Biggest Problem Facing Healthcare Today

[medic170]

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I'm sure this will be a topic on secondaries and at interviews, I just was curious about sdner's opinions.

 

[skypilot]

Millions of uninsured patients getting substandard care.

The demand for high tech/high cost medicine is crowding out basic primary and preventative care.

IMHO 🙂

 

[SaltySqueegee]

Millions of uninsured patients getting substandard care.

The demand for high tech/high cost medicine is crowding out basic primary and preventative care.

IMHO 🙂

I second this. In my words:

Broad coverage of health insurance, with adequate monetary compensation for physicians.

 

[Cerbernator]

Sheesh, where to start.

Rising healthcare costs

Loss of physician Autonomy

Increasing "Dr Vs Patient" mentality due to increased risk for litigation

HMO's

etc

 

[Cerbernator]

I second this. In my words:

Broad coverage of health insurance, with adequate monetary compensation for physicians.

Is the care really substandard? I would say tehy may not be getting enough care but I dont think it is fair to call it substandard.

 

[SaltySqueegee]

Is the care really substandard? I would say tehy may not be getting enough care but I dont think it is fair to call it substandard.

Substandard meaning:

A doctor that is not worried about through put, and more worried about getting to know the patient, so that a successful differential diagnosis can be made.

I suppose that falls in line with the Physician Autonomy problem.

 

[skypilot]

Is the care really substandard? I would say they may not be getting enough care but I dont think it is fair to call it substandard.

In my opinion it is substandard. The reason is that patients with chronic illnesses like diabetes wait till there is an emergency and then show up at the emergency room because they have no other way of getting care.

ER physicians are not even supposed to diagnose in the emergency room, they are there to treat and street the patients. It is not the fault of the ER docs, it is just that the system is being misused.

If they were getting a high standard of care they would have regular periodic consultation and management of their chronic illness. I think quality of care is dependent upon continuity.

 

[Cerbernator]

In my opinion it is substandard. The reason is that patients with chronic illnesses like diabetes wait till there is an emergency and then show up at the emergency room because they have no other way of getting care.

ER physicians are not even supposed to diagnose in the emergency room, they are there to treat and street the patients. It is not the fault of the ER docs, it is just that the system is being misused.

If they were getting a high standard of care they would have regular periodic consultation and management of their chronic illness. I think quality of care is dependent upon continuity.

So how do we change this?

 

[confewshz]

So how do we change this?

Thats the billion dollar question. Perhaps a combination of a national health care program and more emphasis on primary and preventative medicine, amongst other things. Just a thought. Any other ideas? (Keep in mind that most alternatives will be costly during the implementation period, but if we emphasize preventative medicine andprimary care, it may assist in decreasing the cost in the latter years of implementation).

 

[automaton]

the relationship between resource distribution and compensation.

 

[romed81]

how about this - 60% of the healthcare resources are used for patients that have 6 months or less to live; don't have an article to support it, but I heard it from 2 different doctors on 2 separate occasions.
How about the fact that Medicare is "borrowing" against Social Security, that relatively soon, there will be no more social security.
How about the fact that doctors (and hospitals) are being forced to deliver high level of care to people with no insurance, which leads to jacking up the prices so that they make up for the losses (i had a tonsilectomy a couple of months ago - it was day surgery - and the total cost was 10,000, out of which the doctor's fee was $750).
and to those I would also add insurance companies telling doctors what they can, and cannot treat, malpractice lawsuits - which lead to astronomical insurance premiums, and so on.
And by the way - compared to other countries the standard of care here in the US is not by any means substandard.

 

[Asclepius]

this is the "crisis" in US health care - we spend more money on health care than any other country in the world, more than twice as much per capita as the runner-up, Canada. But...our quality of healthcare is not the best...I've seen us ranked as low as #20 in the world.

(from my memory of a few publications I've read on the subject...sorry I can't offer any references at the moment; take a look on the web)

 

[medic170]

this is the "crisis" in US health care - we spend more money on health care than any other country in the world, more than twice as much per capita as the runner-up, Canada. But...our quality of healthcare is not the best...I've seen us ranked as low as #20 in the world.

(from my memory of a few publications I've read on the subject...sorry I can't offer any references at the moment; take a look on the web)

Actually, the U.S. is consistently ranked as #1 in health care.

 

[IndyZX]

Actually, the U.S. is consistently ranked as #1 in health care.

link? the US is right there with 3rd world countries when it comes to infant mortality rates, a commonly used measure of the efficacy of a healthcare system.

http://www.nytimes.com/2004/06/28/opinion/28HERB.html

"The fact is that the U.S. population does not have anywhere near the best health in the world," she wrote. "Of 13 countries in a recent comparison, the United States ranks an average of 12th (second from the bottom) for 16 available health indicators."

She said the U.S. came in 13th, dead last, in terms of low birth weight percentages; 13th for neonatal mortality and infant mortality over all; 13th for years of potential life lost (excluding external causes); 11th for life expectancy at the age of 1 for females and 12th for males; and 10th for life expectancy at the age of 15 for females and 12th for males.

http://csmonitor.com/2004/0505/p02s01-uspo.html

http://washingtontimes.com/upi-breaking/20040503-084924-5336r.htm

 

[CJMPre-Med]

And I'm sure that the nations above us don't have as many crack babies and kids with fetal alcohol syndrome being born; I'm also sure they don't have as many impoverished people who don't avail themselves of the healthcare options present in their communities such as vaccinations and screenings for their infants. Poverty is much more highly correlated with infant mortality (due to malnutrition, lack of general hygiene etc.) than is the quality of medical care, and, unfortunately, due to the nature of these confounding variables, we cannot get a clear picture of the "quality" of our medical system. Notice that nearly all of the statistics cited were for very young children ( < 1 year old), and the others (life expectancy for 15 year olds etc.) can perhaps just as readily be explained by the staggering amount of teenage violence and deaths we have in the US as compared with other nations (if by "life expectancy" they are referring to 15 year olds who will not live to see their 16th birthday). If with the comment "life expectancy at the age of 15" they are referring to something else, please let me know.


But my general point about the various factors which can and do contribute to such things as infant mortality and low birth weight in the US as compared with other nations is, I feel, a valid one. I don't know if it's definitely the case, but it very well may be. I don't know if these other nations have such endemic problems with poverty and quality of life for some as we do here in the states.


I can also nearly guarantee you that no other nation above us in that list has the amount of absolutely unqualified, horrible parents that the US does (which is resultant from various factors). In addition, the number of single-parent families is much higher in the US, which will necessarily lead to a child getting less care when he needs it, as single-parents are overworked or unobservant of certain cues denoting illness due to stress, fatigue, or just bad parenting.


Or maybe I'm just totally off base as regards all this... 😛

 

[SaltySqueegee]

Actually, the U.S. is consistently ranked as #1 in health care.

Sweden?

 

[Zweihander]

Actually, the U.S. is consistently ranked as #1 in health care.

Based on what?

