on to the supreme court

[Eilat87]

http://news.yahoo.com/s/ap/20101213/ap_on_bi_ge/us_health_care_overhaul_virginia

how do you guys think this will pan out?

---

Members don't see this ad.

 

[IvyHopeful20]

I think there is a small chance it will be ruled unconstitutional, but not much. The commerce clause has been stretched to include virtually everything so there is a lot of precedent that the court will rely on.

I think either way, the main battle to keep, expand, or repeal the law will happen in the legislature, not the courts.

 

[JaggerPlate]

I think either way, the main battle to keep, expand, or repeal the law will happen in the legislature, not the courts.

Agreed, but these lawsuits are more symbolic than anything else. The fact that the judge declared it 'unconstitutional' simply gives those who want to replace/repeal more momentum, especially when campaigning. It's actually a pretty big slap in the face, and is going to make the administration look weak on Monday when they begin the inevitable appeals process.

 

[JackADeli]

...The commerce clause has been stretched to include virtually everything so there is a lot of precedent that the court will rely on...

There is not any strong precedent in this case. In essence, unlike any previous application of the commerce clause, the current issue is a mandate to engage in commerce, i.e. purchase healthcare or a penalty for failure to do so. The main argument often tossed around is that of STATE laws requiring auto-insurance. Again, not a really applicable precedent.

First, and probably most important, auto-insurance laws are at the STATE level and within the state rights based on their jurisdiction in licensing. It is not the federal government mandating auto-insurance. Because, that is not an enumerated power of the federal government.

Second, auto insurance requirements are a condition to license/driving. You seek a license within a state and/or choose to drive a specific type of vehicle. This goes back to the healthcare mandate being a penalty for inaction. That is, the law is by effect saying an obligation of mere citizenship, one must purchase health insurance or pay a penalty. There is absolutely no constitution right to obligate the purchase of goods and services as an obligation of citizenship.

That all said, do I or anyone else know what the ivory tower supremes will do? no.

 

[IvyHopeful20]

There is not any strong precedent in this case. In essence, unlike any previous application of the commerce clause, the current issue is a mandate to engage in commerce, i.e. purchase healthcare or a penalty for failure to do so. The main argument often tossed around is that of STATE laws requiring auto-insurance. Again, not a really applicable precedent.

First, and probably most important, auto-insurance laws are at the STATE level and within the state rights based on their jurisdiction in licensing. It is not the federal government mandating auto-insurance. Because, that is not an enumerated power of the federal government.

Second, auto insurance requirements are a condition to license/driving. You seek a license within a state and/or choose to drive a specific type of vehicle. This goes back to the healthcare mandate being a penalty for inaction. That is, the law is by effect saying an obligation of mere citizenship, one must purchase health insurance or pay a penalty. There is absolutely no constitution right to obligate the purchase of goods and services as an obligation of citizenship.

That all said, do I or anyone else know what the ivory tower supremes will do? no.

In the healthcare law, it's written as a sort-of tax, which obviously the government has the power to enact. So we'll see. So you pay a tax, and if you buy healthcare insurance, you're exempt from that tax.

So far, out of three rulings, two were in favor, one against. So it could go either way. I feel from what legal scholars are saying, it'll probably stand. But we'll see.

 

[poorracerkid]

There's no "sort of" about it. It's a tax. A graduated one, but a tax.

 

[JackADeli]

In the healthcare law, it's written as a sort-of tax, which obviously the government has the power to enact. ...So you pay a tax, and if you buy healthcare insurance, you're exempt from that tax...

There's no "sort of" about it. It's a tax. A graduated one, but a tax.

There in is the problem. The way the law is written specifically defines it outside of taxation. In addition, in case someone misunderstood their defining it outside of taxation, all writers and supporters spent the good part of the year explaining and stating that it is NOT a tax. The administration is still claiming it has not raised taxes while it is in court trying to redefine this as a tax.

I am certain plenty of politicians would love to have the loop hole of simply redefining everything under the commerce clause as a power of "taxation". The law is not written that everyone pays the federal government a healthcare tax and those that purchase private healthcare may take a tax deduction. In fact, our tax law already allows for deductions in cost of healthcare.

Rather, the law mandates you purchase healthcare (aka goods/services) and if you do not purchase then you pay the government a fine, aka penalty. The claim of it now being a tax is evidence that they know it was outside the scope of constitutional powers. These are the points specifically addressed by the federal judge.

Your sequence of explanation/redefining is the exact oposite of the reality in the law:
You write, "you pay a tax, and if you buy healthcare insurance, you're exempt from that tax"
vs.
The reality of the written law, "You buy the product or else you get fined". Furthermore, the product has to be the ~model required by the government. That is, you have to purchase as much coverage as they say....

 

[bigmike7104]

http://www.newsweek.com/2010/11/05/why-healthcare-reform-will-survive.html

Check out this article written by a guy whose former job was to stop any health care reform that would hurt the insurance company's profits.

 

[physasst]

There is not any strong precedent in this case. In essence, unlike any previous application of the commerce clause, the current issue is a mandate to engage in commerce, i.e. purchase healthcare or a penalty for failure to do so. The main argument often tossed around is that of STATE laws requiring auto-insurance. Again, not a really applicable precedent.

First, and probably most important, auto-insurance laws are at the STATE level and within the state rights based on their jurisdiction in licensing. It is not the federal government mandating auto-insurance. Because, that is not an enumerated power of the federal government.

Second, auto insurance requirements are a condition to license/driving. You seek a license within a state and/or choose to drive a specific type of vehicle. This goes back to the healthcare mandate being a penalty for inaction. That is, the law is by effect saying an obligation of mere citizenship, one must purchase health insurance or pay a penalty. There is absolutely no constitution right to obligate the purchase of goods and services as an obligation of citizenship.

That all said, do I or anyone else know what the ivory tower supremes will do? no.

Other than the precedent set by the second President John Adams that is, right?

I mean, he mandated that all merchant seamen pay a tax to cover healthcare services, including building hospitals for them. It was our first healthcare mandate, and seamen did not have a choice on whether to pay or not. There wasn't really health insurance at that time, but the 1798 Act for the Relief of Sick and Disabled Seamen basically created one.

So I really wouldn't say that there is no precedent, and I would think that President Adams would know more about Constitutional intent than anyone alive today.

 

[JaggerPlate]

http://www.newsweek.com/2010/11/05/why-healthcare-reform-will-survive.html

Check out this article written by a guy whose former job was to stop any health care reform that would hurt the insurance company's profits.

See, here is where I become confused. I want to explain two conflicting points of view I've heard on this issue. I'm really not interested as to which vision is aligned with which political party, etc, more just looking for clarity:

POV 1:

Insurance companies love the ACA and want it pushed through in it's entirety because it's a huge boom to them

POV 2: Because the mandate does not set a high enough tax nor does it enforce any sort of rules with regard to dropping and signing up for insurance with pre-existing conditions, healthy patients could very easily (especially if the cost for insurance is more than the cost of the tax/penalty for not carrying insurance) simply skip out on insurance when they are healthy, sign up when they get sick, rack up a bunch of costs, get treated/better, then ditch it and continue to pay the tax.

However, insurance companies survive based on the idea that everyone pays in, 90% of the people aren't racking up millions in chronic disease/trauma treatments, so the 90% payments from the 'healthy individuals' cover the big costs of the smaller amount of sick/injured people. However, without this 90% (just a made up number) cushion, the private insurance companies can't stay afloat, and will eventually collapse (leading to what many think will be government stepping in).

