Buying your own health insurance

Out of curiousity, how much does it cost to buy your own health insurance on average? That is, paying for health insurance but not getting it through an employer. Do many PPOs allow this?

Thanks.

Dr Trek 1 said:

Out of curiousity, how much does it cost to buy your own health insurance on average? That is, paying for health insurance but not getting it through an employer. Do many PPOs allow this?

Thanks.

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It's commonly done and shockingly expensive for pretty meager coverage.

Try: http://www.ehealthinsurance.com

Additionally, if you have any exisiting conditions they won't cover it and it doesn't really cover that much. If you want high deductibles there are coverage for about $100/mn.

Well, the amount you'll have to pay will be proportional to your chances of requiring medical service. If you're 25 years old, your premiums should be pretty low. If you're 60 years old, well, then I hope you've been putting some money aside from when your premiums were lower.

Insurance is a poor investment, so I'd suggest selecting a plan with the highest deductible you can afford to have, unless, of course, you know for a fact that you're less healthy than your insurance company thinks you are.

Somewhat off-topic question: If you were to have insurance with a massive deductible, and you went to the hospital, would you be charged the "uninsured" rate, or the "insured" rate? If it is the former, then it may very well be a good call to not follow the advice I gave previously.

SomeGuy said:

Somewhat off-topic question: If you were to have insurance with a massive deductible, and you went to the hospital, would you be charged the "uninsured" rate, or the "insured" rate? If it is the former, then it may very well be a good call to not follow the advice I gave previously.

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I read an article about this recently. Maybe it was in Money? I can't remember the magazine.

At any rate, the article described how health savings accounts were backfiring on people. Instead of pre-negotiated rates, their specialist office visits (one example was a gastroenterologist) and hospital care are billed at regular rates instead of the pre-negotiated rates.

southerndoc said:

I read an article about this recently. Maybe it was in Money? I can't remember the magazine.

At any rate, the article described how health savings accounts were backfiring on people. Instead of pre-negotiated rates, their specialist office visits (one example was a gastroenterologist) and hospital care are billed at regular rates instead of the pre-negotiated rates.

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Hmm, interesting -- I'll have to look it up. I have an HSA and think it's pretty worthless. It just makes it easier for my employer to sell us a high deductible policy. 🙄

SomeGuy said:

Well, the amount you'll have to pay will be proportional to your chances of requiring medical service. If you're 25 years old, your premiums should be pretty low.

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Maybe they should be, but they aren't.

People purchasing their own healthcare in the United States get royally screwed, the fantasy of rational markets notwithstanding.

Well, to an extent, it does make sense to charge the uninsured more. The rationale being that if an operation costs $8000, then one would mind as well bill insurance for$8000 if they knew that there was a 100% chance of being paid, but if there was a 50% chance of getting paid by a walkin, then $16000 would have to be charged.

Its really no different than charging a higher-interest rate to those that are more likely to default, but such a system certainly does present a number of problems (ie: we're charging those who can barely afford it _more_ than those who can afford it?).

There may have been a Money story on the topic, but there was definitely a 60 Minutes story on the topic of the uninsured getting charged unaffordable prices while insured patients were having their insured companies billed much lower amounts.

The latest out of the ama says that all americans who can afford it should have to have insurance or be fined. This is said to be targeted specifically at young people who choose not to have insurance.

If your high deductible policy is a PPO plan, you receive the negotiated rate. Your provider has a contract with the company to provide discounted services, whether your deductible is $250 or $2500 doesn't make a difference (if you get the cheapo high-deductible policy that doesn't have a contracted provider network, you will be charged full price).

el_chavo said:

The latest out of the ama says that all americans who can afford it should have to have insurance or be fined. This is said to be targeted specifically at young people who choose not to have insurance.

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I am so confused, are these people for or against a free market? I'm getting so many signals from both ends here...

f_w: Thanks for clearing that all up

el_chavo said:

The latest out of the ama says that all americans who can afford it should have to have insurance or be fined. This is said to be targeted specifically at young people who choose not to have insurance.

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This is not exactly true. The report recommends utilizing the tax structure to require individuals making more than 500% of the poverty level (about 90k for an individual) to possess catastrophic health insurance (meaning high deductible) and preventive health care coverage (via insurance, HSA, or other means).

You can go and read the actual resolution on the AMA website under the HOD Annual Meeting Section. I do not recall which Reference Committee handled the resolution but it was voted on this morning (Wednesday) following considerable debate and rewording of the original proposal.

If you don't agree with the the policy then join the AMA and share your voice (if you are eligible for membership of course).

This is not exactly true. The report recommends utilizing the tax structure to require individuals making more than 500% of the poverty level (about 90k for an individual) to possess catastrophic health insurance (meaning high deductible) and preventive health care coverage (via insurance, HSA, or other means).

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How stupid and unrealistic is that. It is not the guy making 90k/year who burdens the health system if he has to pay a hospital bill out of pocket. Yes, people in that pay bracket will go into 'medical bankrupcy', but in terms of the net-burden on the system thy certainly don't represent the majority of the problem. Of course it is easier to point fingers at the 'selfish wealthy' rather than offering solutions to the more prevalent problem.

f_w said:

How stupid and unrealistic is that. It is not the guy making 90k/year who burdens the health system if he has to pay a hospital bill out of pocket. Yes, people in that pay bracket will go into 'medical bankrupcy', but in terms of the net-burden on the system thy certainly don't represent the majority of the problem. Of course it is easier to point fingers at the 'selfish wealthy' rather than offering solutions to the more prevalent problem.

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The problem of the uninsured poor can be addressed with Medicare, Medicad, things like the OHP, the Mass. plan, etc.

This addresses another aspect of the the problem of the uninsured. They don't have to be "the majority of the problem" to be part of the problem. Uninsured people equals uncompensated care and distorts the entire market for healthcare. Mandated insurance is one of the ways to get to universal coverage, which we need.

This addresses another aspect of the the problem of the uninsured. They don't have to be "the majority of the problem" to be part of the problem. Uninsured people equals uncompensated care and distorts the entire market for healthcare. Mandated insurance is one of the ways to get to universal coverage, which we need.

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Uninsured poor suckers without property = uncompensated care.

The small business owner in his 50s making 90k who is unwilling to spend ungodly amounts of his post-tax $$ on health insurance is more likely to take out a home equity line to pay medical bills than to leave them unpaid. People with an actual credit rating tend to pay up on their bills, its the ones who don't have anything to loose who don't care whether their kids earache is taken care of at a $75 office visit vs. a $800 ED visit.

If AMA wants universal healthcare, they should come out in a strong way in favor of it. Medicare for all ! Don't we just alll itch to get 100% of our business regulated by the goverment buerocrats, not just the 40 odd % they cover now.

f_w said:

Uninsured poor suckers without property = uncompensated care.

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Why are people without property "suckers"? Or are they "suckers" because they got sick/hurt?