Ditto Indy's point; the U.S. also trails in life expectancies and has high maternal mortality rates. We can argue about underlying reasons for this unrelated to the healthcare system, but the fact of the matter is that even if we do have the best technology (which I think we do), our delivery of it to the population at large is abysmal. We pay up to twice as much per person as other industrialized nations do and we have the worst healthcare indicators. That doesn't put us anywhere NEAR "#1."

 

[Asclepius]

Actually, the U.S. is consistently ranked as #1 in health care.

😕 I have never seen this...

From the World Health Organization (an authority, I'd say):

http://www.who.int/inf-pr-2000/en/pr2000-44.html

"The U. S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, the report finds."

Granted, the info is from 2000...maybe there is something more up-to-date available.

 

[skypilot]

The U.S. certainly has the best technology, and some of the best research. And if you get cancer or a brain tumor or need a liver transplant this is the place to be.

But in the trenches of the management of chronic diseases and primary care, the bread and butter of the internal medicine doctor, and family practice doctor, I think this is where we have the problems of delivering an acceptable level of care to all the patients regardless of ability to pay.

😉

 

[IndyZX]

Poverty is much more highly correlated with infant mortality (due to malnutrition, lack of general hygiene etc.) than is the quality of medical care, and, unfortunately, due to the nature of these confounding variables, we cannot get a clear picture of the "quality" of our medical system.

That is probably true that infant mortality is more closely correlated with poverty than lack of direct medical care. Also, it was well said that there are lots of variable at play here, leading to nothing but a hazy conclusion.

However, infant mortality isn't the only relevant factor, here. For example, poor people, who lack access to health services, put themselves at greater risk than their lives already necessitate them being in, due to the fact that they cannot see a primary care physician for regular checkups, etc., therefore only seeking medical attention when there is a true emergency.

There is a better way to provide healthcare in this country, and that way is also the cheaper way. However, when you have big interests like the AMA, HMOs, and big pharma with all their lobbying clout, good ideas prove to go nowhere. That said, there do exist a large amount of physicians who know what's right for this country, and with the fractionalization of that traditional lobbying base, better healthcare can be provided to all.

 

[CJMPre-Med]

Well, although I am totally against socialized medicine, which is what you seem to be alluding to, I will say that people who legitimately cannot afford to pay should have access to medical care if needed, including comprehensive primary care. This, however, must be subsidized in ways which I know will never be implemented (closing corporate tax loopholes such as offshore banking and funneling those funds to medical programs, an absolute income cap at $50M per annum with anything beyond that fed back into the system etc.), and so I cannot truly support socialized medicine; for if these measures are not implemented, and a hasty, ill-conceived model is foisted upon us, the only people who suffer will be physicians, who under no circumstance should be making $80K/year. I do not philosophically agree with the assertion that a physician-- even a primary care doc-- should not be making at least $150K after their 8+ years of rigorous academic and clinical training, super-specialized knowledge, and noble dedication. And while you may insist that nobody is saying that they should make $80K, I submit that such a fate would be inevitable under a socialized system unless strict care was taken in insuring its viability.


If we as a nation desire socialized medicine along with social justice (in my personal moral schema, justice trumps mercy every time, as I feel mercy to be subsumed under justice, but room can be made for both 😛), we should collect the estimated $35-75B (yes, "billion" with a "b") we lose each year in corporate and personal taxes due to offshore banking, compel the astounding 95% of US-based and 50% of foreign-based corporations who incredibly pay no income tax at all on their earnings (wouldn't we be in jail if we did that? 🙄 ) to finally do so, and, lastly, actively seek out and deport all illegal immigrants who would be a drain on the system and commit massive fraud (at least here in NY; I assure you I'm no xenophobe, to preempt any comments in that regard 🙂). In addition, we need to reign in our out-of-control medmal system, which would cut physicians' ludicrous malpractice premiums (in theory), resulting in more take-home pay. Some specialists such as ob/gyn are paying upwards of $100K/year for malpractice insurance in some states, and that is an absolutely indefensible state of affairs.


All such steps and more would be necessary if one is to institute both a fair and sane nationalized healthcare system. Can you see even a single one of those things happening? Because I sure can't. And it's for that very reason that I cannot in good faith support truly socialized medicine, though I would definitely be more amenable to a system wherein those who can afford to pay for services do, up to a pre-set deductible based upon income bracket (sorry, but someone who makes $55K/year can afford to dish out $70 to his primary care physician once every 2-3 months rather than handing over his insurance card and a $10 co-pay). The folks who truly cannot afford these services would then be subsidized by the rest of us; this would be especially beneficial at the primary care level, as, if poor people realized that they could get quality primary care when they needed it (and there was accordingly less reticence on the part of GP's to treat them, as they would be reimbursed at an acceptable rate, and could be thorough in their evaluations and diagnoses) they would likely avail themselves of that option, which would obviate the need for a lot of the more costly procedures and care which is needed when poor folks let their medical conditions get too far out of hand. This strikes me as fair and sensible.


I guess you can sum up this entire post by saying that I do not believe that socialized medicine can be implemented and sustained in a vacuum, particularly not in the US. Unfortunately, given our government's not-so-sterling record in creating new social programs, which often end up as half-measures lacking the proper support structure (funding, personnel etc.), I don't see it being done properly, and so I cannot support it practically. In theory, however, sure-- but a lot of other stuff has to change first. Foresight is not one of our government's better qualities. 😉

 

[Geronimo]

link? the US is right there with 3rd world countries when it comes to infant mortality rates, a commonly used measure of the efficacy of a healthcare system.

http://www.nytimes.com/2004/06/28/opinion/28HERB.html

First of all, I have trouble believing most things in the nytimes , so I must disregard their ranking. Also, the WHO happens to have some bias of their own. Since when has a country that ranks 37th in healthcare performance been the 1st in medical education, the 1st in medical technology, and the 1st in development of new pharmaceuticals. Someone is looking at the issue through a kaleidoscope to rank our nation as 37th.

If you want the best medical training in the world, you don't go to Singapore or England or even Canada. International applicants repeatedly choose the USA.

My wife and I have traveled extensively through Europe, Central America, and Asia. Our experiences with the healthcare systems in the U.K., France, and Italy were disappointing to say the least. We found them extremely inefficient and lacking in results. Guatemala is sub-par in every way when compared with U.S. healthcare. Two of the physicians I worked with while there were both graduates of Northwestern and they complained the entire time about the standards of care in Guatemala. China was just a completely different world. I would even consider it the same kind of medicine as what we consider medicine. Medical schools throughout the world seek out US Medical School graduates to come and teach in their schools.

In my opinion and from my experience, the US health system is horrible, just likes its government and people. However, there is no such thing as a perfect system. We are the best there is, when you look at the overall picture. We are working on the system and we will continue to work on it every day for the remainder of our careers. As physicians we must realize that this is our system. We are the system and I happen to think we will be responsible for what this system becomes on our watch, not the government or some legislator in Washington. I believe we must strive to help others, be other-centered and not $ centered. By following the golden rule day after day in the little decisions we make, we could revolutionize medicine. Take a smaller paycheck and offer a few free office visits to those uninsured patients, do some gratis surgery, and deliver some babies without charging, and take a cut in pay to cover someone?s crazy expensive meds. The more WE take care of the indigent, the less of the burden they will be to our society.

