure for the cuts, but didn't dispute the analysts' estimate.

In the months since Sen. McCain introduced his health plan, statements made by his campaign have implied that the new tax credits he is proposing to help Americans buy health insurance would be paid for with other tax increases.

But Douglas Holtz-Eakin, Sen. McCain's senior policy adviser, said Sunday that the campaign has always planned to fund the tax credits, in part, with savings from Medicare and Medicaid. Those government health-care programs serve seniors, poor families and the disabled. Medicare spending for the fiscal year ended Sept. 30 is estimated at $457.5 billion.

[Patricia Shannon]

Larry

You don't make an effort to avoid risks you don't believe are a threat to you. Well, guess what. Everybody else is just the same.

[Larry]

@Patricia - If you presuppose that "everybody" has an equally valid understanding of health threats, then your point is valid. I don't so presuppose. I guess I'm not that post-modern after all. Rats.

[Patricia Shannon]

Larry says...

@Patricia - If you presuppose that "everybody" has an equally valid understanding of health threats, then your point is valid. I don't so presuppose. I guess I'm not that post-modern after all. Rats.

Huh? The point is exactly that "everybody" does not have "an equally valid understanding of health threats". We act according to our own knowledge and beliefs. That is what is "valid" to us.

[Larry]

@Patricia - You're too deep into relativism to commmunicate with. When I say "valid", I don't mean "valid for me". I mean valid as in "the most objective representation of the world that we have." E.g., the notion that smoking is bad for you is valid for everybody, not just for those who watch Nova.

[Patricia Shannon]

Larry, you are either totally missing my point, or else deliberately obfuscating. I have to get back to work, so I'll try to clarify later.

[Larry]

Perhaps I am misunderstanding you. To put my point differently, if some people misperceive the impacts of their behavior on their health, having their insurance premiums rise and fall based on the facts is health-preserving and cost-reducing at the same time.

[Icarus]

Larry,

The implications of your proposal is the problem, on this blog.

You're suggesting that people actually have some responsibility over their own health, and that the price mechanism can be used to assist. That's simply anathema here.

What this blog would rather see is the continuation of no individual responsibility. People should be able to grow obese, smoke incessantly, avoid exercise, and pay for no health insurance, and yet be covered, even for pre-existing conditions.

The quick way to achieve that (even in a ficticious society) is to imagine a 'government' providing it. This is the general theme, and it is a malaise in the US.

People in the US live profligate lives, and have been afforded this ability because of the productive capacity of capital. There is a global shift now...capital is moving to more hospitable locations of production, and the traps of middle class consumptive lifestyles are stretching. When that happens, there are losers.

We have a caste of characters in the US who were lead to believe that they could be high school dropouts, and still afford a family. Those days are over, and we haven't swallowed that medicine just yet. Until we do, we'll have populations living beyond their means, screaming for handouts to finance the gaps.

[Larry]

@Ic - Obama's "tax the rich" mentality takes it all a step further. Approaching half of the population no longer pays federal taxes, i.e., they get but they do not contribute. From where they sit, there can be no problem with increasing taxes, and increasing them a lot, because it only affects them if it causes them to lose their job. The latter connection is not obvious to many.

[Real Person from the Real World]

JRossi notes: "Also, bright young college grads are not exactly beating the doors down to become family docs (or nurses for that matter). The work-effort trade-off is better in other specialties."

In some HR offices you don't dare mention money, you are going for a job because of "passion". How is it some jobs are controlled by gatekeepers who look for "passion" despite job experience that may be outside the specialty, but is still related, and income seeking is looked on as evil, and showing a lack of passion?

Basically, one of the reasons so many people are without healthcare is because it is tied to a job, and decent paying jobs, permanent ones, are at a minimum in this country. Some jobs have too many people chasing them. Other, crappy jobs that can be well paid under risky circumstances (sales), are continually trying to attract new suckers. While still other jobs are now, temporary jobs that were really meant for teenagers or for second incomes, but are now mainline jobs.

[Patricia Shannon]

Larry, do you have a link to buttress your claim that "Approaching half of the population no longer pays federal taxes". I guess it's probably true if you count all members of the population, including children and retired people. For those in the workforce, almost everyone is paying social security and medicare taxes.

[lensch]

I got into this late, so I'm just goin' to post my standard rant on health care. I'll check back by tomorrow & see if there are any comments.

My claim is that, in theory, we can solve this problem and provide much better health care for less or the same amount of money for the next 10 or 20 years, at least. The solution is not theoretical; every other wealthy developed country uses it. The theoretical part is whether powerful greedy interests can be overcome to implement it. I also believe that if we adopt a more rational system, it will provide a framework for long term solutions once we solve the dilemma of how much health care do we want. Here is my standard screed on the medium term solution:

I am a mathematician, not an economist, but I have spent some time looking at health care in this country and elsewhere. Forget about the immorality of the uninsured. Disregard the competitive disadvantage of our businesses. Look at health care as a business decision. Suppose you were the CEO of a soulless corporation and you wanted to evaluate some department, the IT department or the health care department. You would develop parameters to see how well the department is doing its job. For health care, these are called public health statistics. You would see how your department was doing in comparison with other similar companies. Then you would compare your cost with their cost.