The small business owner in his 50s making 90k who is unwilling to spend ungodly amounts of his post-tax $$ on health insurance is more likely to take out a home equity line to pay medical bills than to leave them unpaid. People with an actual credit rating tend to pay up on their bills, its the ones who don't have anything to loose who don't care whether their kids earache is taken care of at a $75 office visit vs. a $800 ED visit.

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Do you have any evidence to support your intuition? People who have nothing to lose do not file for bankruptcy (there's no need), and medical expenses are the most common cause of personal bankruptcies in the United States.

I don't know if you were born wealthy or have never been sick, but there is a huge population of working people with plenty to lose who do not have the capability to pay for even a brief hospitalization.

If AMA wants universal healthcare, they should come out in a strong way in favor of it. Medicare for all ! Don't we just alll itch to get 100% of our business regulated by the goverment buerocrats, not just the 40 odd % they cover now.

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There are more ways than one to get universal care. And I trust the "buerocrats" a lot more than I trust "conservatives."

I am trying to find insurance right now for dental and health. I'm unemployed. I haven't found anything that's less than 160 a month that is reasonable. My search continues. 🙁

People who have nothing to lose do not file for bankruptcy (there's no need),

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Yes, they just don't pay. The end result is the same: uncompensated care.

and medical expenses are the most common cause of personal bankruptcies in the United States.

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Then mandate universal healthcare, don't mandate universal healthcare for a small subset of the populace.

I don't know if you were born wealthy or have never been sick, but there is a huge population of working people with plenty to lose who do not have the capability to pay for even a brief hospitalization.

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And that is the great tragedy of the US healthcare system. It is not even the poor suckers that have trouble to access healthcare (they have 'my insurance'=medicaid or their PCP practices in the local ED) , but rather the 'average' joe blow pulling 45k per year at the corner car repair shop (which doesn't provide insurance for their employees or independent contractors).

f_w said:

Yes, they just don't pay. The end result is the same: uncompensated care.

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Exactly what I said. You seem to be missing the fact that if the people who have nothing to lose do not need to declare bankruptcy, and health-related bankruptcies are endemic, then, logically, healthcare expenses are beyond the means of many people with something to lose. This second group is not a small subset of "suckers"; it is a large proportion of the workforce.

Then mandate universal healthcare, don't mandate universal healthcare for a small subset of the populace.

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I'd like nothing better; but universal coverage by stages is better than nothing at all. This is America; if you try and get to universal coverage in one go, people will cry "socialism"! Which is of course a mortal insult, one that they would never dream of applying to their free public education, free fire department, Social Security, Medicare and agricultural substities. The alternative is to gradually expand the safety net of health insurance until everyone's covered somehow. Such a patchwork solution is not unusual in countries with universal care.

Lots of people labor under the missapprehension that universal care = state health service, but in fact, most countries don't do it that way. Countries like France and Germany mix mandates for those who are able to pay with programs for those who can't, along with liberal use of the government's leverage to keep down costs.

You're required to carry car insurance; I don't see why those who are able to pay ought not to be required to carry health insurance. Your illness, like your car accident, has the potential to harm society as a whole, not just yourself.

And that is the great tragedy of the US healthcare system. It is not even the poor suckers that have trouble to access healthcare (they have 'my insurance'=medicaid or their PCP practices in the local ED) , but rather the 'average' joe blow pulling 45k per year at the corner car repair shop (which doesn't provide insurance for their employees or independent contractors).

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If we only had just one tragedy of the US healthcare system, that would represent about a tenfold improvement. How about the tragedy of spending twice what our competitors do on healthcare, and having a population statistically less healthy than Cuba's?

Exactly what I said. It is just that this second group is not a small subset of "suckers"; it is a large proportion of the workforce.

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I think we are talking about the same thing here. I am saying that the singles with a 90k income without health insurance are a small minority and not the problem group clogging our ERs and racking up the unpaid bills.

Countries like France and Germany mix mandates for those who are able to pay with programs for those who can't, along with liberal use of the government's leverage to keep down costs.

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As a result, working as a physician in these countries sucks a##. I can tell you that from first hand experience.

You're required to carry car insurance; I don't see why those who are able to pay ought not to be required to carry health insurance.

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You are required to buy car insurance whether you can afford it or not.

How about the tragedy of spending twice what our competitors do on healthcare, and having a population statistically less healthy than Cuba's?

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Cuba is a stalinist dictatorship that shamelessly lies about their healthcare data. Please, compare the US data with the data from countries where healthcare researchers don't have to fear going to the GULAG if their data doesn't fit the ideology.
The US spends 30%-50% more of GNP than most comparable 1st World countries. Outcomes are worse, which does not appear to be caused by the differences the healthcare systems (see recent US-UK and US-CDN comparison studies).

f_w said:

I think we are talking about the same thing here. I am saying that the singles with a 90k income without health insurance are a small minority and not the problem group clogging our ERs and racking up the unpaid bills.

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They are a small minority, but I am not seeing the evidence that they pay all their healthcare bills.

As a result, working as a physician in these countries sucks a##. I can tell you that from first hand experience.

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Much as I look forward to making a lot of money, medicine does not exist to provide us with a lucrative career. Physician salaries vary but, certainally, the US's are the highest. So maybe they drop 20%, and we get a functioning healthcare system that is not completely unsustainable. Boo friggn' hoo.

You are required to buy car insurance whether you can afford it or not.

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But you have a choice as to whether you own a car or not; you do not have a choice as to whether you will be a human being who sometimes gets sick or injured. Therefore, it is neither reasonable nor practical to require everyone to purchase health insurance.

Cuba is a stalinist dictatorship

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Stalin murdered tens of millions of people. Cuba restricts the freedom of the press and holds sham elections. It is undemocratic, not totalitarian. A comparable analogy would be between Bush's America and Nazi Germany. Keep a sense of proportion.

that shamelessly lies about their healthcare data.

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Evidence? Please, they have us beat cold. Take it like a man.

Much as I look forward to making a lot of money, medicine does not exist to provide us with a lucrative career. Physician salaries vary but, certainally, the US's are the highest. So maybe they drop 20%, and we get a functioning healthcare system that is not completely unsustainable. Boo friggn' hoo.

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Make that 20%, not a drop of 20%

I get paid appropriately for the level of training I have invested and the degree of responsibility I carry. I mess up, somebody dies (and yes, I have messed up before).

Stalin murdered tens of millions of people. Cuba restricts the freedom of the press and holds sham elections. It is undemocratic, not totalitarian.

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Wow, they must have really gotten to you somehow.

Evidence? Please, they have us beat cold. Take it like a man.

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How do you want to conduct research in a place where the goverment censors control the flow of information ?

f_w said:

Make that 20%, not a drop of 20%

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Evidence? No doctors in the Western world make, on average, 20% of what American doctors average. For some reason I have never been able to fathom, opponents of universal coverage seem to think that when it comes to healthcare in other countries, it is OK to simply make things up. It baffles me.