So which is it? Somewhere in between? Am I missing something? I thought I was fairly clear until recently hearing a lot of passionate opinions regarding POV 1 or POV 2, and I simply don't see how both can exist.

 

[JackADeli]

Other than the precedent set by the second President John Adams that is, right?

I mean, he mandated that all merchant seamen pay a tax to cover healthcare services, including building hospitals for them. It was our first healthcare mandate, and seamen did not have a choice on whether to pay or not. There wasn't really health insurance at that time, but the 1798 Act for the Relief of Sick and Disabled Seamen basically created one.

So I really wouldn't say that there is no precedent, and I would think that President Adams would know more about Constitutional intent than anyone alive today.

It is a red herring to try and point to all the SPECIFIC TAX laws past. The current mandate is not written as a tax. It is written, "you must buy this or pay a fine". So, the two are different. The mandate to purchase is that a mandate to purchase. It is not written as a tax and the proponents specifically spent a upwards of a year explaining how it was not a tax.

If the proponents want a specific healthcare tax with an associated deduction, they should have and easily could have written that law in under 2 pages as opposed to over 2ooo. It is very simple, i.e.:

Each American shall pay the IRS a federal tax of ?$5000.00 each year in the name of public medical and health services. Any American that pays in excess of ?$7500.00 in medical and/or healthcare costs shall be exempt from said tax.

Of course, to get it passed, you could add a few pages of bridge building, prescription drug funding, college funds, etc..... What the tax monies ultimately go to in the past present or future is a different argument. We can then talk about social security taxes, medicaid or medicare taxes. But, those are written specifically as a tax. The current issue was written not as a tax but an order to purchase goods and services. Pretty sad to constantly watch people write, say, and do things and then have large masses of people arguing, "he/she didn't mean what they wrote, said, or did.... they are such good people and really meant x, y, z...".

 

[JaggerPlate]

Each American shall pay the IRS a federal tax of ?$5000.00 each year in the name of public medical and health services. Any American that pays in excess of ?$7500.00 in medical and/or healthcare costs shall be exempt from said tax.

If the tax is less than insurance, and there is no limit on pre-existing conditions, why would you pay for insurance? Why not just wait until you get sick, saving $2,500 a year (if they even find out) and then pony up only when necessary?

 

[cbrons]

The law is simply unconstitutional and anyone with a brain (and a basic understanding of constitutional law taught in most high schools) can follow this reasoning easily. Let's look at some of the arguments the clowns in the Obama administration used to sidestep the constitutionality issue (as it pertains to the portion of the law that was struck down - the individual mandate requiring everyone to purchase health insurance):

Tactic 1: Use the Commerce Clause

The Obama administration's argument that the individual mandate (and penalties for non-adherence) are legitimate vis-a-vis the Commerce Clause relied heavily on a case called Wickard vs. Filburn (1942). Now in this particular case, the Supreme Court ruled that a farmer who grows wheat in order to support himself and his family without bringing it to market (never enters inter or even intrastate commerce) can be legitimately regulated under the commerce clause. Why? I'll give you their answer: Because by growing his wheat in excess of what was allowed under New Deal legislation, he was reducing the amount of wheat he would purchase for his chickens on the open market. Ergo he would be affecting interstate commerce because wheat is sold nationally. Now setting aside the shocking stupidity of this decision (and the horrendous ramifications it has had on the size and scope of the federal government's power since then), we have to ask ourselves if this decision applies to the individual mandate in Obamacare and the answer is quite simple: of course it doesn't.

Why? Because the individual who fails to purchase a health insurance policy is not a consumer of his self-underwritten insurance policy. An argument could be made that the farmer producing wheat is much like the underwriter of health insurance policies but it is more than a stretch to say that the individual who doesn't participate in the marketplace must now be compelled to purchase a good/service from another individual or private entity under Wickard reasoning. Judge Hudson wasn't buying this tripe.

Tactic 2 - Backdoor it using the Necessary and Proper Clause

The Obama administration also argued that because the individual mandate is an integral part of the legislation's efficacy, it is necessary and proper that it should be legitimate. Unfortunitely for them, SCOTUS prescident clearly shows that the law must be appropriate and plainly adopted to an enumerated federal power in order to apply. This is clearly not the case because, as I just outlined, the federal government cannot require an individual to purchase another good/service for any reason regardless of whether or not that purpose is necessary for carrying into execution a broad federal policy. In other words, the specific enumerated power (regulation of interstate commerce under the Commerce Clause) must be legitimate before they can say its necessary and proper. So this was another flop.

Tactic 3 - Say its a tax

The Obama administration then went on to argue that the penalty for not complying with the individual mandate is a tax and therefore a legitimate function of the federal government. Of course, this argument was used last because it is clearly not supported by the history of the legislation where Democrats ran around the country specifically stating that the fine for not purchasing health insurance was a penalty and not a tax. They did this because they knew calling it a tax was a voting-losing strategy. The irony of the situation is that if they had just formulated the legislation in such a way as to clearly make it a tax, it most likely would have been upheld but the language used in the bill clearly states that it is a penalty and not a tax.

There is also SCOTUS precedent (and one case in particular called Comstock) that lays out the elements of a tax. This individual mandate met none of those elements. It wasn't a property tax, wasn't an income tax, wasn't a tariff. So this last argument also went out the door with the empty skirts on the Obama admin legal team.

What's next?

No one knows because there are activist judges on the 4th Circuit and at the Supreme Court so no matter how solid the reasoning, they may still reject it for their own political reasons. We'll see what happens.

 

[cbrons]

In the healthcare law, it's written as a sort-of tax, which obviously the government has the power to enact. So we'll see. So you pay a tax, and if you buy healthcare insurance, you're exempt from that tax.

So far, out of three rulings, two were in favor, one against. So it could go either way. I feel from what legal scholars are saying, it'll probably stand. But we'll see.

Even if it was a "sort of tax" (whatever the hell that means), its still not good enough.

There's no "sort of" about it. It's a tax. A graduated one, but a tax.

Wrong... see previous post.

 

[physasst]

It is a red herring to try and point to all the SPECIFIC TAX laws past. The current mandate is not written as a tax. It is written, "you must buy this or pay a fine". So, the two are different. The mandate to purchase is that a mandate to purchase. It is not written as a tax and the proponents specifically spent a upwards of a year explaining how it was not a tax.

If the proponents want a specific healthcare tax with an associated deduction, they should have and easily could have written that law in under 2 pages as opposed to over 2ooo. It is very simple, i.e.:

Each American shall pay the IRS a federal tax of ?$5000.00 each year in the name of public medical and health services. Any American that pays in excess of ?$7500.00 in medical and/or healthcare costs shall be exempt from said tax.

Of course, to get it passed, you could add a few pages of bridge building, prescription drug funding, college funds, etc..... What the tax monies ultimately go to in the past present or future is a different argument. We can then talk about social security taxes, medicaid or medicare taxes. But, those are written specifically as a tax. The current issue was written not as a tax but an order to purchase goods and services. Pretty sad to constantly watch people write, say, and do things and then have large masses of people arguing, "he/she didn't mean what they wrote, said, or did.... they are such good people and really meant x, y, z...".

Please point to where I stated that there was NOT a mandate to purchase insurance. I was merely pointing out that the penalty to purchase insurance is a tax. Which is the purvey of Congressional authority.