Obviously this is a bit idealistic, but it isn?t impractical if you actually believe in the goodness of people (especially physicians).

 

[Cerbernator]

Well, although I am totally against socialized medicine, which is what you seem to be alluding to, I will say that people who legitimately cannot afford to pay should have access to medical care if needed, including comprehensive primary care. This, however, must be subsidized in ways which I know will never be implemented (closing corporate tax loopholes such as offshore banking and funneling those funds to medical programs, an absolute income cap at $50M per annum with anything beyond that fed back into the system etc.), and so I cannot truly support socialized medicine; for if these measures are not implemented, and a hasty, ill-conceived model is foisted upon us, the only people who suffer will be physicians, who under no circumstance should be making $80K/year. I do not philosophically agree with the assertion that a physician-- even a primary care doc-- should not be making at least $150K after their 8+ years of rigorous academic and clinical training, super-specialized knowledge, and noble dedication. And while you may insist that nobody is saying that they should make $80K, I submit that such a fate would be inevitable under a socialized system unless strict care was taken in insuring its viability.


If we as a nation desire socialized medicine along with social justice (in my personal moral schema, justice trumps mercy every time, as I feel mercy to be subsumed under justice, but room can be made for both 😛), we should collect the estimated $35-75B (yes, "billion" with a "b") we lose each year in corporate and personal taxes due to offshore banking, compel the astounding 95% of US-based and 50% of foreign-based corporations who incredibly pay no income tax at all on their earnings (wouldn't we be in jail if we did that? 🙄 ), and, finally, actively seek out and deport all illegal immigrants who would be a drain on the system and commit massive fraud (at least here in NY; I assure you I'm no xenophobe, to preempt any comments in that regard 🙂).


All such steps and more would be necessary if one is to institute both a fair and sane nationalized healthcare system. Can you see even a single one of those things happening? Because I sure can't. And it's for that very reason that I cannot in good faith support truly socialized medicine, though I would definitely be more amenable to a system wherein those who can afford to pay for services do, up to a pre-set deductible based upon income bracket (sorry, but someone who makes $55K/year can afford to dish out $70 to his primary care physician once every 2-3 months rather than handing over his insurance card and a $10 co-pay). The folks who truly cannot afford these services would then be subsidized by the rest of us; this would primarily be beneficial at the primary care level, as, if poor people realized that they could get quality primary care when they needed it (and there was accordingly less reticence on the part of GP's to treat them, as they would be reimbursed at an acceptable rate, and could be thorough in their evaluations and diagnoses) they would likely avail themselves of that option, which would obviate the need for a lot of the more costly procedures and care which is needed when poor folks let their medical conditions get too far out of hand. This strikes me as fair and sensible.


I guess you can sum up this entire post by saying that I do not believe that socialized medicine can be implemented and sustained in a vacuum, particularly not in the US. Unfortunately, given our government's not-so-sterling record in creating new social programs, which often end up as half-measures lacking the proper support structure (funding, personnel etc.), I don't see it being done properly, and so I cannot support it practically. In theory, however, sure-- but a lot of other stuff has to change first. Foresight is not one of our government's better qualities. 😉

i'd vote for you, excellent post 👍 👍

 

[CJMPre-Med]

I believe we must strive to help others, be other-centered and not $ centered. By following the golden rule day after day in the little decisions we make, we could revolutionize medicine. Take a smaller paycheck and offer a few free office visits to those uninsured patients, do some gratis surgery, and deliver some babies without charging, and take a cut in pay to cover someone?s crazy expensive meds. The more WE take care of the indigent, the less of the burden they will be to our society.

While your idealism is refreshing and noble, I have a huge issue with the implications of your post. Doctors should not have to choose between helping people and making a decent living. Under no circumstance (whether serving an underserved area or a metropolitan area) should a physician of any sort earn less than $150K per annum-- it is not philosophically defensible, particularly under our capitalist model. For the rigorous and lengthy training they endure (8+ years), their unwavering dedication to a good cause, and the specialization of their knowledge and skill-set, doctors should always be among the most well-compensated of professions.

And why should doctors take a cut in pay to help someone pay for expensive meds? Shouldn't you instead be pushing for the pharmaceutical companies to take a hit in their record profits each year? As for the other proposals you make, well, I'm sure many physicians wouldn't mind doing things such as some free services/visits etc. as long as they are making a living commensurate with their training and expertise. Unfortunately, many in primary care are not (and they certainly will not under socialized medicine unless it is implemented correctly, which it will not be), and this results in rushed care and a general antagonistic attitude between physicians and their patient population.


In other words, you must fix a lot of other things first, before you undertake some of these plans. No offense, but your reasoning is pretty suspect. Sure, it's easy to say that money should not be the primary motivating factor in medical care, and, for many-- if not most-- physicians, I'm sure that it isn't. But to say that they shouldn't be concerned about compensation at all? Well, I think that's being a bit naive, particularly after all they've been through and the debt they've incurred-- do you believe that the government is going to repay the $150K+ in loans for thousands of medical graduates? Doubtful.


If you want to institute reform as sweeping as socialized medicine, you had better have a damn good plan for physicians to earn their due, because I don't think that most doctors will work for $90K. In fact, I don't think that anyone who had to endure 8-10 years of academic and clinical training, including a grueling, 80-100 hour/week residency for 3-6 years for sub-minimum wage (hourly), and came out with a $150K+ debt would be as altruistic as you suppose (and I insist that you would not be either, human nature being what it is).

Wanna have these programs you propose? Cut CEO compensation from $20M+ to $2-5M, and give the excess to the doctors who will be doing everything for "free". Nobody in this nation does things for free; I would argue that physicians already do more than any other profession for free, including consulting with other physicians/labs, ordering tests, bureaucratic paperwork, wrangling with insurance companies and their high school grad representatives for reimbursement (why should physicians have to take their valuable time to do this?) and permission to prescribe certain medications given the patient's health plan. With rising overhead and diminishing payments from "insurance" companies (who also reap record profits; why should doctors-- the actual providers of health care-- get shafted, while these 2-year MBA grads make out like bandits? Say "medicine should not be a business" and entirely miss the point), physicians are being put in a squeeze.

If nationalized healthcare is such a priority (as people would have you believe; I believe it's important to have adequate care, but I believe people exaggerate and engage in hyperbole such as health care being a "right"-- where? Which amendment was that?), then we as a society should have no problem drawing funding from other sources which have heretofore been immune from criticism and regulation (see my previous posts).


I admire your motives-- I really do (no sarcasm). I have much of that goodwill in myself as well; but logic and common sense dictate that other things must be changed first in order for any form of socialized medicine to be sustainable and beneficial for all involved parties (patients and providers).