I get paid appropriately for the level of training I have invested and the degree of responsibility I carry. I mess up, somebody dies (and yes, I have messed up before).

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That's a crock. If I mess up, someone dies, but i must have missed that line item on my paycheck. Hell, if a bus driver messes up, someone could die, but he doesn't pull down $200k a year. And if education entitled one to a fat salary, I know lots of English professors who have been scammed out of beach homes rightfully theirs.

Maybe you'd like to share with us the formula that determines what an appropriate level of pay is. We know it's not up to the market -- the AMA controls the supply of doctors in a fashion that makes OPEC look like a sewing circle.

Wow, they must have really gotten to you somehow.

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Yeah, with facts, evidence, and a basic sense of moral responsibility -- that stuff is like kryptonite to me.

How do you want to conduct research in a place where the goverment censors control the flow of information ?

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Let's ask the NASA scientists who have been told to shut up on global warming, or the whistleblowers at the FDA who have been fired.

Exercising censorship in some cases does not equate to controlling all the information, all the time.

I will reiterate; do you have any concrete evidence that Cuba (which, like dozens of countries, has longer-lived citizens and a lower rate of infant mortality than we do) has falsfied the statistics? If so, have all the 35 or so countries the WHO found to have better healthcare than we do lied, or just Cuba?

Nutmeg1621 said:

I am trying to find insurance right now for dental and health. I'm unemployed. I haven't found anything that's less than 160 a month that is reasonable. My search continues. 🙁

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Unless you have reason to believe that you have really bad teeth, dental insurance is BARELY worth the cost, if you are paying yourself.

$160 a month seems reasonable for health insurance, no? What do you pay for car insurance?

jota_jota said:

Unless you have reason to believe that you have really bad teeth, dental insurance is BARELY worth the cost, if you are paying yourself.

$160 a month seems reasonable for health insurance, no? What do you pay for car insurance?

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You're probably right about the dental. My current coverage has a maximum annual benefit of $1000, and the premiums are apparently about $50/month (saw my cobra worksheet). So my employer and I pay $600/year for $1000 of benefits. I guess it works out if you know for sure you'll spend $1000k, and that's not too improbable if you need something done like wisdom teeth removal, a crown or a root canal. Even then, the benefit is so small that it's not worth sweating over.

QuikClot said:

Evidence? No doctors in the Western world make, on average, 20% of what American doctors average. For some reason I have never been able to fathom, opponents of universal coverage seem to think that when it comes to healthcare in other countries, it is OK to simply make things up. It baffles me.

I will reiterate; do you have any concrete evidence that Cuba (which, like dozens of countries, has longer-lived citizens and a lower rate of infant mortality than we do) has falsfied the statistics? If so, have all the 35 or so countries the WHO found to have better healthcare than we do lied, or just Cuba?

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Obviously your problem is that you're stuck in a reality-based world. Just get over that hang up, and you'll see that f_w makes a ton of sense. 😉

No doctors in the Western world make, on average, 20% of what American doctors average.

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I personally would make 20% of my current pre-tax income if I went back to the western paradise of universal healthcare I came from.
(addendum: just went back and checked the numbers: You where right, it is not 20%, it is 20.4% !)

For some reason I have never been able to fathom, opponents of universal coverage seem to think that when it comes to healthcare in other countries, it is OK to simply make things up. It baffles me.

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Don't have to make things up. Just have to look at the labor contract for physicians in my home country vs. my paycheck (and that is before taxes and cost of living).

Hell, if a bus driver messes up, someone could die, but he doesn't pull down $200k a year.

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There are more people who can drive a bus than people who can do my job. Look at the airline pilots. Was a high-paying profession, now many are happy if they can make minimum wage (if they get paid to fly at all).

And if education entitled one to a fat salary, I know lots of English professors who have been scammed out of beach homes rightfully theirs.

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Supply and demand at work. Supply is thankfully somewhat controlled, demand is good.

If so, have all the 35 or so countries the WHO found to have better healthcare than we do lied, or just Cuba?

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No, just Cuba. (well, and knowing people who dealt with the swedish health buerocracy before, I take their information with a 'healthy' degree of skepticism).

By the way. I am all for universal healthcare coverage. I am just against a single payor goverment administrated system (bad enough that medicare strongarms their pricing into the market, any larger proportion of goverment control would be detrimental).

f_w said:

I personally would make 20% of my current pre-tax income if I went back to the western paradise of universal healthcare I came from.
(addendum: just went back and checked the numbers: You where right, it is not 20%, it is 20.4% !)

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You know what anedoctal evidence is, right? If we find one doctor who moved out of the US, started a thriving practice, and tripled his income, does that mean universal care will triple doctors' incomes?

Don't have to make things up. Just have to look at the labor contract for physicians in my home country vs. my paycheck (and that is before taxes and cost of living).

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Your argument is about six degrees of seperation from validity. Is your country a typical example of what doctors earn outside the US? Is your present salary reflective of what the typical American doctor earns? Is the shortage of multi-millionare doctors outside the US caused by universal care, or, like their lower-paid CEOs, a reflection of less inequality generally? And so on.

There are more people who can drive a bus than people who can do my job. Look at the airline pilots. Was a high-paying profession, now many are happy if they can make minimum wage (if they get paid to fly at all).

Supply and demand at work. Supply is thankfully somewhat controlled, demand is good.

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Saying that supply and demand give you a fat payday is very different from what you said at first; that you deserve it.

Interestingly, you seem to be saying not that single-payer would distort the market, but that the present distortion of the market (restricting supply) might be compromised if the government got more involved. Relax. Government paying the bills doesn't mean they'll use their clout to stop cartels from robbing the public blind. Look at the prescription drug "benefit." Look at the defense budget.

No, just Cuba. (well, and knowing people who dealt with the swedish health buerocracy before, I take their information with a 'healthy' degree of skepticism).

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As a rule of thumb, when you make of same assertion (Cuba is falsifying their statistics) in an Internet forum three times without offering a shread of evidence, it's a good bet you don't have any evidence, just an assumption based on prejudice.

By the way. I am all for universal healthcare coverage. I am just against a single payor goverment administrated system (bad enough that medicare strongarms their pricing into the market, any larger proportion of goverment control would be detrimental).

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Determental to the public or to your personal finances? You seem to have trouble distinguishing the two.

For the record, I am all for universal health coverage, and it is relatively unimportant to me how we get there. Requiring well off people to buy health insurance is a modest step in that direction. If that is too much "government control" for you, I wonder what steps you would take to get everyone covered.

> Is your country a typical example of what doctors earn outside the
> US? Is your present salary reflective of what the typical American
> doctor earns?

Neither. Didn't say that all docs abroad have to live like paupers, I just know what the situation would be for someone in a comparable position to me.

> Is the shortage of multi-millionare doctors outside the US caused

Hard to become a multi-millionaire in US medicine these days. I make a good living, don't want to complain. Far from multi-millionaire though.

> Interestingly, you seem to be saying not that single-payer would
> distort the market,

With a single payor there is no market. They payor determines what they want to pay for your services and that is what they pay. No market involved.