This has all been done for our health care system. Obviously there is no one way to do this, but the result is so robust (as we mathematicians are wont to say) that it makes scant difference if you vary what countries you use or what public health statistics you use as long as you don't do a Cato Institute type of analysis where you only look at people making over $10,000,000 a year. The most famous of these analyses was published in the New England J. of Medicine about 15 years ago, but has been brought up-to-date many times. (BTW you can check this and all other figures I use at www.pnhp.org.) The author took 12 wealthy countries and the US and ranked them according to 16 public health statistics (life expectancy, infant mortality, etc.). The US ranked last or next to last in every category. No other country was anywhere near as bad. Yet, yet, we spend 2.5 times as much per patient as the average of the other countries. We spend 50% more than the Switzerland which is second in highest cost per patient. In another measure of how well we do, WHO ranks the US 37th in the world in health care. I think that's above Slovenia, but below Costa Rica.

O.K. we spend much more money for much worse health care. What do the other countries do that we don't. They have very different systems from pure socialized medicine to a national insurance scheme like Medicare. The one thing they have in common is that they are all single payer systems. There is one entity that makes the rules and does it in the interest of efficiency and helping people stay well and treating them when they are sick. Under our system, there are 1,500 different insurance plans with different rules and forms run by companies whose goal is not to be efficient or give good care, but simply to make money for their stockholders. If a complicated form cuts down on the money it has to give to physicians, and it can make more money even after processing the form, the company will adopt such a form even though it significantly increases costs overall by wasting the time of physicians. One of my doctors says her job is filling out forms. She gets paid depending on how well she fills them out. It's a hard job because there are many different forms, and they are tricky and complicated, but she works hard and thinks she is pretty good at it. She also has a hobby which she loves--the practice of medicine. She would like to do much more of it and hopes if she makes enough money filling out forms, maybe she can practice more medicine.

A conservative estimate says we waste $200,000,000,000 (two hundred Billion) a year on physicians filling out forms that the single payer systems do not spend. Another $100,000,000 000 is wasted by the overhead of private insurance companies. This includes their processing of the unnecessary forms, fantastic executive compensation, and profit. The overhead for our private companies averages 15% (this may be low as it is several years old and the trend is up). The overhead for the public part of Medicare is 2% and the overhead for the entire Canadian system is 1.3%. I do not have the figures for how much we waste on high drug prices, but I do know that Big Pharma spends 11% a year on research, about 19% on profit, and 34% on marketing. We could cut drug prices by a third and not touch the amount spent on research. Here is a simple example that shows what is wrong.

Suppose you had $100 to give out to 10 people. You could give $10 to each person. Alternatively, you could decide to determine who really needs the money. You could develop a set of criteria, investigate to see who meets the criteria, and then give those the money. Say it costs you $50 to develop the rules and investigate, and suppose you decide to take $25 for your work in distributing the funds. Suppose you find only 5 are deserving. That would leave $25, so you could give $5 to each of your deserving folks. We spend much too much money denying medical care.

Perhaps you are going to trot out the horror stories about health care in other countries. It takes 400 years to get a hip replacement in Portugal or something. A lot of these stories are lies. Some are because of special conditions in some countries The real reason for the real problems is simply that other countries do not spend enough money. Can you imagine what our system would look like if we cut spending by 60%? There is, however, a more important point to be made. In spite of all their problems, the bottom line is that the other countries are getting much better results. We have already seen that.

What about choice? I am 70 years old and retired. During my career I had 5 HMO's and 5 indemnity health plans. I have much more freedom of choice under Medicare than I had under any of the private insurance plans. I have no more referrals, no more in plan - out of plan nonsense. As for choice of insurance plan, why would anyone want choice if everyone had a plan that covered everything? In any case, you could still have private insurance for those who can afford it as most European countries still do.

Some say the American people would never put up with a single payer system. But Medicare is such a system which would work much better if everybody had it. We would save so much in the three areas mentioned above that we could cover everyone with no deductibles, no co-pays, and 100% drug coverage and not spend a penny more than we are already spending. In fact, covering everybody for everything would make even the Medicare bureaucracy simpler. And Americans love Medicare.

[Patricia Shannon]

lensch
Thank you for the information.

[Larry]

@Patricia Shannon - I answered your request on the Tax-cut follies thread.

@lensch - The US healthcare system is indeed a fabulous mess. Fabulous because it is by far the most innovative system in the world, producing drugs, devices, and techniques at a far greater rate than the rest of the world. And we pay list price, further subsidizing them. A mess because it's so wasteful and riddled with holes. I've seen numbers that claim that we waste 50% of our spending.

Our quite different demographics and lifestyles explain a significant part of the difference in outcomes, also.