Sorry about all the parentheticals-- my thoughts tend to be all over the place on these matters. 🙂

 

[NICEWHITEKID]

Its a very subjective process when the medical schools are trying to fill quotas and are judging people on "Diversity". Unfortunately bc Im white i have none of that.

 

[bigdan]

I'd vote for racism as a huge societal issue; I'm not convinced that "racism in admissions policies" is the biggest problem in healthcare today, however.

I think that, in no particular order, frivolous malpractice suits, the "code of silence" in error reporting, the uninsured millions, and insurance fraud are the biggest issues.

dc

 

[sweatybrain]

Biggest problem facing healthcare today:

medical students' debt load 😉

 

[Geronimo]

If you want to institute reform as sweeping as socialized medicine......
Wanna have these programs you propose?

First of all, I'm afraid I must have performed poorly in communicating my views. I am proposing no "programs" as such. I am really making no such proposal at all, I'm simply stating that the best way to revolutionize medicine and make it ideal is through the physicians and not through government, bureaucracy, or regulations. Fundamental shifts in the paradigm of medicine must first take place. Follow me as I try and articulate the history of this shift.

For much of this century, health care reform has been on the public agenda. Efforts to enact some form of national health insurance date back over 75 years. During these periodic debates, proponents of national health insurance ? access egalitarians ? typically have pressed for a broad, vision: universal access for all citizens to a unitary system of medical care and to a package of comprehensive benefits without financial barriers. The rhetoric has been that of entitlement ? a right to health care ? and that of egalitarianism ? equal access to a single system for all.

Under a proposal from Senator Edward Kennedy in 1978, the government would have paid for the poor, disabled, elderly, and unemployed through a revised Medicare program. Medicaid also would have been eliminated as unnecessary. Much of the current health care reform debate has its roots in this proposal, with all its struggles and impasses. As much as anything, ideology has hindered reform; different ideological perspectives have, in turn, influenced the way political protagonists have framed the issues and shaped the dialogue.

A good example of this ideological points is the government?s role in the treatment of catastrophic illness. As I am sure is obvious to you, a disease may be deemed ?catastrophic? because of its seriousness or because of the high costs associated with treatment. Focusing on catastrophic disease as a distinct policy matter presupposes that government?s obligation to assure the provision of medical services is not unlimited. If one advocates a ?national cradle-to-grave health care system? and views access to all needed medical care as a ?right,? then consideration of funding for particular illnesses or concern about especially high levels of expense would not be deemed a separate problem to be addressed as a matter of public policy (as you pointed out appropriately). Such advocates might argue that ?equity requires a redistributive allocation of in-kind medical benefits across the board to assure equal access to all types of health care, whatever the health problem.? For such access egalitarians, focusing on catastrophic care may be seen as betraying a fundamental tenet, unacceptably providing only half a loaf, instead of the whole of the bread.

Similar tensions as those surrounding catastrophic care abound in the current round of health care reform debate.

Understanding this, we must define the problems to be addressed by health care reform. In developing and assessing a strategy of health care reform, it is important to define and analyze the problems to be addressed. Broadly speaking, there are two sets of rather distinct health policy issues: those that focus on the characteristics of the medical care marketplace (i.e., efficiency issues), and those that concentrate on assuring better access to care to those without adequate existing levels of access (i.e., equity issues).

The first set of issues deals with the medical care as an industry. The goal of public policy analysis in this regard is to examine the marketplace to determine where it functions properly and where defects in market conditions warrant some form of corrective action. This sounds very much like your point of view with regards to manner of correction. Some would say ?why fix it if isn?t broke??

Once defects in market conditions are identified, a strategy of intervention must be formulated. Regulation-oriented analysts tend to view market imperfections as a justification for substituting a system of government regulation for an imperfectly functioning market. Historically, those analysts prevailed in the health care arena, proposing regulatory approaches without seriously considering market-based alternatives. The analysts assumed that medical care was different from other economic sectors and that market-based principles had little or no place in the formulation of public policy. (I?m afraid this is where you think I am on this issue ? you are mistaken).

In the face of market defects, market-oriented analysts first seek to develop policies designed to improve the functioning of the market. For example, enforcement of the anti-trust laws is a traditional form of government intervention aimed at establishing or preserving a functioning market. Restructuring or redesigning institutions also can improve the functioning of the market by establishing appropriate incentives that lead to responsible public and private decision making. Providing better information to consumers, either directly or through information intermediaries, can improve their ability to make choices in the marketplace.

Over the past twenty years (a little less than my lifetime), market-oriented analysis has played an increasingly important role in national health care policy debates. It is by now beyond dispute that the traditional market paradigms have become an extremely important part of the health care industry and the national policy debate. Attention has been directed to market-based strategies of change, accommodation, and policy implementation. Market oriented theorists do not concede that a regulatory response is necessarily or automatically appropriate when shortcomings in the health care marketplace are identified. Even if government intervention is warranted in certain circumstances, the nature of that intervention can be a critical issue ? whether to improve the functioning of the market or to substitute a regulatory (i.e. political) system as a replacement for the market.

In the private sphere, there are a number of items on the health care reform agenda from the perspective of market-oriented critics. First, the unrestrained tax incentive for high-style medical coverage results in a biased decision making process. Modification of this incentive would require action by the federal government (be careful in jumping to conclusions here just yet). Second, there are legitimate insurance market reform issues relating to the availability and cost of insurance for small groups. Risk is heightened when the size of the insured group is small. Insurance companies demand higher premiums as compensation for greater levels of risk. Reforms that lower transactions costs and facilitate multi-employer grouping would improve the insurance market.
Third, concerns about the system of liability ? the effect of the standard of care on medical practice and the degree to which insurance companies and providers can appropriately balance costs, risks, and benefits ? may exacerbate cost pressures. Some type of reform of the liability system might achieve optimal quality and provide better methods of compensation for medically induced injury. Fourth, some relief from the excesses of current interpretations of the federal fraud and abuse legislation would facilitate rationalization of the medical care marketplace with minimal risks to quality. Once government payment mechanisms emphasize capitation, much of the government?s interest in the more aggressive interpretations of the fraud and abuse legislation diminishes. (Remember I am not necessarily arguing this, I am just pointing this out). Fifth, traditional market-based critiques focus on the constraints imposed by licensure laws. Tasks assigned by law tend to restrict the ability of consumers and providers to develop creative ways to deliver services efficiently, at a low cost, and in consumer friendly ways (your typical capitalistic argument).

Finally, for a market-oriented system to function properly, consumers or their agents (information intermediaries) must have access to data and an ability to act on that information. The most fundamental critique of a market-oriented health care policy focuses on the asymmetry of information between professional providers and consumers. It is now all too common that even the professionals often act in the absence of good information. A market0based strategy of health care reform would encourage the sharing of information, facilitate the understanding of that information, and promote outcomes research to improve our knowledge regarding the efficacy of different modes of treatment.