> Determental to the public or to your personal finances? You seem
> to have trouble distinguishing the two.

Detrimental to my personal finances and the condition of the healthcare system.

> I wonder what steps you would take to get everyone covered.

I believe I pointed that out in a prior post (in the parallel thread http://forums.studentdoctor.net/showthread.php?t=290526 ), go back read.
(If they want to mandate something, mandate it for everyone. And help the ones who can't afford it along the way by providing tax credits e.g. for the people that would be pushed below 180% FPL through the insurance mandate.)

And yes, maybe my criticism of single payor systems is clouded by the fact that my mom just got diagnosed with breast cancer, 22 months after her last mammogram (after the single payor had decided that a 2 year cyle in a woman in her 60s with a family history of breast cancer was clearly sufficient)

And my view, doubtless, is affected by the fact that my father works 50 hours a week selling furniture, and has no health insurance at all.

Your particular case, while interesting, does not imply anything about what American doctors would make under single payer or any other scheme of universal care.

Single-payer changes, but does not eliminate, the market for healthcare, any more than the AMA's restrictions on the supply of doctors, or ER legal requirements to treat walk-ins, eliminate the market now; all markets deviate from the theorectical lassie-faire ideal to a lesser or greater extent. And in single-payer, as I'm sure you know, private inviduals can typically purchase healthcare on their own (thus making single-payer something of a misnomer, in most countries.)

Mandating health insurance for everyone and subsitizing it with tax credits would not work for the tens of millions of Americans who do not pay enough taxes to pay for health insurance, if they pay any taxes at all.

While I would rather have a solution that covers everyone right away, I'm resigned to the fact that piecemeal efforts, like requiring the well-off to buy insurance and expanding Medicaid, are probably the only way, politically, we are going to get to the universal coverage we both want to see.

And my view, doubtless, is affected by the fact that my father works 50 hours a week selling furniture, and has no health insurance at all.

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And if you had bothered to read my post on the issue, you would have realized that your dad would be exactly the person benefitting the most from a divorce between employers and health-insurance. Going back to the world of inappropriate analogies: I don't get my car-insurance provided by my employer although I need the car to get to work. Why should he be obliged to pay my health insurance ?

People like you dad who work hard but for the 'wrong' employer (or self-employed), are the ones who really get the shaft in the US healthcare system these days. It is close to impossible to buy individual health insurance at this point in his life and if he pays cash the goverment forces the physician to charge him the highest rate he ever charged anyone else (if the goverment wouldn't force me to overcharge your dad, I would have a credit-card reader at the front-desk and a sign: 'Will haggle. Ask us about our working uninsured discount'. You pay cash up front, you get your study for whatever medicare would pay me if you where 15 years older. If I did that and medicare audited me, they would rip me a new one exactly for doing that.)

Your particular case, while interesting, does not imply anything about what American doctors would make under single payer or any other scheme of universal care.

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I didn't say that.
The only 'single payor' we have in the US at this time (medicare) depresses our incomes to 60% of what is 'reasonable, common and appropriate' already. I don't know where you get the delusion from that this would be any different if you extended the reach of medicare to 100% of the market ?

the AMA's restrictions on the supply of doctors,

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It is the federal goverment that determined the number of funded residency slots in 1997, not AMA. AMA did have his fingers in the decision, but ultimately it is the will of congress to train about 22k new physicians per year (they know that an oversupply of physicians increases healthcare cost even further). You seem to believe that the 'supply of physicians' is determined by the number of allopathic medical school admissions. And this is just not the case. AMA has no influence whatsoever on the admissions of DO schools and only limited influence on the influx of FMGs through ECFMG. It is the number of residency positions that determines the supply, nothing else.

or ER legal requirements to treat walk-ins,

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That would be the first law to go if I was the king around here. Well intentioned, poorly carried out, wreaking havoc on the healthcare system. It is nice to mandate people to provide healthcare. Nobody would have a problem with this mandate if they had also come up with some idea on how to fund this (or at least the courtesy to make me an 'agent of the federal goverment' similar to a physician working at a federally funded community health center. Then at least I would be covered under FTCA and wouldn't have to worry that I can get my pants sued off by one on the poor souls stranded in the ED)

eliminate the market now;

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The market is constrained and distorted right now and barely resembles a market, that is correct. The main distortion is that it is not the patient who is the buyer of healthcare, but rather corporations and the goverment. Both have interests that don't align with the interests of the patients, and certainly not with mine.

And in single-payer, as I'm sure you know, private inviduals can typically purchase healthcare on their own (thus making single-payer something of a misnomer, in most countries.)

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In some of the paradises of universal coverage, the individual HAS to buy his healthcare privately because the goverment provided system, while free, is entirely insufficient. That are the lucky ones (e.g. UK and Spain), at least you can buy healthcare if the goverment system effectively denies it through their ineptness. In other systems private delivery of healthcare is either unlawful or at least actively discouraged by the monopoly (some provinces in Canada, Sweden).

Mandating health insurance for everyone and subsitizing it with tax credits would not work for the tens of millions of Americans who do not pay enough taxes to pay for health insurance, if they pay any taxes at all.

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Similar to the 'earned income credit', this can be a credit you can receive even if you don't have a tax liability at all. If at the end of the year your income liability was 0 but your expense for catastropic coverage lets say 2k, you get a check for 2k for your return (Any solution involving a tax credit would require the goverment to destroy rackets like HR-Block who would take that check right out of peoples hands.)

While I would rather have a solution that covers everyone right away, I'm resigned to the fact that piecemeal efforts, like requiring the well-off to buy insurance and expanding Medicaid, are probably the only way, politically, we are going to get to the universal coverage we both want to see.

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Don't get me started about medicaid.

The average employer pays like $500/mo per employee per month for insurance. You can get major medical for less. Still, ouch.

f_w said:

The only 'single payor' we have in the US at this time (medicare) depresses our incomes to 60% of what is 'reasonable, common and appropriate' already.

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Perhaps I missed something, but I'm curious as to where this number came from.

Perhaps I missed something, but I'm curious as to where this number came from.

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The way medicare originally determined their fee scale was a survey of what physicians commonly charged for certain services. Then they turned around and told the physicians : 'You are going to give uncle Sam a discount, won't you ?' and set their fee scale at 60% of that average fee. All further modifications/increases took it from there. The RBRVS (the current scheme) was based on the original 60% scale, in the end it was just a redistribution of reimbursements between procedural and nonprocedural services. The overall budget is capped and it is up to the RVU commission (that every specialty society sends members to) to haggle out the individual slices of the pie.

Initially, you where allowed to 'balance bill' the patient if you thought the medicare reimbursement was a bit paltry and your patient could afford to pay the price that you as a professional deemed appropriate for your services. Later they did away with that and medicare has become a 'take it or leave it' deal. If you opt-out in order to bill your medicare patients directly, you are banned from rejoining the fold for a couple of years.