As far as the size of the bill, number one who cares? Number two, as a health policy analyst, I've read it 3 times through, have you? You do realize that every page of the bill now needs appoximately 50 pages of regulations written in order to make it operational, it's not as simple as you seem to think. This is what my friends at HHS are doing now.

 

[physasst]

If the tax is less than insurance, and there is no limit on pre-existing conditions, why would you pay for insurance? Why not just wait until you get sick, saving $2,500 a year (if they even find out) and then pony up only when necessary?

Exactly, to be honest, the economist in me, is worried. I've seen data, don't have them on hand, but seen recent projections that if nothing changes, by 2030, the average family of four will spend close to 35% of take home income on health insurance. It was a very rough projection, but probably somewhere in the ballpark. We need to completely tear down the existing system, and re-engineer it from the top down. ACO's are a good start...

 

[JackADeli]

If the tax is less than insurance, and there is no limit on pre-existing conditions, why would you pay for insurance? Why not just wait until you get sick, saving $2,500 a year (if they even find out) and then pony up only when necessary?

Not going to say what the exact nuances of the law should be. The same argument is being played out with the mandate and penalty issues too. The argument early on was that the mandate and penalty would lead to companies finding it cheaper to pay the penalty and off-load everyone to medicare/medicaid instead of purchasing the amount of insurances mandated...Thus, it leads to a single payer socialized, government system.

Please point to where I stated that there was NOT a mandate to purchase insurance. I was merely pointing out that the penalty to purchase insurance is a tax. Which is the purvey of Congressional authority.

As far as the size of the bill, number one who cares? Number two, as a health policy analyst, I've read it 3 times through, have you? You do realize that every page of the bill now needs appoximately 50 pages of regulations written in order to make it operational, it's not as simple as you seem to think. This is what my friends at HHS are doing now.

First, no need to get pissy.

Second, read as much as i could tolerate. No, most bills do not require omnibus massive stature. But, yes, they did put into place many nuances and regulations. Again, these many regulations and nuances to assure the mandate was not a tax and that this was a penalty or fine.... We can sit back and try to spar about this all day. yes, they can write a one paragraph tax as I described and then use 50 pages to describe what healthcare purchases qualified for the tax deduction. They didn't.

In the end, the mandate and associated fine/penalty if you do not purchase a specific good is not within the scope of previous precident of comerce clause taxation. I get a speeding ticket, generally do not call that a "tax". I park in a handicap spot and get a fine of $500 generally do not call that a tax. I sell government secrets and get a penalty of $50k, generally do not call tha a tax. If I choose to not buy healthcare of the amount or caliber as dictated by said mandate and then get fined/penalty, I call that a fine or penalty not a tax. And, that is on top of being required to buy specific goods and services.... simply cause I am a US citizen.

...Tactic 3 - Say its a tax

The Obama administration then went on to argue that the penalty for not complying with the individual mandate is a tax and therefore a legitimate function of the federal government. ...but the language used in the bill clearly states that it is a penalty and not a tax.

There is also SCOTUS precedent (and one case in particular called Comstock) that lays out the elements of a tax. This individual mandate met none of those elements. It wasn't a property tax, wasn't an income tax, wasn't a tariff. So this last argument also went out the door with the empty skirts on the Obama admin legal team...

Exactly

 

[JaggerPlate]

We need to completely tear down the existing system, and re-engineer it from the top down.

Eh, I don't know about tearing it down ... it needs to be streamlined and refigured a bit for sure, but I really don't think the entire system should be scrapped.

ACO's are a good start...

Nooooo thanks.

 

[physasst]

Eh, I don't know about tearing it down ... it needs to be streamlined and refigured a bit for sure, but I really don't think the entire system should be scrapped.



Nooooo thanks.

ACO's are coming, whether you like them or not. Many of those in the healthcare leadership positions are looking favorably upon them.

We need to focus on value in healthcare, and not volume. My research focus is in particular on healthcare workforce, and to a lesser degree reimbursement models, but I think the combination of the use of ACO's with novel payment methods makes sense.

We need to get rid of fee for service....that anachronism needs to go the way of the dodo.

I've been at many meetings with various healthcare leaders, including the most recent one that I posted a thread on, and that seems to be a uniform thought. That and medical education reform, but that is an entirely separate topic.

Anyway, back to writing.

 

[physasst]

Not going to say what the exact nuances of the law should be. The same argument is being played out with the mandate and penalty issues too. The argument early on was that the mandate and penalty would lead to companies finding it cheaper to pay the penalty and off-load everyone to medicare/medicaid instead of purchasing the amount of insurances mandated...Thus, it leads to a single payer socialized, government system.

First, no need to get pissy.

Second, read as much as i could tolerate. No, most bills do not require omnibus massive stature. But, yes, they did put into place many nuances and regulations. Again, these many regulations and nuances to assure the mandate was not a tax and that this was a penalty or fine.... We can sit back and try to spar about this all day. yes, they can write a one paragraph tax as I described and then use 50 pages to describe what healthcare purchases qualified for the tax deduction. They didn't.

In the end, the mandate and associated fine/penalty if you do not purchase a specific good is not within the scope of previous precident of comerce clause taxation. I get a speeding ticket, generally do not call that a "tax". I park in a handicap spot and get a fine of $500 generally do not call that a tax. I sell government secrets and get a penalty of $50k, generally do not call tha a tax. If I choose to not buy healthcare of the amount or caliber as dictated by said mandate and then get fined/penalty, I call that a fine or penalty not a tax. And, that is on top of being required to buy specific goods and services.... simply cause I am a US citizen.
Exactly

Not being pissy, merely clarifying what I actually said. My point is, there is precedent, and we can argue about whether or not President Adams mandate was Constitutional in 1798, but it was there. A tax was levied, without choice by either the ships owners or the seamen, making it a "mandate", and while they could not force the purchase of health insurance (didn't really exist in any real form at that time), they did force the purchase of healthcare through a tax. So to state that there is no precedent is not exactly true.

Let's read the Act:

Wth July,1798. CHAP. [94.]
An act for the relief of sick and disabled seamen.1
§ 1. Be it enacted, Sfc. That from and after the first day of September next, the master or owner of every ship or vessel of the United States, arriving from a foreign port into any port of the United States, shall, before such ship or vessel shall be admitted to an entry, render to the collector a true account of the number of seamen that shall have been employed on board such vessel since she was last entered at any port in the United States, and shall pay, to the said collector, at the rate of twenty cents per month for every seaman so employed ; which sum he is hereby authorized to retain out of the wages of such seamen.
§ 2. That from and after the first day of September next, no collector shall grant to any ship or vessel whose enrollment or license for carrying on the coasting trade has expired, a new enrollment or license, before the master of such ship or vessel shall first render a true account to the collector, of the number of seamen, and the time they have severally been employed on board such ship or vessel, during the continuance of the license which has so expired, and pay to such collector twenty cents per month for every month such seamen have been severally employed as aforesaid ; which sum the said master is hereby authorized to retain out of the wages of such seamen. And if any such master shall render a false account of the number of men, and the length of time they have severally been employed, as is herein required, he shall forfeit and pay one hundred dollars.
§ 3. That it shall be the duty of the several collectors to make a quarterly return of the sums collected by them, respectively, by virtue of this act, to the secretary of the treasury ; and the president of the United States is hereby authorized, out of the same, to provide for the temporary relief and maintenance of sick, or disabled seamen, in the hospitals or other proper institutions now established in the several ports of the United States, or in ports where no such institutions exist, then in such other manner as he shall directrovided, that the moneys collected in any one district, shall be expended within the same.
§4. That if any surplus shall remain of the moneys to be collected by virtue of this act, after defraying the expense of such temporary relief and support, that the same, together with such private donations as may be made for that purpose, (which the president is hereby authorized to receive,) shall be invested in the stock of the United States, under the direction of the president; and when, in his opinion, a sufficient fund shall be accumulated, he is hereby authorized to purchase or receive cessions or donations of ground or buildings, in the name of the United States, and to cause buildings, when necessary, to be erected as hospitals for the accommodation of sick and disabled seamen.
§ 5. That the president of the United States be, and he is hereby, authorized to nominate and appoint, in such ports of the United States as he may think proper, one or more persons, to be called directors of the marine hospital of the United States, whose duty it shall be to direct the expenditure of the fund assigned for their respective ports, according to the third section of this act; to provide for the accommodation of sick and disabled seamen, under such general instructions as shall be given by the president of the United States for that purpose, and also, subject to the like general instructions, to direct and govern such hospitals, as the president may direct to be built in the respective ports : and that the said directors shall hold their offices during the pleasure of the president, who is authorized to fill up all vacancies that may be occasioned by the death or removal of any of the persons so to be appointed. And the said directors shall render an account of the moneys received and expended by them, once in every quarter of a year, to the secretary of the treasury, or such other person as the president shall direct; but no other allowance or compensation shall be made to the said directors, except the payment of such expenses as they may incur in the actual discharge of the duties required by this act.[ A pproved, July 16, 1798]
1 Curtis, George Tickner. A Treatise on the Rights and Duties of Merchant Seamen, According to the General Maritime Law, and the Statutes of the United States. (Boston: Charles C. Little and James Brown, 1841), 407-409