I have to pause now and bake some chicken for my wife (she?s busy studying for the bar). I?ll be back in a bit to discuss tax reform and the insurance market imperfections (and oh my, do they ever abound).

 

[jlee9531]

First of all, I have trouble believing most things in the nytimes , so I must disregard their ranking. Also, the WHO happens to have some bias of their own. Since when has a country that ranks 37th in healthcare performance been the 1st in medical education, the 1st in medical technology, and the 1st in development of new pharmaceuticals. Someone is looking at the issue through a kaleidoscope to rank our nation as 37th.

If you want the best medical training in the world, you don't go to Singapore or England or even Canada. International applicants repeatedly choose the USA.

My wife and I have traveled extensively through Europe, Central America, and Asia. Our experiences with the healthcare systems in the U.K., France, and Italy were disappointing to say the least. We found them extremely inefficient and lacking in results. Guatemala is sub-par in every way when compared with U.S. healthcare. Two of the physicians I worked with while there were both graduates of Northwestern and they complained the entire time about the standards of care in Guatemala. China was just a completely different world. I would even consider it the same kind of medicine as what we consider medicine. Medical schools throughout the world seek out US Medical School graduates to come and teach in their schools.

In my opinion and from my experience, the US health system is horrible, just likes its government and people. However, there is no such thing as a perfect system. We are the best there is, when you look at the overall picture. We are working on the system and we will continue to work on it every day for the remainder of our careers. As physicians we must realize that this is our system. We are the system and I happen to think we will be responsible for what this system becomes on our watch, not the government or some legislator in Washington. I believe we must strive to help others, be other-centered and not $ centered. By following the golden rule day after day in the little decisions we make, we could revolutionize medicine. Take a smaller paycheck and offer a few free office visits to those uninsured patients, do some gratis surgery, and deliver some babies without charging, and take a cut in pay to cover someone?s crazy expensive meds. The more WE take care of the indigent, the less of the burden they will be to our society.

Obviously this is a bit idealistic, but it isn?t impractical if you actually believe in the goodness of people (especially physicians).

obviously im in the minority when i agree with this post but oh well. haha.

yeah agencies like to use the biased WHO ranking system to try and enact change here in the states, which i guess is a good thing for us if anything does get changed for the better.

but in the end, the US does have the best medical care. we just need to improve the way the health care is dispensed to the masses.

 

[ZappBrannigan]

I think a lot of reasons why the US keeps getting ranked low has less to do with our health care system and more to do with social reasons. We would probably fair better if people didn't eat so much and exercised a bit. For example, Japan has a higher life expectancy than the US, but Japanese people living in America have the same if not higher life expectancy, depending on if they've adopted a more western diet.

 

[g3pro]

Don't the WHO figures also take into account how much "free" treatment is given out? There are some bogus other things they do to make sure socialized medicine comes out on top with capitalist/third world on the bottom. It figures for a socialist-leaning organization such as the WHO. Ditto for the NYT.

 

[Geronimo]

Oh, by the way, sorry if I am boring anyone with my ramblings! Let's see, where was I...

Tax Reform

The general issue. Probably the most significant private sector structural bias in the current medical care environment stems from the tax treatment of medical insurance when provided by employers to employees as a fringe benefit. Employer-provided medical insurance is deductible to the employer as an ordinary and necessary business expense. The medical insurance benefit, without limitation, is excluded from an employee?s income. In practical terms, the tax preference encourages employees and employers to choose comprehensive benefits packages since such benefits are not subject to taxation. Medical care can therefore be paid for in untaxed dollars.

By encouraging adoption of comprehensive benefits plans with relatively small co-payments and deductibles, the existing tax regime has both a static and a dynamic effect on the costs of medical care. Statistically, there is a reduction in revenue to the federal Treasury from this tax structure. Absent the favored tax treatment, expenditures on medical care or other employee benefits such as wages would be subject to taxation. Dynamically, the implicit government subsidy of medical care biases decisions regarding the purchase of medical care. It encourages adoption of ?the type of plan that biases decision making toward spare-no-expense medical practice.? This surely has contributed to the price and cost escalation confronted in the medical care sector.

Implications for government role in the private sector. The tax reform issue is critical in understanding the nature and propriety of government intervention in private medical care. In a market economy, private resource allocation decisions are made at a decentralized level by individual firms and households. Aggregated data regarding allocative choices are ascertained after the fact; such macro choices are, in a fundamental sense, discovered ex post by national income accountants. They are not made ex ante in any conscious, collective sense. Thus, where the private market reigns, government has little role in determining how resources are to be allocated. For example, it would be quite foreign to pose, as a problem for government consideration, the question of whether resources for personal computers are excessive. The fact that the allocation of resources for such uses in recent years has escalated in not the government?s concern. Thus, the collective problem of resource allocation is foreign to a properly functioning private market, because resource allocation decisions are observed in a statistical sense, not made in a consciously collective sense.

If resource allocation decisions in a private market are not legitimate concerns of the federal government, why do we hear so much about government?s interest in medical care cost containment? For example, in public dialogue, the Clinton Administration did not differentiate between government?s concern regarding cost containment in public expenditures in the Medicaid and Medicare programs and government?s role regarding private medical care expenditures. It appears the Bush administration has followed suit.

The case for government?s concern regarding the expenditure of public funds is clear cut: unless government?s is prepared to cede to patients and providers full authority to allocate public dollars in accordance with professional perceptions of medical need, it is self-evidently necessary for government to consider resource allocation priorities in the expenditure of public medical care dollars. Because of the need to view government medical expenditures in light of other claims on public financial resources, consideration of aggregate levels of public program expenditures is essential.

With private sector medical care expenditures, the primary rationale for government?s interest in the issue stems form the structural bias resulting from the tax subsidy. Government?s role in the private marketplace is to improve the functioning of the marketplace, and in the medical care arena the bias toward ?spare-no-expense? practice styles arguably can be traced to the distortions imposed by the tax subsidy. In the absence of that governmentally created bias, or some other form a market failure, government?s role in the private medical care marketplace only can be justified on the basis of equity, not efficiency.

Political considerations. Dealing with the tax bias issue raises considerable political problems. Unions have opposed any move to eliminate or water down existing tax advantages. They tend to view these initiatives as undermining core supporting elements of fringe benefit packages won during years of tough labor negotiations. Tax reform of this kind can be seen as a ?take away.? Thus, the equitable or distributive dimension has blocked this important reform. To offset the distributive consequences of tax reform, measures to mitigate the effect must be linked with tax reform initiatives.

Despite these political realities and crosscurrents, the major Democratic plans recognize the potency of the market-based critique of these tax incentives. The Clinton Administration acknowledged the significance of the issue, but dodged the political hot potato by delaying any change. The Clinton plan did not limit deductibility of medical insurance expenditures by employers but rather included the extra value of such an employer-provided benefit as income to the employee. Given the political realities, this raises a question whether the cap contemplated by the Clinton plan can ever be realized.