If you want the 'dirt' on medicare, talk to a really old physician, someone who lived in the pre-medicare days. Back when you could run a village GP office accepting food and services for payment (back in those days, the village docs grass was allways mowed and the driveway plowed). Also, there was nobody who forced you to bill a needy patient if you didn't feel it to be appropriate. AMA got a bad rap for fighting the introduction of medicare tooth and nail for many years. In hindsight, some of their objections predicted exactly the developments we are looking at today.

bananaface said:

The average employer pays like $500/mo per employee per month for insurance. You can get major medical for less. Still, ouch.

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This is one reason why I am more hopeful than I have been that we are going to see some sweeping reforms. It's getting to the point where healthcare costs are seriously damaging business interests, as well as those of poor and working-class people.

Access is part of the problem. So is cost control. We can't have perpetual double-digit growth in healthcare spending.

The only 'single payor' we have in the US at this time (medicare) depresses our incomes to 60% of what is 'reasonable, common and appropriate' already. I don't know where you get the delusion from that this would be any different if you extended the reach of medicare to 100% of the market ?

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So we've gone from 20% of present income (your first prediction) to 60%? Bravo! Our income has tripled! With taxes hitting high earners harder, that figure places the income of physicians pretty close to the 20% loss I speculated, rather than the 80% loss you predicted.

It is the federal goverment that determined the number of funded residency slots in 1997, not AMA. AMA did have his fingers in the decision,

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The point being that markets exist, even though there are always "flaws" in the form of regulation, taxation, government programs, etc. To benifit from the efficiency of markets, one need not keep them absolutely pure.

In some of the paradises of universal coverage, the individual HAS to buy his healthcare privately because the goverment provided system, while free, is entirely insufficient.

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Absent evidence, I don't believe you. In Russia, say, this might be the case, but in a functioning, reasonably wealthy society? Sounds like propaganda. Conservatives like to tell tales about how bad these systems are, but studies have refuted those accusations over and over, and the final result is always a healthier population for less money. In the broader context, the accusations are kind of silly; as if a baseball team shunned spring training, got beat year after year after year, and to top it off, published screeds about how spring training hurts baseball players' performance.

Similar to the 'earned income credit', this can be a credit you can receive even if you don't have a tax liability at all. If at the end of the year your income liability was 0 but your expense for catastropic coverage lets say 2k, you get a check for 2k for your return (Any solution involving a tax credit would require the goverment to destroy rackets like HR-Block who would take that check right out of peoples hands.)

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Still would not work for the many people who are homeless, household-less, or too poor to pay expenses out of pocket and wait months for the rebate (that would be the millions of households living paycheck to paycheck.) I have nothing against a better market for health insurance, but for the people at the very bottom of the ladder, it would probably work best to just have the government pay the premium directly.

Don't get me started about medicaid.

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You don't have to like these programs. I don't have to like them. But they are all we have now and for the forseeable future. I, like you, am fond of crafting reasonable solutions without reguard to the political realities. But an un-implementable perfect solution is no reason to avoid or defer a messy, partial solution if it gives us something better than what we have now.

Absent evidence, I don't believe you. In Russia, say, this might be the case, but in a functioning, reasonably wealthy society? Sounds like propaganda.

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It is one thing to make lofty proclamations based on self-reported WHO data. It is another thing to have lived and worked in such a system and to have relatives struggling to get appropriate care there.

Still would not work for the many people who are homeless, household-less, or too poor to pay expenses out of pocket and wait months for the rebate (that would be the millions of households living paycheck to paycheck.)

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People living paycheck to paycheck already have to budget for various recurring expenses such as rent. Make it a pre-tax payroll deduction, if people never see the money, there is no risk that it is not there when they need it.

it would probably work best to just have the government pay the premium directly.

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I hate the conservative lingo of 'entitlement'. But I think people value their healthcare coverage a lot more if they actually have to pay for it.

I, like you, am fond of crafting reasonable solutions without reguard to the political realities. But an un-implementable perfect solution is no reason to avoid or defer a messy, partial solution if it gives us something better than what we have now.

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By implementing little cheapo fixes, the overall problem remains unaddressed. This festering boil has to mature a bit more until it can be popped. Putting band-aids on it makes us all feel better, but it still remains a boil (had to bring an ill fitting analogy, just couldn't resist).

I am not sure who is more annoying in the universal coverage debate:
- The conservative talking heads that tell us that uninsured people just made bad choices and that any solution that provides broader coverage would lead to people dying in the streets of pestilence and leprosy.
- The socialist dreamers who have never set foot into a hospital abroad but keep telling me how perfect things are everywhere else and how 'THE DATA, THE DATA, THE EVIDENCE, THE DATA, THE STUDIES, THE DATA, THE EVIDENCE' support their assertion that only an expropriation of the evil ruling physician class is the way into the light.

f_w said:

The way medicare originally determined their fee scale was a survey of what physicians commonly charged for certain services. Then they turned around and told the physicians : 'You are going to give uncle Sam a discount, won't you ?' and set their fee scale at 60% of that average fee. All further modifications/increases took it from there.

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Could you reference this, please? My information is a little different.

f_w said:

If you want the 'dirt' on medicare, talk to a really old physician, someone who lived in the pre-medicare days.

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The old physicians who I've spoken with all state that before the institution of DRG's in 1982-1986 the reimbursement policies of medicare had turned hospitals into veritable rivers of gold.

Could you reference this, please? My information is a little different.

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Took a wee bit of searching.

http://thomas.loc.gov/medicare/history.htm

Until the RBRVS came upon us, physicians where paid based on the 'reasonable customary charge' concept. In the document on the history of medicare referenced above, you can find an explanation of how the goverment computed this:

3 The reasonable charge for a service or supply is the lowest of (1) the actual charge, (2) the physician's or supplier's customary charge, or (3) the prevailing charge. The customary charge is defined as an amount high enough to cover the actual charge for the service or item made by the physician or supplier 50 percent of the time. The prevailing charge is an amount sufficient to cover at first 83 and later 75 percent of customary charges for the service or item in the applicable geographic area.


You are right, it is not 60%. It was 50% of your own charges OR 75% of the regional average charge. No matter how, the goverment lowballed us and they could get away with it because they control a large share of the market. If physicians had the reasonable option of telling medicare to take a hike, they wouldn't act like this.

The old physicians who I've spoken with all state that before the institution of DRG's in 1982-1986 the reimbursement policies of medicare had turned hospitals into veritable rivers of gold.

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The hospitals made away like thieves before the introduction of DRGs, doesn't mean physicians had the same bonanza.