Anyway, I do actually have work to return to at this time. See ya later.

 

[cbrons]

Not being pissy, merely clarifying what I actually said. My point is, there is precedent, and we can argue about whether or not President Adams mandate was Constitutional in 1798, but it was there. A tax was levied, without choice by either the ships owners or the seamen, making it a "mandate", and while they could not force the purchase of health insurance (didn't really exist in any real form at that time), they did force the purchase of healthcare through a tax. So to state that there is no precedent is not exactly true.

Let's read the Act:

Wth July,1798. CHAP. [94.]
An act for the relief of sick and disabled seamen.1
§ 1. Be it enacted, Sfc. That from and after the first day of September next, the master or owner of every ship or vessel of the United States, arriving from a foreign port into any port of the United States, shall, before such ship or vessel shall be admitted to an entry, render to the collector a true account of the number of seamen that shall have been employed on board such vessel since she was last entered at any port in the United States, and shall pay, to the said collector, at the rate of twenty cents per month for every seaman so employed ; which sum he is hereby authorized to retain out of the wages of such seamen.
§ 2. That from and after the first day of September next, no collector shall grant to any ship or vessel whose enrollment or license for carrying on the coasting trade has expired, a new enrollment or license, before the master of such ship or vessel shall first render a true account to the collector, of the number of seamen, and the time they have severally been employed on board such ship or vessel, during the continuance of the license which has so expired, and pay to such collector twenty cents per month for every month such seamen have been severally employed as aforesaid ; which sum the said master is hereby authorized to retain out of the wages of such seamen. And if any such master shall render a false account of the number of men, and the length of time they have severally been employed, as is herein required, he shall forfeit and pay one hundred dollars.
§ 3. That it shall be the duty of the several collectors to make a quarterly return of the sums collected by them, respectively, by virtue of this act, to the secretary of the treasury ; and the president of the United States is hereby authorized, out of the same, to provide for the temporary relief and maintenance of sick, or disabled seamen, in the hospitals or other proper institutions now established in the several ports of the United States, or in ports where no such institutions exist, then in such other manner as he shall directrovided, that the moneys collected in any one district, shall be expended within the same.
§4. That if any surplus shall remain of the moneys to be collected by virtue of this act, after defraying the expense of such temporary relief and support, that the same, together with such private donations as may be made for that purpose, (which the president is hereby authorized to receive,) shall be invested in the stock of the United States, under the direction of the president; and when, in his opinion, a sufficient fund shall be accumulated, he is hereby authorized to purchase or receive cessions or donations of ground or buildings, in the name of the United States, and to cause buildings, when necessary, to be erected as hospitals for the accommodation of sick and disabled seamen.
§ 5. That the president of the United States be, and he is hereby, authorized to nominate and appoint, in such ports of the United States as he may think proper, one or more persons, to be called directors of the marine hospital of the United States, whose duty it shall be to direct the expenditure of the fund assigned for their respective ports, according to the third section of this act; to provide for the accommodation of sick and disabled seamen, under such general instructions as shall be given by the president of the United States for that purpose, and also, subject to the like general instructions, to direct and govern such hospitals, as the president may direct to be built in the respective ports : and that the said directors shall hold their offices during the pleasure of the president, who is authorized to fill up all vacancies that may be occasioned by the death or removal of any of the persons so to be appointed. And the said directors shall render an account of the moneys received and expended by them, once in every quarter of a year, to the secretary of the treasury, or such other person as the president shall direct; but no other allowance or compensation shall be made to the said directors, except the payment of such expenses as they may incur in the actual discharge of the duties required by this act.[ A pproved, July 16, 1798]
1 Curtis, George Tickner. A Treatise on the Rights and Duties of Merchant Seamen, According to the General Maritime Law, and the Statutes of the United States. (Boston: Charles C. Little and James Brown, 1841), 407-409

Anyway, I do actually have work to return to at this time. See ya later.

You should brush up on more of the recent case law. There are elements of a tax and the individual mandate does not have any of them.

 

[JackADeli]

...A tax was levied, without choice by either the ships owners or the seamen, making it a "mandate", and while they could not force the purchase of health insurance ...they did force the purchase of healthcare through a tax. So to state that there is no precedent is not exactly true.

Let's read the Act:...

Again, you are arguing two completely different things. Every tax is a "mandate". Otherwise, nobody would pay them.

The Act you cite clearly draws a taxation on working sailors. Licensure of the ships appears dependent on accurate tax payment. The later portion states how the government will spend said collected taxes. This is not the case in the current healthcare law mandate and penalty.

First, as has been stated numerous times by the writers and proponents of the law, "it is not a tax", and it was not written to be a tax. Second, the mandate requires you to buy a good or service from an industry. It does not say you will pay a tax and later in another paragraph, as the Act you cite, say the USA government will spend these tax revenues on x, y, z.....

ACO's are coming, whether you like them or not. Many of those in the healthcare leadership positions are looking favorably upon them...

Maybe. But, many in leadership have their own agendas. Just because they like it does not mean we as a whole must accept it. We do not have to resign to the popular belief and accept it. Like most things in healthcare, if they come to pass, it will be cause physicians complained amongst themselves in the corner and did not take a leadership as a whole.

...We need to focus on value in healthcare, and not volume. My research focus is in particular on healthcare workforce, and to a lesser degree reimbursement models...

We need to get rid of fee for service....that anachronism needs to go the way of the dodo...

As to fee for service, the majority of patients I have seen have never been fee for service in the true sense of that phrase. However, when people are more directly paying for a product and true competition is present, quality and value has increased in just about every industry in the USA. Competition and direct pay have been hindered, thus seperating people from product choice and product cost while simultaneously seperating producers from true incentives towards value and quality. Socializing and demonizing fee for service, etc... will only diminish the product more.

Value is very much focused on and in numerous occassions, volume is associated with quality, hence the leap frog initiative, etc.