The health care reform plan sponsored by Representative Jim Cooper (a good ?ol Tennessee boy) would raise significant sums by curtailing the current tax treatment of employer-provided medical insurance benefits. Under the Cooper approach, deductibility of medical insurance expenditures by employers would be capped at the cost of the least expensive plan that met federal guidelines. If implemented, that approach would reduce the distortion of private choice resulting from the current unlimited deductibility of medical insurance expenditures. The Cooper plan also would extend deductibility for medical insurance payments to employees so that persons employed by companies that did not provide medical insurance could purchase coverage on their own and receive the same tax treatment as their employers would.

Clearly, both the Clinton and current administration have sought and seek to minimize the political effect of its tax reform initiative by delaying the impact for several year and by capping the tax benefit at a very generous level that will rise with the increase in medical care costs. By placing the onus on employees, the plan faces maximum political headwinds as the election approaches and may never be implemented even if approved during the present health care reform debate. The Cooper plan is much more faithful to the market critique, but it suffers from a lack of political appeal to unions and employees, who will undoubtedly view the proposal as a take-away. Representative Cooper relies on savings from the reduced subsidy to finance other portions of his proposal, making the take-away dimension of the plan clear. It will be interesting to see whether the impetus for health care reform linked with the desire for some form of bipartisan compromise will make the Cooper strategy politically viable. Not considering distributive effects, the Cooper plan is clearly preferable to the Clinton proposal in efficiency terms by improving the functions of the medical care marketplace, but faces great political opposition.

Again, I find myself returning to the kitchen. Will continue later----

 

[Geronimo]

Insurance market imperfections

When individuals or small groups seek to purchase medical insurance, the face high prices. The reason are largely two-fold: Administrative costs are high and actuarial risk is great. The administrative issue is easy to understand. The one purchases in volume, unit costs tend to decline. The same is true of the insurance market. It is expensive to set up an administrative system to handle small numbers of enrollees. There are economies of scale in administering larger group plans. Furthermore, the actuarial risk is great with individuals or small groups. Insurance companies do not have assurance that individuals or small groups are not likely to be more costly to insure. In those circumstances, the insured probably will have better information about risk than the insurance companies. This is often called the problem of adverse selection. As a consequence of that market reality, insurers understandably need considerable risk premiums to undertake those potentially higher risks.

The idea of a health insurance purchasing cooperative was designed in large part to deal with the problem of small businesses into larger pools of insureds to lower unit costs for administration. It also should reduce the actuarial risk premium because the risk is spread over a larger population pool and the risk of adverse selection is mitigated.

The Cooper plan (if you?ll recall from my last post) retains the market-improving dimension of the purchasing cooperatives. The health plan purchasing cooperatives (HPPCs) called for by Rep. Cooper would be state-chartered, non-profit institutions with an exclusive geographic territory. They would empower small businesses by allowing the combination of employees from many employers to negotiate with providers and thereby increase their leverage. The HPPCs would negotiate with and provide access by members to accountable health plans (AHPs), which must offer at least a standard package of federally defined minimum benefits, but may offer coverage beyond the standard federal package.

All businesses with fewer than 100-500 employees would be eligible to join an HPPC, as would all individuals not employed by large businesses. Small businesses and individuals would not be required to join an HPPC, however, and employers would not be required to provide medical insurance for their employees. Employers, employees, and self-employed persons that pay for medical insurance all can deduct 100% of those premiums. This deductions would be capped at the cost level of the least expensive AHP available through the HPPC.

By allowing small business and individuals to join HPPCs, the Cooper plan focuses on improving the insurance market. The capping of the tax benefit for medical insurance expenditures at the price of the least expensive AHP means that extra medical benefits will be purchased with after-tax dollars. The Cooper plan therefore retains the federal government subsidy to the point that a plan is qualified under federal guidelines to satisfy the requirement of a core benefit package. Beyond that level, private decision making is relied on to determine appropriate expenditures. This conforms to the market-improvement rationale, which holds that resource allocation decisions in the private medical care marketplace are to be left in private hands provided that they are not biased by federal tax subsidies. The tax benefit cap in the Cooper plan satisfies that criterion and therefore makes unnecessary and unwarranted any attempt by the federal government to establish an overall expenditure cap for private sector outlays. Those are private allocative choices that, unbiased by a tax subsidy, reflect the sovereignty of the purchaser in determining what and how much to buy.

The Cooper plan also strikes a balance between providers/insures and consumer/employers by not allowing large companies to join the HPPCs. Large employers would be expected to negotiate with insurers or providers on their own. Thus, insurers and providers would be assured of a market that has more than a single purchaser. Providers would have the option of not participating in some plans and even not participating at all in an HPPC plan, provided that there was enough of a market among large employers to support them. (This is where physicians taking less pay comes in. By choice a physician can choose to treat, and even purchase meds for patients who are not in any ?plan? and cannot otherwise receive treatment.

Under certain liberal versions of the Cooper plan, participation in a Regional Alliance is mandatory and employers are required to pay for medical insurance for their employees (California being a good example). Detailed provisions regarding cost sharing are included in the proposal, and the mandated comprehensive package of benefits is defined in the legislation. Caps on overall expenditures and insurance premiums are establish by statutory formula.

Alain Enthoven, one of the founders of the concept of managed competition (which was embraced by Clinton during his presidential campaign, has been critical of the concept of health insurance purchasing cooperatives. He observed the problems small groups had in purchasing health insurance, that is, the goal was the improvement of the market to establish an institution mechanism by which the market could function efficiently. Insurers charge high prices to small groups because the cost of administration and marketing are high and because if someone in the group is sick, the costs cannot be spread out. Health plan purchasing cooperatives?.would spread risk over a large population, achieve economies of scale in marketing and administration, and ensure a choice of health plans to all employees of small firms.

Enthoven notes the incongruity of the plan with the objectives of those who developed the concept of managed competition. The Regional Alliance thus appears as a monopolistic, regulatory government agency that will cause more problems than it solves. By requiring all employers with fewer than 5000 employees to provide medical insurance through a Regional Alliance, the whole U.S. population would purchase care through these alliances, making them virtually the only customer in the market. Because of the one percent of payroll tax for large employers that choose not to join the alliances, the liberal version of the Cooper plan ?virtually forces? these large employers into the Regional Alliance as well. These monolithic alliances look suspiciously like a government-controlled single-payer system, which may be the intention of those who seek the inclusion of large employers in the Health Alliance system.

When looking at this ?revised plan? one must raise the broader question of what objectives the plan is pursuing. One might argue that the plan has gone well beyond the market-improvement goals of the original managed competition plan. The plan?s treatment of antitrust reform issues demonstrates the internal tensions within the proposal. In a concession to consumers wishing to have an option for a traditional fee-for-service plan, some who propose this ?revised plan? would guarantee that each Regional Alliance offer at least one fee-for-service plan. Fee-for-service plans would operate under a fee schedule, which could be negotiated by each Alliance with providers within its region or, at the discretion of the state, could be established statewide by any state.