Initially, physicians did manage to increase their income with medicare vs the period before that. It is later that things went awry and CMS has morphed into this vengeful monster that keeps a stranglehold on our all existence.

duplicate

f_w said:

Until the RBRVS came upon us, physicians where paid based on the 'reasonable customary charge' concept. In the document on the history of medicare referenced above, you can find an explanation of how the goverment computed this:

3 The reasonable charge for a service or supply is the lowest of (1) the actual charge, (2) the physician's or supplier's customary charge, or (3) the prevailing charge. The customary charge is defined as an amount high enough to cover the actual charge for the service or item made by the physician or supplier 50 percent of the time. The prevailing charge is an amount sufficient to cover at first 83 and later 75 percent of customary charges for the service or item in the applicable geographic area.


You are right, it is not 60%. It was 50% of your own charges OR 75% of the regional average charge. No matter how, the goverment lowballed us and they could get away with it because they control a large share of the market. If physicians had the reasonable option of telling medicare to take a hike, they wouldn't act like this...

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For one, you've made an rather significant error in stating that the payment is 50% of your own charges or 75% of regional average charges. Cigna has a very nice illustration of the correct interpretation here.

For two, none of this is unique to medicare. In fact, the reasonable cost method outlines above was adapted from private insurance payment schedules.

For one, you've made an rather significant error in stating that the payment is 50% of your own charges or 75% of regional average charges. Cigna has a very nice illustration of the correct interpretation here.

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My bad. It was the 50th percentile of your prior years charges, not 50% and the 75th percentile of the prevailing charges and not 75% (in the end it works out to be 60% of what is on your bill).

f_w said:

(in the end it works out to be 60% of what is on your bill).

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How do you figure?

f_w said:

If physicians had the reasonable option of telling medicare to take a hike, they wouldn't act like this.

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After some pondering, I'm really not sure what you mean by this. You are clearly anti-medicare, but if it were to disappear tomorrow, I predict the following things would happen:

1. The number of people over 65 who could afford private health insurance would plummet to miniscule numbers. If you think it's expensive for young healthy people to get coverage, imagine the premiums for a 68-year old with several chronic health problems.

2. Since those over 65 are (by far) the largest consumers of healthcare, most physicians would be faced with the dilemma of either not providing services to uninsured seniors or providing services but running a high risk of not being compensated for the services they do provide. From a financial standpoint the doctors stand to lose either way.

In other words, this would be an excellent way to trim the senior population, but I doubt it would be very popular with anyone. To make money doctors need to 1. perform services, 2. get paid. Deep sixing medicare would severely hamper our ability to do that for the segment of the population which consumes the bulk of our services. And, unfortunately, there would be no one to step in and fill the void, as it would be financial suicide.

In summary, does medicare suck? Yes. Is it better than the alternative? Hell yes.

I am not anti-medicare. I actually think that they do a marvellous job for their beneficiaries. I just don't think that the way the 'contracts' they give to physicians are rigged is very fair (neither are HMO and some PPO contracts btw.). I don't want medicare to go away, I would like to see some changes to the system. Just by virtue of the number of beneficiaries almost doubling in the next 25 years, medicare will dominate the market even more than they do right now. And as markets go, the growth of an evil monopoly is just not particularly helpful.

One change would be to allow physicians to balance bill, at least for elective procedures. The patients would have the choice whether they want to accept a larger co-pay to have their procedure done by a particular practicioner, or whether they just want to go with whoever accepts medicare as full payment (this larger co-pay is of course something you can insure yurself against if you have the financial means to do so).

The other would be that you have the option to accept medicare or not without having to lock yourself out of the system for years (with its secondary consequence of often being unable to bill the blues).

f_w said:

It is one thing to make lofty proclamations based on self-reported WHO data. It is another thing to have lived and worked in such a system and to have relatives struggling to get appropriate care there.

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It isn't just WHO data, as I'm sure you know. Study after study shows their superiority, in terms of delivering a healthier population at a far lower cost. This mountain of evidence getting rubbed in your face is what you bemoan below.

People living paycheck to paycheck already have to budget for various recurring expenses such as rent. Make it a pre-tax payroll deduction, if people never see the money, there is no risk that it is not there when they need it.

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So, basically, you want the government to take a piece out of a person's paycheck, and provide him or her with access to healthcare, but you would rather call it a deduction and insurance than a tax and a service. Whatever.

By implementing little cheapo fixes, the overall problem remains unaddressed. This festering boil has to mature a bit more until it can be popped. Putting band-aids on it makes us all feel better, but it still remains a boil (had to bring an ill fitting analogy, just couldn't resist).

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The overall problem is addressed, in stages. I would like a single, sweeping, self-consistant reform, but most reforms do not happen that way; things like workplace safety, labor law, and public education happened not by the sudden creation of a comprehensive set of laws and programs, but by the gradual accumulation of successful small-scale reforms.

- The socialist dreamers who have never set foot into a hospital abroad but keep telling me how perfect things are everywhere else and how 'THE DATA, THE DATA, THE EVIDENCE, THE DATA, THE STUDIES, THE DATA, THE EVIDENCE' support their assertion that only an expropriation of the evil ruling physician class is the way into the light.

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Quite a straw man you have there -- does he keep the crows off your crops? The data, the evidence, the studies, and the data would not get rehashed ad nauseum if people would face the reality that they reflect; our healthcare system sucks. Other systems work better. The evidence proves it. All the other side has is anecdote and fear-mongering; for example the idea that providing healthcare to everyone is an evil communist plot to seperate hard-working doctors from their Lamborghinis.

So, basically, you want the government to take a piece out of a person's paycheck, and provide him or her with access to healthcare, but you would rather call it a deduction and insurance than a tax and a service. Whatever.

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I don't want the goverment to do anything except to NOT tax the money individuals pay for healthcare (regardless of whether the employer or the employee writes the check). Making it a pre-tax payroll deduction would just make it easier for people who can't handle money once it is in their hands. If someone is in the low-income earning group that gets a tax-credit, that credit can be used to offset federal income tax or FICA obligations.

The overall problem is addressed, in stages.

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Yes. Stage 1 now, stage 2 never. Because after all, the politicians have done something to address the problem, ribbons have been cut, group photographs at the signing have been taken.
You are not suggesting a reform, you suggest a quick-fix by mandating people to do something they often don't want to do. Just like EMTALA was a quick-fix for the problems of the day. 'Nobody will be denied care' is easy to proclaim, the consequences 15 years down the line are dire.

The data, the evidence, the studies, and the data would not get rehashed ad nauseum if people would face the reality that they reflect; our healthcare system sucks.

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I knew socialists are humor deficient. You prove that point again.

The evidence proves it. All the other side has is anecdote and fear-mongering;

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The evidence also proves that the VA healthcare system provides equal outcomes at lower cost.
So why don't we tear down all those community hospitals, replace them with VA style concrete high-rises, hire a couple of 100thousand physicians and provide healthcare for all medicare beneficiaries using the VA model. It is going to be great ! And with the couple of bucks we save, we can do all these wonderful things. Like: invade a couple more countries, develop another non-functioning missile defense system......

Bitching about your healthcare system is a universal human right. You ask the brits about their healthcare, they will give you a long litany of complaints, but if you ask them whether they want to get rid of the NHS, they will tell you that they value it as a key part of being british and they would never want to change anything. If you ask the germans about their healthcare, they will give you a long litany of complaints, but if you offer them to fix all that, but that you will introduce a $8 co-pay for physician visits, they will go on national strike.