I always find it simple and naive to hear individuals talk about a mistaken focus on volume over value. True volume producers do focus on quality, efficiency, and value. They do not get referrals and can not produce volume unless the referral base and patients migrate towards them. Thus, volume is often a result of producing value.... It is the same as in other industry. It is like saying a company focuses on earnings instead of producing a good product. Yes, they try to be efficient in what they produce but they know earnings/profits are the result of how much product is demanded.... which, other then a monopoly or government shackled system, [demand] is a result of quality and competition.

 

[physasst]

Maybe. But, many in leadership have their own agendas. Just because they like it does not mean we as a whole must accept it. We do not have to resign to the popular belief and accept it. Like most things in healthcare, if they come to pass, it will be cause physicians complained amongst themselves in the corner and did not take a leadership as a whole.

As to fee for service, the majority of patients I have seen have never been fee for service in the true sense of that phrase. However, when people are more directly paying for a product and true competition is present, quality and value has increased in just about every industry in the USA. Competition and direct pay have been hindered, thus seperating people from product choice and product cost while simultaneously seperating producers from true incentives towards value and quality. Socializing and demonizing fee for service, etc... will only diminish the product more.

Value is very much focused on and in numerous occassions, volume is associated with quality, hence the leap frog initiative, etc.

I always find it simple and naive to hear individuals talk about a mistaken focus on volume over value. True volume producers do focus on quality, efficiency, and value. They do not get referrals and can not produce volume unless the referral base and patients migrate towards them. Thus, volume is often a result of producing value.... It is the same as in other industry. It is like saying a company focuses on earnings instead of producing a good product. Yes, they try to be efficient in what they produce but they know earnings/profits are the result of how much product is demanded.... which, other then a monopoly or government shackled system, [demand] is a result of quality and competition.

And I too always find it simple and naive for individuals to ascertain market behaviours in other commodities to healthcare. There are a number of economic reasons for why healthcare does not respond to normal market pressures, but the biggest of which is probably an implicit price inelasticity. There is no empiric or modeling evidence to suggest that the purchase of healthcare will behave like the purchase of TV's. In fact, most econometric evidence suggests otherwise.

As far as diminishing the product, I would just say this. We have the finest medical education system in the world (WAY overpriced, but the best in terms of education given), we have the finest medical technology on the planet. Yet, we rank 37th in healthcare delivery, and our outcomes lag far behind other OECD countries. We lead overall in really one category, money spent. Sure, there is a whole discussion to be had regarding comparative statistics, and how they are produced, but it is the data we have, and what we have currently to work with. There is only one rational explanation for the disconnect....and that is the delivery system itself. It needs to be re-engineered, and it should NOT be done by physicians alone. They don't have the pedigree or education to really do it right. It should be done by a collaborative team of systems engineers, economists, researchers, and physicians working together. Unfortunately, that's not what we've done so far.

As far as value, we don't get value for our healthcare dollar now. Not in any sense of the term, the Gawande article regarding McAllen Texas highlighted that fact very well. I do agree that focusing on value can lead to higher volumes, but the incentives have to change. This is what I advocate for, and work towards on almost a daily basis. Luckily, I am in a position to at least have a voice in the discussion.

I am a big fan, and advocate of the Prometheus system (NO, not the god who ate his liver daily)...in fact, I have a meeting with a good friend on the Senate Finance Committee about this very system next month when I am back in DC. I would suggest looking it up. It's gaining in popularity, and may be coming to an area near you soon....or at least some variant..

Here's a short primer:

http://healthpolicyandreform.nejm.org/?p=1514

 

[physasst]

You should brush up on more of the recent case law. There are elements of a tax and the individual mandate does not have any of them.

Yep, recent case law is different, and more comprehensive. I was merely stating that to claim that there is "NO precedent", is not completely accurate. It's not exactly the same, but there is some similarity.

Enough that my friend on the Hill who actually IS a constitutional law scholar, and clerked for O'Connor, thinks that this will pass SCOTUS. I defer to his judgment. Health and Consitutional Law is not an area of expertise for me. Health economics and workforce is.

Who knows though.....We've known since the reconciliation that this was going to end up at SCOTUS. 2 judges have voted to support it, and only 1 has voted against it.

 

[JaggerPlate]

As to fee for service, the majority of patients I have seen have never been fee for service in the true sense of that phrase. However, when people are more directly paying for a product and true competition is present, quality and value has increased in just about every industry in the USA. Competition and direct pay have been hindered, thus seperating people from product choice and product cost while simultaneously seperating producers from true incentives towards value and quality. Socializing and demonizing fee for service, etc... will only diminish the product more.

Value is very much focused on and in numerous occassions, volume is associated with quality, hence the leap frog initiative, etc.

I always find it simple and naive to hear individuals talk about a mistaken focus on volume over value. True volume producers do focus on quality, efficiency, and value. They do not get referrals and can not produce volume unless the referral base and patients migrate towards them. Thus, volume is often a result of producing value.... It is the same as in other industry. It is like saying a company focuses on earnings instead of producing a good product. Yes, they try to be efficient in what they produce but they know earnings/profits are the result of how much product is demanded.... which, other then a monopoly or government shackled system, [demand] is a result of quality and competition.

You summed up just about everything I wanted to say (quite nicely).

 

[JackADeli]

...As far as diminishing the product, I would just say this. We have the finest medical education system in the world (WAY overpriced, but the best in terms of education given), we have the finest medical technology on the planet. Yet, we rank 37th in healthcare delivery, and our outcomes lag far behind other OECD countries. We lead overall in really one category, money spent. Sure, there is a whole discussion to be had regarding comparative statistics, and how they are produced, but it is the data we have, and what we have currently to work with. There is only one rational explanation for the disconnect....and that is the delivery system itself. It needs to be re-engineered, and it should NOT be done by physicians alone. They don't have the pedigree or education to really do it right. It should be done by a collaborative team of systems engineers, economists, researchers, and physicians working together. Unfortunately, that's not what we've done so far...

Yes, I think types comparatives are quite important consideration. Aside from the differences in systems & populations, we should assure our grades/rankings are actually based on taking the same ~examination. A "B" average student in one high school may far exceed the "A" average student from another high school.... Let us not forget what we consider as a viable child birth vs other countries, and several other nuances that have big impacts on our "rankings".

One of the biggest glaring issues in the comparisons are the fact that we are trying to compare a 300+ million population to often 30+ million populations. Another issue is the "we have the finest medical technology on the planet". That technology costs. Many of the comparative countries do not have the same tech or have significant restrictions on access to this tech. Americans want the latest chemo, latest procedures, hell they want surgery over exercise for weight loss.... they just don't want to pay for it.

Just stepping down from the technology (of which patients are often seperated from cost), in numerous comparative nations, patients do NOT get "spa like" facilities, single occupancy rooms, room service meals, cable TV (sometimes no TV); unless they specifically pay for these services. In the USA, we have seperated the recipients of services from the costs. Patients continually expect private rooms, spa like settings, TV, telephone, even taxis to and from the hospital. But, they do not pay and their employers pay for increased, shiny new services. There is great waste that adds to cost. If patients had direct pay, fee for service involvement, they may actually look for a discount and simplified services.

During my residency, we had a religious community that did not purchase health insurance. The town paid all healthcare costs. When a member of their congregation was hospitalize, they met with the hospital admins and assured their care was stripped down to actual required care. The brought in meals and TVs from home!

...Yet, we rank 37th in healthcare delivery, and our outcomes lag far behind other OECD countries. We lead overall in really one category, money spent...