However, ---okay, must pause for "Everybody loves Raymond"
The wife calls, so the husband must answer 😀

 

[CJMPre-Med]

Geronimo, thanks for taking the time to articulate your (extremely well-considered) views on this matter. 🙂 Though it was difficult to locate any sort of thesis, as this seemed more of an expository essay, the one recurring strain in the work seemed to be the role of the tax subsidies afforded to employers who provide group care packages, which then compelled government to stick their grubby little paws into the health care field due to the resultant loss of tax revenue. That's something that I had honestly never considered previously; most of my thoughts on this field are merely informal, and my "evidence" anecdotal, as I haven't done any sort of research (as you obviously have) as to the various explicit and hidden costs associated with the system and the reasons for their existence. I have more to say, but it will have to wait for tomorrow at the very least, as I have an exam to study for. 🙂


Oh, and please tell me that that was an analysis you had written previously for some course or journal-- it was of impeccable quality in both the writing and its manner of progression and clarity. It strikes me as academic writing, and high-quality writing at that. If, however, you just wrote that from scratch for the purposes of this thread, well, considered me very impressed. 😛 And I'm not easily impressed. 😀 But I don't buy it. 😉 🙂

By the way, I'm sorry if I misrepresented your stance in any of my posts; I'm sure your posts thoroughly clarified your position for anyone who was curious (though as I mentioned, it was more elucidation than exhortation; so it is difficult to get a read on your personal feelings re: these issues 😛).


PS: I take exception to your previous post regarding how "horrible" the people of the US are. I'm a US citizen, and I'd like to think that on my good days I'm not so terrible as you would suppose. 😉 You wouldn't happen to be French by any chance, would you? 😛


EDIT: I posted this prior to seeing/reading your latest post just above, so I will do so now.

 

[SaltySqueegee]

I'm sure this will be a topic on secondaries and at interviews, I just was curious about sdner's opinions.

Doctors...

 

[Geronimo]

It strikes me as academic writing, and high-quality writing at that. If, however, you just wrote that from scratch for the purposes of this thread


You wouldn't happen to be French by any chance, would you? 😛


EDIT: I posted this prior to seeing/reading your latest post just above, so I will do so now.

As it turns out, I'm TN born and TN bread and when I die, I'll be TN dead

No, this isn't scratch for the purposes of this thread. I'm pulling this from my lecture notes. My students seemed to have hated this but I'm pretty sure they got my point after 12 weeks of this stuff. I've got plenty more to say on the subject so I'll type it up in a minute. Raymond led to other activities last night 😍 To be honest though, I think the fact that I cooked dinner did it !!!

 

[aingeal]

In my opinion it is substandard. The reason is that patients with chronic illnesses like diabetes wait till there is an emergency and then show up at the emergency room because they have no other way of getting care.

ER physicians are not even supposed to diagnose in the emergency room, they are there to treat and street the patients. It is not the fault of the ER docs, it is just that the system is being misused.

If they were getting a high standard of care they would have regular periodic consultation and management of their chronic illness. I think quality of care is dependent upon continuity.

often the problem is in the mindset of patients who frequent ERs rather than going to regular checkups

also, this is not a b&w issue, HMOs emphasize preventative care, and do have some good programs out there (help quit smoking, healthy lifestyle, etc)

the fact is, more and more its about the bottom line
and in reality, regulation of a field like medicine is a necessary evil

there needs to be balance, though, and good docs shouldnt be punished for the actions of a few bad seeds

also, many docs signed upw HMOs for the attractive sign-on benefit, and are now dealing w the consequences

 

[Geronimo]

For those who feel I have totally lost my point, you are right. I feel that in order for me to completely express myself of the concept of the biggest problem facing healthcare, you must understand where my view of healthcare comes from. That is why I have begun this exposition on health care reform..

to continue...To facilitate negotiations between providers and each Regional Alliance, the more liberal proposal creates antitrust immunity for the establishment of a fee schedule and for collective negotiations between providers and the Regional Alliance. Clearly, this is not a market-oriented paradigm but a countervailing-power model, which is why antitrust immunity is necessitated. Nonetheless, this proposal is unwilling to abandon the antitrust law?s reliance on a market-based model in favor of its collectivist/political, countervailing-power model. After establishing antirust immunity for collective negotiations by providers regarding a fee schedule, the proposal hedges. The antitrust immunity extends only to collective negotiations, defined as the process by which providers collectively and jointly meet, confer, consult, discuss, and share information. The immunity, however, does not cover threatening or engaging in a boycott, which is the conventional way to secure leverage from collective negotiations. This admixture of different conceptions of what path to pursue seems to permeate this proposal and exemplifies the kind of doctrinal shifts that Enthoven has criticized.

Equity Issues (the other big side of this debate)

Market based reforms, which are designed to improve the functioning of the marketplace and thereby to enhance economic efficiency, are not intended directly to address questions of equity or income/wealth redistribution. Concerns regarding equity or distributive justice are not problems ?unique to or caused by the health care system.?

The desire to provide access to medical care to ?defined groups of needy persons? may raise important public policy issues, but any perceived sense of injustice does not derive from an inability to perform the medical delivery function well but from an inability to transfer income in the process. The objective of market-based reforms is to restore a system in which decision makers face appropriate incentives and share in the benefits and burdens that arise from their own choices. Such reforms seek to minimize the distorting effect of governmental redistributive efforts on private health care decision making. In short, the competitive approach is designed to improve efficiency in the allocation of resources. It does not directly address the question of equity of access, except that it rejects the ideological stances that (1) health is an ultimate good and therefore not subject to tradeoffs and (2) equal utilization of medical services is an absolute equitable imperative, unrelated to private preferences and different private resource constraints.

Therefore, the market oriented strategy makes no specific claim about the proper eligibility criteria or level of medical services that society should provide to worthy and needy persons. It takes no position on what degree of redistributive munificence is proper in the medical services field.

Dealing with equity questions, therefore, requires examination of a different set of issues than those involved in improving the efficiency of the medical care marketplace. Some normative benchmark is needed to determine the nature and scope of society?s obligation to provide or pay for medical care for those currently without access. Further, once the nature and scope of public responsibility is determined, public policy formulation must take into account considerations of institutional design, including whether to create an entitlement or, following the recommendation of the President?s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, to focus on society?s obligation to provide equity of access and avoid using the rhetoric of rights.

Looking to the background of this issue, the concern about access to medical care has a long history in the USA, dating back to the period prior to WWI. For example, the Bull Moose platform of 1912 on which Theodore Roosevelt ran for president called for national health insurance. Comprehensive national health insurance also was advocated by Presidents FDR and Harry S. Truman. In the mid-1960?s, the enactment of Medicare and Medicaid reflected the triumph of an incrementalist approach toward expanding access to medical care. Proponents of comprehensive national health insurance viewed Medicare and Medicaid as a beginning and not a culmination of over fifty years of effort. They represented a first step toward a strategic phase-in of broader comprehensive national health insurance.