Same in the US. The US has exactly the healthcare system it wants and deserves, all bitching nonwithstanding. And there is exactly one poll that is relevant when it comes to americans opinions about their healthcare: It is called 'general election'. If you guys wanted to have cheap gasoline and universal healthcare, you would have voted for the Hillary Clinton/Ted Kennedy ticket in the 2004 presidential election. But no, you elected two oil company officials back into office. Gee, big suprise that you have high gasoline prices and more uninsured than ever.....

But I forgot, everything is just swell in Cuba. Every poll taken by the goverment shows that the workers and farmers are deliriously happy. Just ask around in Cubas second largest city: Miami.

f_w said:

I don't want the goverment to do anything except to NOT tax the money individuals pay for healthcare (regardless of whether the employer or the employee writes the check).

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Which doesn't get you to universal care, and doesn't solve the problem of uncompensated care.

Yes. Stage 1 now, stage 2 never. Because after all, the politicians have done something to address the problem, ribbons have been cut, group photographs at the signing have been taken.

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Again, your dislike of facts and evidence is showing.

You are not suggesting a reform, you suggest a quick-fix by mandating people to do something they often don't want to do. Just like EMTALA was a quick-fix for the problems of the day. 'Nobody will be denied care' is easy to proclaim, the consequences 15 years down the line are dire.

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The first consequence is that people get care even if they can't afford it. That's necessary. Your fantasy of everyone buying health insurance with the help of a few tax credits is ludicrious. Meantime, you want to tear down anything that allows the poor to recieve care; Medicaid, Medicare, EMTALA. And oppose anything that threatens your paycheck. This is basic Social Darwinist crap with a Utopian gloss.

I knew socialists are humor deficient. You prove that point again.

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And if we didn't know you were Ann Coutler in drag, the fact that anyone who believes in government services is a "socialist" to you underscores the point.

Maybe you're just not funny. Laughable, but not funny.

The evidence also proves that the VA healthcare system provides equal outcomes at lower cost.

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Citation? Proof? Or would they rip off your Rush Limbaugh merit badges if you lowered yourself to the level of your enemies?

So why don't we tear down all those community hospitals, replace them with VA style concrete high-rises, hire a couple of 100thousand physicians and provide healthcare for all medicare beneficiaries using the VA model.

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That would basically be the British/Spanish model of a national health service. We could do that. We'd end up with a healthier population for less money. We don't do it for many reasons. For example: smug, self-satisfied doctors who do everything they can to stop reforms that might derail their gravy train. Know anyone like that?

Same in the US. The US has exactly the healthcare system it wants and deserves, all bitching nonwithstanding.

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So, by your logic, nothing ever changes in democracies, because people know exactly what they want and they vote for it. Consequently, we should talk about stupid and ineffective healthcare, because if it were going to change, it already would have changed. You don't have a rational argument backed up by evidence, but that is irrelevant, because the voters have spoken.

Maybe you're new to democracy, so I should explain that elections actually recur periodically. Officials change, sometimes even policies change, especially when they are glaringly stupid, patently unsustainable and damage powerful interests along with the rest of us. And no one can predict whose ideas will come to the fore when the consenus shifts. It is sometimes a shift in favor of -- gasp -- the expansion of government services. If you're not comfortable with that, maybe you'd be happier in Cuba or China with your fellow historicists.

Which doesn't get you to universal care, and doesn't solve the problem of uncompensated care.

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But closer. And as you so eloquently pointed out, it is more realistic to reform the system one step at a time, rather than trying to revolutionize it. If after making healthcare more accessible and affordable, some individuals still refuse to get covered, maybe it wouldn't be entirely unreasonable to impose the type of tax on living you propose.

The first consequence is that people get care even if they can't afford it. That's necessary. Your fantasy of everyone buying health insurance with the help of a few tax credits is ludicrious.

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Show me the facts, the evidence that this is 'ludicrious'. Have we tried it yet and it didn't work ?

Why don't you look at other goverment policies that are ragingly successful as a model. I am mainly thinking about housing here. In the US, it is possible for anyone with a regular income and minimal discipline to afford a piece of owner occupied real-estate (something you can't say about many other countries). The main mechanisms used by the goverment to promote this desireable situation are tax-breaks for the people who pay taxes, and access to capital for the people who, lets say pay less taxes (e.g. HUD mortgage insurance). Also, through mechanisms like Fannie Mae, the federal goverment uses its power in the financial markets to make mortgages available.
It is not like the goverment builds housing and gives it to people for free (oh, wait, the US did that, its called 'projects', a less successful arm of the housing system).

Oh. I forgot something (just to get you a bit more fired up). I like HSAs ! I don't like the fact that you can't roll them over from one year to the next. If you could put lets say up to 20% of your income tax-free into an HSA (which should actually be a HIA, a health investments account). If you have medical expenses (catastrophic coverage insurance, out of pocket expenses, health-club fees), you can cover them out of the HIA using your 'HIA debit card'. If you don't use the money, you have the option to either invest it at the end of the year, or to get it paid out (-taxes). Lets say you work for 35 years and you manage to put 2k per year into the account, that is 70k principal you can spend on out of pocket medical expenses in retirement (medicare 20% coinsurance, prescription drugs) without the goverment having to give you a dime. I know, investing and saving are evil capitalist concepts, but just give it a thought, won't you.

Meantime, you want to tear down anything that allows the poor to recieve care; Medicaid, Medicare, EMTALA.

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Medicare is not there to provide care for the poor, it exists to provide care for the retired. As I pointed out, I don't want to tear it down, I would like to see it to be a little less of a goverment buerocracy and a bit more of an insurance company. The concept of the working subsidizing healthcare for the retired was the basis of Bismarcks social insurance. It tends to work better if populations are either stable or have a stable growth. In the US with the problem of the postwar baby-boom, the system faces some challenges but overall it is a worthwhile concept. CMS actually does an admirable job in keeping their administrative expenses down. Why would I want to tear it down ?

Medicaid on the other hand is a bit of an anachronism. The fact that the US provides free healthcare if you don't work at all, but takes it away before you even make minimum wage is a disincentive for people who could work, to actually do so. (I am not talking about old folks who are dual eligible where medicaid essentially functions as a medigap policy with prescription benefits. They have contributed to the system, they should be eligible to receive the benefits).
Either the US should make a decision that EVERYONE has a right to healthcare and extend medicaid eligibility to anybody who can't afford commercial insurance, or they should take a hard look at whether it makes sense in the current setup.

As for EMTALA, I have pointed out why it failed (well, the law didn't fail, the hospitals do). If the goverment decided that everyone has a right to be treated in the ER, they should have come up with some sort of mechanism to pay for this mandate (in some of the northeastern states there used to be a mechanism where hospitals essentially billed a state fund for the uncompensated ED care they provided. Didn't cover the full expenses, but at least it provided some measure of relief for hospitals with higher uncompensated ED volumes).

And oppose anything that threatens your paycheck. This is basic Social Darwinist crap with a Utopian gloss.

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Uh, big words.

And if we didn't know you were Ann Coutler in drag, the fact that anyone who believes in government services is a "socialist" to you underscores the point.

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No need to turn this personal. 'Socialist' is not an insult in my book, 'Ann Coulter' is.

You use socialist speak to promote socialist concepts. Consider yourself whatever you want, for me you are a socialist (nothing wrong with being a socialist. some of my best friends are socialists, you wouldn't know it if you met them in the street, they look just like normal people).

The evidence also proves that the VA healthcare system provides equal outcomes at lower cost.

Citation? Proof? Or would they rip off your Rush Limbaugh merit badges if you lowered yourself to the level of your enemies?

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e.g.
N Engl J Med. 2000 Dec 28;343(26):1934-41.
Outcome of myocardial infarction in Veterans Health Administration patients as compared with medicare patients. Petersen LA, Normand SL, Daley J, McNeil BJ.

There are a couple more. I don't think anyone has compared the overall outcomes, when it comes to individual diseases the VA holds its own after you correct for issues such as the often lower socioeconomic status of patients seeking their healthcare in the VA system.

That would basically be the British/Spanish model of a national health service. We could do that.

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That was a rhetorical question.

Maybe you're new to democracy, so I should explain that elections actually recur periodically. Officials change, sometimes even policies change,

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Universal healthcare was on the table in 92, it was voted down by the electorate in 94.
Maybe you are right, the level of 'pain' over the healthcare system has increased in the past 12 years. If a democratic politician put universal healthcare on his platform for 2006, there is a chance that he would win in a landslide

It is sometimes a shift in favor of -- gasp -- the expansion of government services.

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I don't mind them expanding. The healthcare market is expanding, if the goverment has its fingers in some of it why not. I don't think it is healthy if they expand their share of the market.
If the american people, as represented through their elected officials wanted to change to a system of nationalized healthcare, I would deal with that (by either packing up my bundle and moving on, or by leaving medicine to become a consultant to the corrupt healthcare buerocracy). I just don't think that they want that.

If you're not comfortable with that, maybe you'd be happier in Cuba or China with the other historicist

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Say what ?


Oh. While we are at it. I believe that SSI-DI should be reformed. Not abolished, just reformed. Add that to the list of things I want to take away from poor people.

f_w said:

But closer. And as you so eloquently pointed out, it is more realistic to reform the system one step at a time, rather than trying to revolutionize it. If after making healthcare more accessible and affordable, some individuals still refuse to get covered, maybe it wouldn't be entirely unreasonable to impose the type of tax on living you propose.

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I have no problem with the idea of making healthcare more accessible and affordable. I agree that the ideal system would have those who can afford it paying for their health insurance, and the state stepping in to help the very poorest. The primary difference between us seems to be that I am less hostile to the programs we have in place now, even though I recognise their many shortcomings and support their reform.

My primary concern with your position, as I understand it, is that you seem content to do nothing, or perhaps even to reduce or reverse the programs that exist to provide healthcare to the poor, until and unless a global, systematic, market-friendly, doctor-friendly reform is instituted. You would seem to reject a program like the one in Mass., what re-directs existing government spending to get a system that covers almost everyone. Thus it seems as though what you are advocating is, in practice, the same as the ultra-conservative position; end government services and devil take the hindmost.

I know, investing and saving are evil capitalist concepts, but just give it a thought, won't you.

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I compared you to Ann Couter, so I'm going to give you a pass on this one, but I repeat; supporting a certain level of government services and market regulation puts me square in the mainstream, not on the socialist fringe. I do not believe that markets are evil; I have The Wealth of Nations on my bookshelf, years of upper-division econ courses on my transcript, and hundreds of molding Economists in the basement. I have forgotten more about politics and liberal economics than most "small government" dittoheads have ever known.

Medicare is not there to provide care for the poor, it exists to provide care for the retired.

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Prior to Medicare and Social Security, most of the eldery were poor. These are not means-tested programs but they are still an important part of the social safety net.

Medicaid on the other hand is a bit of an anachronism. The fact that the US provides free healthcare if you don't work at all, but takes it away before you even make minimum wage is a disincentive for people who could work, to actually do so. (I am not talking about old folks who are dual eligible where medicaid essentially functions as a medigap policy with prescription benefits. They have contributed to the system, they should be eligible to receive the benefits).
Either the US should make a decision that EVERYONE has a right to healthcare and extend medicaid eligibility to anybody who can't afford commercial insurance, or they should take a hard look at whether it makes sense in the current setup.

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I agree; what we have found in Oregon is that, basically, we can cover all the working poor, along with the poor poor, with the money we spend on Medicaid. What is takes is some mild rationing of care. Apply the same logic to Medicare, and you could cover every person, which is what we need.

As for EMTALA, I have pointed out why it failed (well, the law didn't fail, the hospitals do). If the goverment decided that everyone has a right to be treated in the ER, they should have come up with some sort of mechanism to pay for this mandate (in some of the northeastern states there used to be a mechanism where hospitals essentially billed a state fund for the uncompensated ED care they provided. Didn't cover the full expenses, but at least it provided some measure of relief for hospitals with higher uncompensated ED volumes).

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I agree that the healthcare system is broken. I agree we need a better system. To what you write here I would add that deciding people have a right to emergency care, but not primary care or routine care, creates disasterous incentives that strain the healthcare system from top to bottom. All I am saying is that any reforms need to recognise that people are going to receive care; people having heart attacks are not (and should not) be left to die in the streets. I'm open to any reform that perserves the moral substance of EMTALA.

e.g.
N Engl J Med. 2000 Dec 28;343(26):1934-41.
Outcome of myocardial infarction in Veterans Health Administration patients as compared with medicare patients. Petersen LA, Normand SL, Daley J, McNeil BJ.

There are a couple more. I don't think anyone has compared the overall outcomes, when it comes to individual diseases the VA holds its own after you correct for issues such as the often lower socioeconomic status of patients seeking their healthcare in the VA system.

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Thats for the citation.

Universal healthcare was on the table in 92, it was voted down by the electorate in 94.
Maybe you are right, the level of 'pain' over the healthcare system has increased in the past 12 years. If a democratic politician put universal healthcare on his platform for 2006, there is a chance that he would win in a landslide

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Most popular ideas had an infancy as unpopular ideas. Some good ideas are going to langish forever as political suicide, either because they are stupid in a way that doesn't clearly and immediately effect the electorate and/or the powerful (let's ship more free weapons to Israel!) or because the bad idea gives short-term advantages vs. long-term costs (let's borrow another trillion dollars!) I have some hope, however, that healthcare will not be like that, because the cost increases are unsustainable, the damage to large employers is mounting, and the evidence that you can get better results for vastly less money is all around us.