That a flawed and unusually biased ranking places the USA at 37 I do not disagree. What that means, I have greatly different take then you seem to suggest or imply as to significance. As to "outcomes", it depends on what outcomes you measure and if you have actually use common and very simple techniques for analysis that corrects for variations... In other words, you can not compare infant mortality based on raw numbers and ignore that we consider premies at far younger gestation to be viable and live births where other countries do not, etc, etc, More below. Clearly The essay by Dr. Constantian has a different take on us leading in only one category.... If all else fails, I pose you ask if the health system in Greece (ranked 14) is what one would like vs USA care ranked at a paltry 37th.

... http://granitegrok.com/blog/2010/01/the_real_healthcare_rankings.html
The real healthcare rankings

From the Wall Street Journal, an Op-Ed by a New Hampshire reconstructive surgeon:

Last August the cover of Time pictured President Obama in white coat and stethoscope. The story opened: "The U.S. spends more to get less [health care] than just about every other industrialized country." This trope has dominated media coverage of health-care reform. Yet a majority of Americans opposes Congress's health-care bills. Why?

The comparative ranking system that most critics cite comes from the U.N.'s World Health Organization (WHO). The ranking most often quoted is Overall Performance, where the U.S. is rated No. 37. The Overall Performance Index, however, is adjusted to reflect how well WHO officials believe that a country could have done in relation to its resources.

The scale is heavily subjective: The WHO believes that we could have done better because we do not have universal coverage. What apparently does not matter is that our population has universal access because most physicians treat indigent patients without charge and accept Medicare and Medicaid payments, which do not even cover overhead expenses. The WHO does rank the U.S. No. 1 of 191 countries for "responsiveness to the needs and choices of the individual patient." Isn't responsiveness what health care is all about?

Data assembled by Dr. Ronald Wenger and published recently in the Bulletin of the American College of Surgeons indicates that cardiac deaths in the U.S. have fallen by two-thirds over the past 50 years. Polio has been virtually eradicated. Childhood leukemia has a high cure rate. Eight of the top 10 medical advances in the past 20 years were developed or had roots in the U.S.

The Nobel Prizes in medicine and physiology have been awarded to more Americans than to researchers in all other countries combined. Eight of the 10 top-selling drugs in the world were developed by U.S. companies. The U.S. has some of the highest breast, colon and prostate cancer survival rates in the world. And our country ranks first or second in the world in kidney transplants, liver transplants, heart transplants, total knee replacements, coronary artery bypass, and percutaneous coronary interventions.

We have the shortest waiting time for nonemergency surgery in the world; England has one of the longest. In Canada, a country of 35 million citizens, 1 million patients now wait for surgery and another million wait to see specialists.

When my friend, cardiac surgeon Peter Alivizatos, returned to Greece after 10 years heading the heart transplantation program at Baylor University in Dallas, the one-year heart transplant survival rate there was 50%—five-year survival was only 35%. He soon increased those numbers to 94% one-year and 90% five-year survival, which is what we achieve in the U.S. So the next time you hear that the U.S. is No. 37, remember that Greece is No. 14. Cuba, by the way, is No. 39.


But the issue is only partly about quality. As we have all heard, the U.S. spends a higher percentage of its gross domestic product for health care than any other country.

Actually, health-care spending now increases more moderately than it has in previous decades. Food, energy, housing and health care consume the same share of American spending today (55%) that they did in 1960 (53%).

So what does this money buy? Certainly some goes to inefficiencies, corporate profits, and costs that should be lowered by professional liability reform and national, free-market insurance access by allowing for competition across state lines. But the majority goes to a long list of advantages that American citizens now expect: the easiest access, the shortest waiting times the widest choice of physicians and hospitals, and constant availability of health care to elderly Americans. What we need now is insurance and liability reform—not health-care reform.

Who determines how much a nation should pay for its health? Is 17% too much, or too little? What better way could there be to dedicate our national resources than toward the health and productivity of our citizens?

Perhaps it's not that America spends too much on health care, but that other nations don't spend enough.

Dr. Constantian is a plastic and reconstructive surgeon in New Hampshire....​

...World Health Organization (WHO) ranked US health care a lowly 37th in the world, considerably below France and Canada. But, ...the rankings are far from impartial or empirically sound.

...The most obvious bias is that 62.5% of their weighting concerns not quality of service but equality. In other words, the rankings are less concerned with the ability of a health system to make sick people better than they are with the political consideration of achieving equal access and implementing state-controlled funding systems...

...So, remember during the health care debate..that whole thing about America ranking like, what, 38th or some nonsense?

...that ranking is determined by weighing several factors, among them are infant mortality statistics, availability of medical care and life expectancy.
Life Expectancy. ...if you live in Japan, life is good [and long].

Coming in #1 and reigning Champion of the world is Japan. Citizens of Japan can expect to live, on average, up to 82. years. Here in America? ...We can only expect to live 78.1 years giving us a ranking of 30–THIRTY–in the world...

Thousands of Japanese centenarians may have died decades ago
More than 230,000 Japanese people listed as 100 years old cannot be located and many may have died decades ago, according to a government survey released today.
The justice ministry said the survey found that more than 77,000 people listed as still alive in local government records would have to be aged at least 120, and 884 would be 150 or older.
​

The reason Japan may be so far ahead of the rest of the world has perhaps more to do with BAD advances, things like record keeping and fraud prevention, than with good health care:

The figures have exposed antiquated methods of record-keeping and fuelled fears that some families are deliberately hiding the deaths of elderly relatives in order to claim their pensions....
​

 

[MOHS_01]

All of this:

"There is a consensus..."

"of 'healthcare leaders'"

"who all believe they should be directing you, your livelihood, your labors, your monies"

pompous technocratic pile of monkey **** makes me wanna

 

[MOHS_01]

...and I've been fine, physasst, thanks for asking in the other thread. I remain convinced that your good intentions are misguided, dangerous, tyrannical, and economically untenable however.

 

[JackADeli]

...physasst ...I remain convinced that your good intentions are misguided, dangerous, ...untenable however.

I think anyone that uses the biased and flawed WHO report as justification or evidence to any degree, to change and/or alter our healthcare system is misguided. The report is vastly flawed and individuals that go beyond pop press to see how silly it is would know that. Greece? really.......

I also question anyone that spends a good deal of time citing "precedent" to include posting a previous law and then slides behind....

...my friend on the Hill who actually IS a constitutional law scholar, and clerked for O'Connor... I defer to his judgment. Health and Consitutional Law is not an area of expertise for me. Health economics and workforce is...

So, are you an undergrad, masters student, in medical school? Just curious about where you actually are in the continuum of "expertise".

 

[MOHS_01]

Correct me if I am wrong, but physasst is/was a practicing PA... who has been unfortunate enough to suffer from an intractable case of Mayo-itis. Very sad.

 

[physasst]

I think anyone that uses the biased and flawed WHO report as justification or evidence to any degree, to change and/or alter our healthcare system is misguided. The report is vastly flawed and individuals that go beyond pop press to see how silly it is would know that. Greece? really.......

I also question anyone that spends a good deal of time citing "precedent" to include posting a previous law and then slides behind....So, are you an undergrad, masters student, in medical school? Just curious about where you actually are in the continuum of "expertise".

Well, the WHO report is what we have, and I believe that some data is better than none, recognizing that it is not perfect. As one of my mentors used to say "Our healthcare system is broken beyond repair. 80% of Americans are satisfied with their coverage, because 80% of Americans don't use the healthcare system on a regular basis"

As far as spending a "good deal of time". Not really. Just an example that there is some precedent out there. How it will play out I do not know.