During the 1970?s, both Democrats and Republicans backed some form of national health insurance, although the Carter Administration rejected enactment until its economic recovery program had more time to succeed. In the early 1980?s, escalating health care costs focused attention on Medicare and Medicaid. This concern about costs of public programs added a ?Sense of balance? to health policy discussions, which had focused almost exclusively on the goals of access and quality. Worries about public expenditure raised questions about the so-called uncontrollable items in the federal budget?the various government entitlement programs, which reduce governmental budgetary flexibility because they are not required to run the political gauntlet and compete for annual appropriations. The previous ?political untouchability? of health care entitlement programs was purportedly to be subject to ?review and reappraisal.? Skepticism was expressed regarding ?more expansive national health insurance commitments? because they would exacerbate the problem of uncontrollable federal expenditures.

While voices of concern regarding the scope of government expenditures were being raised, access issues would once again come to have great political potency. In the mid-1980?s, access issues re-emerged as part of the problem of uncompensated hospital care. More uncompensated care means less revenue is available for hospitals to cross-subsidize other institutional objectives.

Professor Frank Sloan and his colleagues were among the first to quantify the magnitude of uncompensated hospital care, finding that it amounted to about six percent of total payments to hospitals nationwide in1982. Hospitals complained about this drain on their revenues and helped to place the issue on the national agenda. However, while hospitals were raising concerns about their revenue picture stemming from uncompensated hospital care, analysts were quick to point out that the term uncompensated care reflects the perspective of health care providers. The broader societal perspective is the problem of providing adequate health care to all members of our society, including members of the lower-income groups who may not be able to pay for such care or who can do so only with hardship. Resolution of that problem requires reaching a determination regarding the appropriate scope of public responsibility?what constitutes ?adequate? health care, who qualify as beneficiaries and on what terms, and how access will be paid for.

In the 1980?s, considerable expansion of access to public medical care programs occurred. This expansion was achieved largely by adding to the coverage under Medicaid. It was incremental in character, focusing on access for those deemed most in need or most deserving. Pregnant women and children represented the primary groups of persons receiving greater access as a result of legislation enacted during the Reagan and Bush Administrations. Perhaps the single largest expansion of Medicaid coverage occurred as part of the famous tax and budget deal of 1990 when children in poverty of age six through eighteen were added as required beneficiaries under state Medicaid programs. That benefit was to be phased in on a year-by-year basis until the entire age group was mandatory covered. At the end of Bush Senior?s Administration, therefore, indigent pregnant women were entitled to Medicaid benefits, children through age five in families with income not exceeding 133% of the federal poverty level were entitled to Medicaid benefits, and, on a phase-in basis, children of age six through eighteen in families with income not exceeding 100% of the poverty level were entitled to Medicaid benefits. The current health care reform debate must take into account the expanded access for children in poverty already provided for as a result of legislative change over the past twenty years.

 

[skypilot]

What about the 44 million uninsured? Maybe that is the biggest problem.

http://www.commondreams.org/headlines04/0511-07.htm

 

[flighterdoc]

 

[ken37]

Well, although I am totally against socialized medicine, which is what you seem to be alluding to, I will say that people who legitimately cannot afford to pay should have access to medical care if needed, including comprehensive primary care. This, however, must be subsidized in ways which I know will never be implemented (closing corporate tax loopholes such as offshore banking and funneling those funds to medical programs, an absolute income cap at $50M per annum with anything beyond that fed back into the system etc...

?!? Are you saying that there should be no incentive to earn more money than that? I'm pretty sure if the government took 100% of earnings above that, that people would mnot see any incentive to earn above that. All this would do would be to stifle the entrepeneurs that build capital and jobs (God, I sound like a republican without the God rhetoric). Reall, eliminating tax loopholes is great, but there can never be a 100% bracket, or either people would dtop earning above that amount, or cheat and hide money like crazy.

... and, lastly, actively seek out and deport all illegal immigrants who would be a drain on the system and commit massive fraud (at least here in NY; I assure you I'm no xenophobe, to preempt any comments in that regard 🙂).

Xenophobe!

Really, though, illegal immigrants take jobs that most Americans would never take. It seems as though legal Americans would rather stay home and collect welfare, WIC, etc than to work a low paid manual labor which is mostly what illegal immigrants do.

In addition, we need to reign in our out-of-control medmal system, which would cut physicians' ludicrous malpractice premiums (in theory), resulting in more take-home pay. Some specialists such as ob/gyn are paying upwards of $100K/year for malpractice insurance in some states, and that is an absolutely indefensible state of affairs

Well, then have those ob-gyns stop killing babies!!! 😀 Really, you are right about this. A part of the solution that many doctors seem to ignore in favor of blaming the lawyers for everything is that bad doctors need to have their licenses revoked.

... though I would definitely be more amenable to a system wherein those who can afford to pay for services do, up to a pre-set deductible based upon income bracket (sorry, but someone who makes $55K/year can afford to dish out $70 to his primary care physician once every 2-3 months rather than handing over his insurance card and a $10 co-pay). The folks who truly cannot afford these services would then be subsidized by the rest of us; this would be especially beneficial at the primary care level, as, if poor people realized that they could get quality primary care when they needed it (and there was accordingly less reticence on the part of GP's to treat them, as they would be reimbursed at an acceptable rate, and could be thorough in their evaluations and diagnoses) they would likely avail themselves of that option, which would obviate the need for a lot of the more costly procedures and care which is needed when poor folks let their medical conditions get too far out of hand. This strikes me as fair and sensible.

Hmmm, I got a physical earlier this year, paid 2 copays of $25 each (one for lab draws, the other for the visit the next week), and still got billed another $375 for non covered services. I would love to have the $10 copay (which i did until this year), but many companies seem to have sharply increased their copays and decreased their reimbursement schedules this year, all while increasing the premiums. However, that being said, if you can go to the doctor too cheaply, people may tend to overutilize the doctor, stressing the sytem and costing the insurance company unneccesarily. Additionally, what makes you think that poor people, or any people for that matter, would be more likely to go to the doctor for preventative workups more than they do now. Most people know what they should do to avoid heart disease, HBP, etc in the future, but still eat like crap, don't exercise, smoke, drink, etc. The whole culture of America needs to change, not just the copay schedule for preventative care. Hell, even the American medical system has a much greater emphasis on curing disease rather than prevention. Even the government, which is the only entity that can reasonably guide the public health system, spends almost nothing on preventative public health expenditures, such as vaccination, education, etc (there is a great article in this month's Harper's about this).

I guess you can sum up this entire post by saying that I do not believe that socialized medicine can be implemented and sustained in a vacuum, particularly not in the US. Unfortunately, given our government's not-so-sterling record in creating new social programs, which often end up as half-measures lacking the proper support structure (funding, personnel etc.), I don't see it being done properly, and so I cannot support it practically. In theory, however, sure-- but a lot of other stuff has to change first. Foresight is not one of our government's better qualities. 😉

Agreed 😀