Let's mention Medicare. It is single payer, but it too is more expensive than European systems, and has not produced lifespans equal to those of Europe, despite the fact that it has fewer limits on the kinds of therapies it covers.

[anne]

"Let's mention Medicare. It is single payer, but it too is more expensive than European systems, and has not produced lifespans equal to those of Europe, despite the fact that it has fewer limits on the kinds of therapies it covers."

Care to reference this destructive, lying rubbish.

[BJ Feng]

"Suppose you were the CEO of a soulless corporation and you wanted to evaluate some department, the IT department or the health care department. You would develop parameters to see how well the department is doing its job. For health care, these are called public health statistics. You would see how your department was doing in comparison with other similar companies. Then you would compare your cost with their cost."

Lensch, you are getting close to the real issue here. We also have to judge cost effectiveness and something called value right? We have to judge if a surgery is WORTH the cost. Let's say, just for kicks, that it would cost $1,000,000 to cure a 70 year old person of lung cancer with 90% probability. Is this worth it? This is the main issue here. How do we figure out if costs justify the rewards? At what point do we say, no your treatment is denied because it costs more than it is worth.

In a perfect system, one that WE DO NOT HAVE let me make that clear, the patient would know the costs and the costs would have to be paid by him alone. He would decide if hip replacement surgery is worth X amount of dollars, or would he rather keep the dollars and not go ahead with the surgery. This is a fantasy model because it requires the patient to be aware of all options and all prices and all the benefits and to calculate correctly the probabilities, but in crux of the model is that we need a way to figure out costs and benefits.

Now the leftists here don't care about the cost/benefit part of the problem. They state that treatment should be given regardless of the cost and regardless of the benefit. Of course you see automatically that this model will have a lot of problems, including huge cost overruns. When a person doesn't have to pay directly for a service, yet will receive some benefit, he will want to use that service. I would like to have a free liposuction, right now that is cosmetic, but you see my point. I want everything possible to be done for me if I don't have to pay anything for it. I demand doctors give me every single drug that can even remotely help me, that they fly in the best specialists, that the best equipment be used, that no cost be spared to treat me.

If a treatment costs $1 million and only will improve my condition 5%, is it worth it? If I'm not paying, I say yes, bring it on, I want that treatment. Do you see the problem here? Who is going to say this is not worth it? Who will make the determination that your treatment is denied, even though it will help you, it is not worth it, sorry. This is the real issue.

Right now we have a mixture of laws and health care companies who decide. They limit costs by trying to deny as much as they can, certain laws force them to provide benefits. It is an inefficient system to be sure as a lot of paperwork and fighting occurs in the process. But the underlying issue is the same. Someone has to make a determination, how do we effectively do this? What is the best way to judge. That is a very very difficult problem to solve! I hope you understand now the real problem here. It's easy to make platitudes saying everyone has the right to health care. Harder is crafting a detailed proposal that will be more efficient than the one we have. There is good reason why many here doubt that health care costs can be reduced under the "treat everyone for any reason" model.

[Larry]

@anne - Here are some approximate numbers for you:

$412B Medicare budget for 2008 - http://www.washingtonpost.com/wp-dyn/content/article/2008/02/04/AR2008020402490.html

divided by

37.4M seniors in 2005 ifrom http://www.meps.ahrq.gov/mepsweb/data_stats/MEPSnetHC.jsp

= $11,154 per individual senior - a slight overestimate because the # of seniors increased between 2005 and 2008

And of course, Medicare doesn't pay for every last thing, and charges premiums for drugs and potentially for other things. Are you saying that European health care costs per senior are higher? Or that our lifespan is longer?

@BJ Feng - "Now the leftists here don't care about the cost/benefit part of the problem."

Not true of Europe. They are more aggressive at limiting treatment that they deem insufficiently valuable. Perhaps they tolerate it because since it's the nice government deciding for everyone rather than the mean dude at the managed care company denying your "your" care. We're the real softies here in the US.

[anne]

http://online.wsj.com/article/SB122315505846605217.html?mod=special_page_campaign2008_mostpop

OCTOBER 6, 2008

McCain Plans Federal Health Cuts: Medicare, Medicaid Spending Would Be Reduced to Offset Proposed Tax Credit
By LAURA MECKLER

John McCain would pay for his health plan with major reductions to Medicare and Medicaid, a top aide said, in a move that independent analysts estimate could result in cuts of $1.3 trillion over 10 years to the government programs....

[The Wall Street Journal story was false:
http://www.nytimes.com/2008/10/19/us/politics/19health.html?ref=politics&pagewanted=print]

[Falstaff]

Universally government provided health care is a lie. It does not exist, anywhere. The truth is that either 1) government provided care coexists with a significant private/market sector which takes the political and queue pressure off the government side, or 2) the government care sharply rations the care away.

McCain (Holtz-Eagan) was right on health care. The employer tax deduction has got to go, or health costs increasing a 9%/year will sink the country.