As far as my educational pedigree, I have a BS in econ, 2 masters degrees (PA and Sports Medicine), and am one year from finishing my DHSc degree. I still practice as a PA in Emergency Medicine, although my clinical time is reduced. Yes, I am at Mayo Clinic, I also function in an administrative role....I have developed a national reputation as an analyst and advocate in health policy for various organizations, and also frequently give presentations and lead discussions about health reform. I am also a health services researcher, primarily in physician/medical workforce, and have about 6 projects currently in the works.

Thanks for asking.

 

[MOHS_01]

physasst,

I trust that you understand my posts above were more in the vein of friendly ribbing than spiteful condescension. I have to admit, though, that I am a little surprised to hear you say you hold a degree in econ. We should bat that around a bit when discussing the "optimal" structuring of health care reimbursement.

 

[physasst]

physasst,

I trust that you understand my posts above were more in the vein of friendly ribbing than spiteful condescension. I have to admit, though, that I am a little surprised to hear you say you hold a degree in econ. We should bat that around a bit when discussing the "optimal" structuring of health care reimbursement.

I do. We have a history of good discussion here. I have incredibly thick skin anyway. Both sides have some good ideas (interstate health insurance sales MAY help a little with federal regulation), and some bad ones (Tort Reform{listed as bad because of the limited fiscal effect} which won't save much money, and according to NBER research could increase patient mortality), and we need to be able to discuss things rationally. The problem for me comes with ideologues....who speak and act on intuition and philosophy, and not on facts. I am a liberal, progressive, conservative in the Teddy Roosevelt mold, but alas, there are not many of us left. I care more about discussions of facts, research, and modeling than abstract discussions such as "Government is the problem". I usually tune out in about 5 seconds with that sort of rhetoric. I have voted GOP for most of my life until the past 6 years.

Yeah, my BS degree was in Econ with a focus on Macro.....My descent into healthcare came with my enlistment into the Navy during the first party in the sandbox over there back in 1990. I became a Navy Corpsman, and was stationed with the Marines. Roundabout sorta path, I know.

To be truthful, while my econ degree helps, and is better than not having one, it is only at the baccalaureate level.

Workforce research is really my forte, and this is where I am slowly trying to develop my reputation. The two are intrinsically linked however....

 

[MOHS_01]

... I am a liberal, progressive, conservative in the Teddy Roosevelt mold, but alas, there are not many of us left. ...

Ignoring the remainder for a moment -- how in the bloody blue do you associate these very disparate (and I believe conflicting) terms? I hate the usurpation and subsequent perversion of the term "liberal"... as the modern day "liberal" has precious little in common with the historical bent of the term. TR was a progressive... and therefore you lost me on the "conservative in..." In any event, if you have not gathered as much to date, I am a liberal in the classical sense... and inching ever so closer to becoming a Rothbardian anarchocapitalist.

Yeah, my BS degree was in Econ with a focus on Macro.....

To be truthful, while my econ degree helps, and is better than not having one, it is only at the baccalaureate level.

Workforce research is really my forte, and this is where I am slowly trying to develop my reputation. The two are intrinsically linked however....

Seriously then -- how in the hell do you believe this central planning nonsense is going to work out? Can you point to any instance where it has / does work without flaw? Surely you understand that healthcare demand, especially in this artificial insurance dominated world, does not have standard elasticity?

The demand for healthcare services is dependent upon a number of things: demographics, disease prevalence, supply and mix of available services, etc. Keyne's restating of Say's Law is an observable condition in this non-functioning market that is healthcare.... Demographics and disease burden are transient phenomenon subject to both the natural temporal fluctuations of the population pyramid and medical advances... For a few examples consider the bread & butter of general surgery through the 80's -- peptic ulcer and gastric disease -- procedures that were essentially eradicated with the discovery of H. pylori. Syphilis and other VDs were such a prominent component of dermatology through the mid 20th century that the AAD's name was the "American Academy of Dermatology and Syphilology". The name was dropped after a little thing called penicillin came on the scene. On and on. Similarly, disease states that are unique to old age will become increasingly prevalent over the next couple of decades most likely -- but the time frame of the boomers' existence does not correspond all that well with the working career length of a medical professional.... so what then would your philosopher king friends have the now-less-needed highly trained professional do once their "demand" has dried up? Send them back to a reeducation camp?

Say you were to "get the numbers right" and were as deft in doing so as the Federal Reserve is in their control of both inflation and unemployment ( ). How do you address the issue of distribution? The only obvious answer is to resort to more authority, more control, and more dictatorial command.

 

[JackADeli]

Well, the WHO report is what we have, and I believe that some data is better than none, recognizing that it is not perfect. As one of my mentors used to say "Our healthcare system is broken beyond repair. 80% of Americans are satisfied with their coverage, because 80% of Americans don't use the healthcare system on a regular basis"...

Yes, we have a WHO report. However, if it is crap, just because it is published does not make it meaningful. My point is that if we are to have meaningful discussion we should not allow ourselves to be distracted by crap. Seriously, the WHO report was geared towards trying to push an agenda. It did not correct for real variables to allow a reasonable comparison. It would be like choosing to get a heart surgery from a low volume surgeon with "low mortality rate" as compared to the high volume and not taking into account the low volume surgeon does only relatively young, limited co-morbid patients and ships all the "re-do" work to the high volume surgeon.

So, the WHO report is crap (to paraphrase from the WHO Report Editor & Chief). Any report that ranks the health care in Greece that far ahead of the USA is ridiculous. Also, a ranking based primarily (i.e. >62%) not on actual healthcare but what they feel should be provided for wealth of the nation. Thus, I say if the WHO report is what we have then we have no data. And, for you, with proclaimed training, background, experience, etc., to discuss healthcare policy and such, cite the WHO report and claim the USA is only number one in expenditures, it suggests only a superficial understanding of this document. If you want to continue to cite the WHO report and the silly ranking CREATED, I would suggest you look at this and then look deeper:
http://online.wsj.com/article/SB125608054324397621.html
http://www.nejm.org/doi/pdf/10.1056/NEJMc1001849

..."The number 37 is meaningless, but it continues to be cited, for four reasons. First, people would like to trust the WHO and presume that the organization must know what it is talking about. Second, very few people are aware of the reason why in this case that trust is misplaced, partly because the explanation was published 3 years after the report containing the ranking. Third, numbers confer a spurious precision, appealing even to people who have no idea where the numbers came from. Finally, those persons responsible for the number continue to peddle it anyway…Analyzing the failings of health systems can be valuable; making up rankings among them is not. It is long past time for this zombie number to disappear from circulation."...

Just to point back to some highlights of US healthcare as compared to other nations with "higher rankings":

...cardiac deaths in the U.S. have fallen by two-thirds over the past 50 years.
...Polio has been virtually eradicated.
...Childhood leukemia has a high cure rate.
...Eight of the top 10 medical advances in the past 20 years were developed or had roots in the U.S.

...The U.S. has some of the highest breast, colon and prostate cancer survival rates in the world. And our country ranks first or second in the world in kidney transplants, liver transplants, heart transplants, total knee replacements, coronary artery bypass, and percutaneous coronary interventions.

We have the shortest waiting time for nonemergency surgery in the world...In Canada, a country of 35 million citizens, 1 million patients now wait for surgery and another million wait to see specialists.

So what does this [USA healthcare] money buy? ...the majority goes to a long list of advantages that American citizens now expect:
...easiest access,
...the shortest waiting times the widest choice of physicians and hospitals,
...constant availability of health care to elderly Americans...

 

[physasst]

Yes, we have a WHO report. However, if it is crap, just because it is published does not make it meaningful. My point is that if we are to have meaningful discussion we should not allow ourselves to be distracted by crap. Seriously, the WHO report was geared towards trying to push an agenda. It did not correct for real variables to allow a reasonable comparison. It would be like choosing to get a heart surgery from a low volume surgeon with "low mortality rate" as compared to the high volume and not taking into account the low volume surgeon does only relatively young, limited co-morbid patients and ships all the "re-do" work to the high volume surgeon.

So, the WHO report is crap (to paraphrase from the WHO Report Editor & Chief). Any report that ranks the health care in Greece that far ahead of the USA is ridiculous. Also, a ranking based primarily (i.e. >62%) not on actual healthcare but what they feel should be provided for wealth of the nation. Thus, I say if the WHO report is what we have then we have no data. And, for you, with proclaimed training, background, experience, etc., to discuss healthcare policy and such, cite the WHO report and claim the USA is only number one in expenditures, it suggests only a superficial understanding of this document. If you want to continue to cite the WHO report and the silly ranking CREATED, I would suggest you look at this and then look deeper:
http://online.wsj.com/article/SB125608054324397621.html
http://www.nejm.org/doi/pdf/10.1056/NEJMc1001849

Just to point back to some highlights of US healthcare as compared to other nations with "higher rankings":

It isn't crap. I read the letter from Musgrove, and certainly you also read the reply from Murray and Frenk.

They are correct, you can't continue to distract from the fact that we spend more than anyone else, and have poorer outcomes on most diseases than any other OECD country. I have read the WHO report several times. I have been critical of some parts of it myself, particularly the lack of control for geographic disease occurence variation.

As far as the data you posted.

#1 agree on polio and cardiac disease.
#2 Wait times.....who cares? Seriously, do you really think wait times matter? Canada's wait times are well documented. Yet they have a lower rate of heart disease deaths per 100,000 people....

Canada is 94.9 per 100,000 while the US is 106.5 per 100,000.

http://www.nationmaster.com/graph/hea_hea_dis_dea-health-heart-disease-deaths

There are longer wait times in the UK too, yet they have a lower rate of death from cancer (all types) than the US.

http://www.nationmaster.com/graph/hea_dea_fro_can-health-death-from-cancer

#3 I would argue that we SHOULD have a longer wait time to see specialists, and that we need a gatekeeper system.

There was a MOE inherent in the WHO report, as any sampling of a large number of complex variables across such a large span of cultures and people would yield. Their methodology might have been better, but it's detractors simply choose to ignore some of the main facts presented.

Here is another critique of the WHO report, which I agree with, and have agreed that there should have been weighting performed. But even when adjusted for that. The US never really gets above a median of 15.

http://www.scribd.com/doc/13673616/...ealth-Care-Systems-Cato-Briefing-Paper-No-101-

Again, we need to look at the positives as well. The WHO data was fairly comprehensive, and did generate a ranking system to assess delivery system performance. You might not like the "Financial Fairness" assessment, but as any proponent of a distributive justice would tell you, it is an important part of any societal delivery system evaluation.

I mean, any first year PhD student could rip apart pretty much any study, and health services research is often much more difficult to structure than clinical studies due to the problem of controlling for so many fluctuating variables and often scant or partial data.

BTW, just out of curiosity, what is your obsession with Greece?

 

[JackADeli]

It isn't crap. I read the letter from Musgrove, and certainly you also read the reply from Murray and Frenk...

...Their methodology might have been better, but it's detractors simply choose to ignore some of the main facts presented.

I mean, any first year PhD student could rip apart pretty much any study, and...

Yes, read them. However, even the OECD avoids using this so called WHO data. You don't need a PhD to see obvious flaws in the WHO report, a HS education would suffice. To cite this ranking number, is ridiculous. Yes, our healthcare system can be improved. We should discuss that without bringing in such flawed "research" that utilizes more invention then reality. the report is from 2000. It apparently was so complex that it couldn't be done again... But, if we are to believe that some portions of this old "data" is of value, we can at least agree the so called rankings are crap. To open up with the rank of 37th as the reference point, it is troubling. It does suggest either failure to understand the report or an intent to sensationalize. It is a 10 year old ranking that has really been discredited. I believe the WHO itself and others involved in the report have stated their main intent was not accuracy but to spark/stimulate discussion.

...Yet they have a lower rate of heart disease deaths per 100,000 people...

But, is this an issue of social and cultural behavior or healthcare delivery. Physicians are not the answer to all things bad and obesity and diet, while we can counsel is still a patient responsibility. They are also and indicator of prosperity in a particular country. Some may believe it better we are poor so individuals don't use money on junk food and don't sit on the couch and don't drive to work (instead walk or bike)......

...Seriously, do you really think wait times matter?...

I absolutely do. Maybe not in the realm of a rhinoplasty... But, yes, wait times for care are important. Waiting 6 months or longer for a cardiac angio and/or angioplasty can be significant. Waiting weeks to months to complete work-up of a tumor and/or resection can be significant. Waiting 6 months or longer for joint surgery has real pain and suffering implications and delays a person from moving forward. Yes, I believe wait times for care can and often are important.

....BTW, just out of curiosity, what is your obsession with Greece?

No problem with Greece (?14), you can insert Costa Rica (?36), Dominica (?35), Ireland (19), etc.. into the spot where Greece was referenced....

...I would just say this. We have the finest medical education system in the world... we have the finest medical technology on the planet. Yet, we rank 37th in healthcare delivery, and our outcomes lag far behind other OECD countries...

...Here is another critique of the WHO report, which I agree with, and...

http://www.scribd.com/doc/13673616/-WHOs-Fooling-Who-The-World-Health-Organizations-Problematic-Ranking-of-Health-Care-Systems-Cato-Briefing-Paper-No-101-
...

Did you actually read that? I just don't get how one can read that and understand the WHO report and its flaws and then first WHO report citation go straight to the ranking of "37"..... It's hard to go there even if you just read the opening abstract on that link you posted.

 

[themule]

Other than the precedent set by the second President John Adams that is, right?

I mean, he mandated that all merchant seamen pay a tax to cover healthcare services, including building hospitals for them. It was our first healthcare mandate, and seamen did not have a choice on whether to pay or not. There wasn't really health insurance at that time, but the 1798 Act for the Relief of Sick and Disabled Seamen basically created one.

So I really wouldn't say that there is no precedent, and I would think that President Adams would know more about Constitutional intent than anyone alive today.

Though I'm late to the party I would point out that to the best of my research not everyone was required to be a seaman/seawoman while everyone who is a citizen and breathing is required to have health insurance under the ACA. Requiring someone purchase something as a condition of employment, regardless of who the employer is, is not unconstitutional but requiring people to purchase something as a condition of citizenship is not enumerated anywhere in the Constitution.

 

[MOHS_01]

Though I'm late to the party I would point out that to the best of my research not everyone was required to be a seaman/seawoman while everyone who is a citizen and breathing is required to have health insurance under the ACA. Requiring someone purchase something as a condition of employment, regardless of who the employer is, is not unconstitutional but requiring people to purchase something as a condition of citizenship is not enumerated anywhere in the Constitution.

Nice. Not sure how I missed the original post, but for this: