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Please Vote on Health Care!

Discussion in 'Medical Students - MD' started by def jeff, Feb 19, 2007.

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Which form of healthcare best fits the United States?

  1. The Present System

    12 vote(s)
    5.4%
  2. The Present System (with major reforms)

    93 vote(s)
    41.7%
  3. Two-Tier

    34 vote(s)
    15.2%
  4. Single Payer

    38 vote(s)
    17.0%
  5. Socialized System

    29 vote(s)
    13.0%
  6. Other (Please write about your suggestions)

    6 vote(s)
    2.7%
  7. Undecided

    11 vote(s)
    4.9%
  1. def jeff

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    Hello! Since health care reform is such a hot topic amongst today’s politicians and obviously very relevant to today's medical students, I thought it would be nice to survey everyone’s basic opinions on the topic. So, please choose one of the options, and feel free to explain yourself!
     
  2. indo

    indo Feed me a stray cat
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    If I'm a surgeon who is the absolute best at total knee replacements in America, under a single payer system would I only be paid the same as everyone else even though my success rate is huge and the complication rate and recovery time are much lower than everyone else's? If that is the case then all of my hard work was pretty much wasted. I should have gone into construction where a better quality job gets higher reimbursement.

    Would you pay the same amount for a 4000 square foot manufactured home and a 4000 square foot home that you designed? Well, you would if the home building industry was run by a single payer system. Who is going to waste the time learning how to build a quality 4000 square foot house if they know that they know that they won't be paid any more than the guy down the street who builds crappy 4000 square foot houses? Nobody. All the talent will go into other fields where their efforts will actually pay off.
     
  3. braluk

    braluk SDN Surgerynator
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    What exactly is the single payer system?
     
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  4. stargirl50

    stargirl50 Member
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    Indo-- your example isn't unique to single payer systems. It's my understanding that if your "best" surgeon sees patients with insurance or medicare or medicaid, he still gets paid according to rates that were negotiated with those parties. On the other hand, pay for performance could work with a single payer system too.
     
  5. Gut Shot

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    No, you get paid per procedure according to an established fee schedule, pretty much the same as it is now. Pro: way less bureacracy. Con: only one party to negotiate with.
     
  6. USCTex

    USCTex Minding My Own
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    For those new to health policy, I really encourage you (no matter what your personal political philosophy) to get involved in learning about this stuff. It really is important. Not to mention interesting (but maybe I'm just a big nerd).

    A summary of the poll:

    The Present System - Speaks for itself. The US is a unique country with a complicated way of funding health care. For more look at KaiserEDU's Private Insurance 101, Medicaid 101, and Medicare 101. This doesn't even get into TRICARE or the VA system or more disparate topics like un- or underfunded care such as EMTALA.

    Everyone has heard the complaints against the current system. It doesn't control costs, it leaves millions without adequate access to health care, and on and on. Just turn on CNN to learn about the problems.

    Two-Tier System - Government funded health care for all but without provisions outlawing private insurance. Basically, if you want it or cannot afford private insurance the government will pay for your health care. If you want the convenience of private insurance and can afford it you can still buy it. When politicians speak of "Medicare-For-All" this is the type of system they envision.

    Opponents of a two-tier system claim it suffers from a unique problem in that it gradates health care quality. The theory is that the "best" hospitals and doctors will only take private insurance, creating health inequalities. Beyond that a two-tier system suffers from the same major complaint as a single payer or socialized medicine system. Although not a true single payer system with a global budget, once a single entity provides some high threshold for health care financing (let us say that the government pays for ~85% of all healthcare - probably a low figure - in a hypothetical two tier system) then for all intents and purposes you have the same effect as a global budget.

    Global budgets lead to rationing - which is why you hear attacks against the Canadian health care system always talk about patient wait times - and suppress market forces so that providers don't get paid as much.

    Single Payer - As it says, health care funding comes from a single payer (the government). There is no private funding, such as insurance, or indeed in a true single payer system even out of pocket. So, for instance, if you were a physician and wanted to open a high end "boutique" practice and only take cash, well in a true single payer system it would be illegal for you to bill those patients more than the reimbursement scale set by the government. Actually that isn't that different from the current system, except in today's world you DON'T HAVE to sign up as a provider for services that won't let you bill the excess directly to the patient. For instance, if you accept Medicare as a physician you do so by signing a contract which prohibits you have billing more than Medicare's reimbursement to yourself. Most managed care plans - HMOs, PPOs, etc. - have the same provisions when you become a provider for them as well.

    Anyway, with a global budget, this potentially suffers from the same problems already described - waiting times, access to care issues, "unfair" reimbursement practices for physicians and other providers.

    Socialized Medicine
    - Think the NHS over in Britain. Basically physicians are employees of the government or a governmental entity and hospitals are physically operated by the government. This is different than single payer where the health care providers are still private entities but their only source of reimbursement for services is the government.

    Notice, that some of the terms in this poll aren't exclusive. For instance, Britain has basically a socialized medicine program in the form of the NHS which provides the VAST majority of health care in the UK, but also has private sector health care with private insurance. In this way you might describe it as a two-tier system.

    I should have addressed this up in the two-tier system, but I'll do it now. Many cite the fact that private insurance in the UK is forgone by so many as an example of general satisfaction with socialized medicine and as an argument that such a system could work in the U.S.

    I'm going to let my persona views creep in for a brief moment to say that I think the argument above is fallacious. In a two-tier system the increased tax burden to fund health care for all, prohibits many from being able to afford private insurance. Basically, even if you don't outlaw private insurance funding and allow a two-tier system, you're still, for all intents-and-purposes, mandating government funded health care (or in the case of socialized medicine - government provided health care) for the vast majority who cannot afford both the tax burden and to pay for private insurance. So, while two-tiered systems have many benefits, proponents shouldn't argue that they maintain personal choice while also providing coverage for all.

    Anyway those are the very broad options available in the poll. Understand that these systems could take many forms, with uniquely American manifestations. I encourage everyone to go out there and educate themselves on the nuances of the debate take a look at some of the Presidential candidate's plans, on Bush's proposed tax breaks, and on some of the vocabulary which has been thrown around such as Consumer Directed Health Plans, blah, blah, blah.

    Great resources:

    [Commonwealth/Harvard Health Policy Education Initiative]
    [KaiserEDU - Absolutely amazing resource. Online lectures on SO many health policy topics, that break them down into really simple terms. I am in love with this website]
    [Robert Wood Johnson Foundation]
    [Dartmouth Atlas of Healthcare]
    [Georgetown Health Policy Institute]
    [Survey of Income & Program Participation - Minor survey of uninsured]
    [Medical Expenditure Panel Survey - Minor survey of uninsured]
    [Current Population Survey - Major source of uninsured figures]

    In any case, I'm better versed on some health policy issues than others, but I certainly love the stuff so if you ever have any questions or comments or just want a discussion please feel free to PM me. If I don't know (and what I don't know in the policy-sphere could fill a house I'm sure) I have collected a whole bunch of resources on the web which I'd be happy to share in search for health policy answers.
     
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  7. Miami_med

    Miami_med Moving Far Away
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    You left a free market health system off of the list.
     
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  8. Gut Shot

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    One reason why a free market system won’t work is called EMTALA (the Emergency Medical Treatment and Active Labor Act). While codified in its latest form in 1996, it’s built on an established sentiment of hospitals providing emergent, life saving care that isn’t going to vanish.

    From http://www.emtala.com/faq.htm

    A similar provision exists for pregnant women who are in labor.
     
  9. USCTex

    USCTex Minding My Own
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    Not to put words in the OP's mouth, but I think he listed the most politically tenable "solutions" for the American health care system.

    I'm pretty libertarian myself (see my blog: Frommedskool.com) so while I find a true free market system a noble ideal it is many times less likely to happen than say, even a socialized system (which is itself already not very likely to happen in this country).

    A free market system only enhances the problems which are pressuring reform right now - it decreases access to health care and broadens health care inequalities. We can try to debate those consequences of a free market, but I think that they're generally well accepted and conceded by many libertarian minded health policy wonks. While I personally don't believe that improving access to health care should lie within the scope of government's role, clearly the vast majority of the world does. It simply will not be socially acceptable for such a system to exist in our life time.

    I think that is why it was grouped in with 'Other'.
     
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  10. pagemmapants

    pagemmapants Unknown Member
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    *standing ovation*
     
  11. monday_best

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    Sigh, the sense of entitlement.

    So, then you would do what the many of the "best" surgeons in the U.S. do now, and not take insurance at all, and only be accessible to rich people who can pay you cash. That way, you get reimbursed what you deserve for all of your merit and hard work. It's in your best interest.

    Anyway, that's the American dream. To be the best at something and be insanely well-compensated for it. Who can fault anyone for aspiring to that?

    Unfortunately, our current system isn't sustainable, even with "major reforms" (?).

    I voted for Two Tier as most appropriate for the U.S.; everyone gets covered, but there's still financial incentive for innovation and excellence, for those who require it.
     
  12. Rogue Synapse

    Rogue Synapse The Dude Has Got No Mercy
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    Those who require it are going to be the ones who took out hundreds of thousands in student loans to make it through college/med school. I'm already working with 100k+ debt, and I'm just a first-year. Honestly, I didn't get in the business to excel and be well-rewarded for my excellence; my focus is more outward on patients. I really do want to help people, make a difference, all that touchy-feely personal statement stuff. I don't care how much I get paid as long as I'm comfortable and can support a family and get to do what I love, but supporting a family would be difficult if I have mountains of debt, so I'm forced to aspire to make a lot of money to pay that off, at least in the first part of my career.
     
  13. indo

    indo Feed me a stray cat
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    If we can get healthcare providers to form a powerful body that is actually capable of negotiating with a single payer we could give it a go. That isn't going to happen. What are we going to do? Strike? The simplicity of that kind of system would be nice though.

    Since the government is paying I might as well order all the tests I can just to cover my ass.
     
  14. sirus_virus

    sirus_virus nonsense poster
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    You are only saying this because you have not been pushed far enough. When you get kicked in the nutz by the system(guaranteed to happen in a socialized system), you will not think of strikes as an impossibility.
     
  15. OP
    OP
    def jeff

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    I did consider free market under "other" but I can certainly make it an option. I know how to edit the post, but does anyone know how to edit the poll options?
     
  16. monday_best

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    I understand that. I would like to think that the costs of healthcare and medical education are not independent, and that a major reduction in healthcare costs, if that does lead to reduced physician compensation, would also lead to reduced cost of medical education.

    My admittedly soapboxy tone was really in response to the attitude that practicing medicine could be analogous to providing "boutique"/exclusive service. The idea skeeves me out. I do think physicians should be comfortable, but I hate the implication that medicine is just like any other business.
     
  17. Miami_med

    Miami_med Moving Far Away
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    Dude,

    I'm not trying to turn this into another me vs. you universal healthcare thread. I pointed out that my option, which has had representation in previous discussions, wasn't on the list. We can go back and fight about this on one of the other 800 threads that debate this point.
     
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  18. Gut Shot

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    Dude,

    That thread's exhausted. This one is the wave of the future.
     
  19. indo

    indo Feed me a stray cat
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    Well, right now, physician strikes are forbidden.
     
  20. OncoCaP

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    Maybe so, but calling in sick isn't. Also working really slowly isn't illegal either. If physicians wanted to "fight," they probably could. The question is ... would they want to? And, if so, is striking the best approach to get what they want? Take a look at what the TMA is doing for Texas Physicians (http://www.texmed.org/Template.aspx?id=39). Although they are doing a good job, they are not exactly able to save our crashing healthcare financing system; that would require significant reforms at the State & Federal level. At least the TMA is participating in the process and was able to make a big difference on liability reform (they have a good track record).

    If my memory serves me well, something like this (striking) happened with the neurosurgeons in Austin a few years back, and they got a pay raise that they demanded. It didn't really solve the problem tho'. Rumor has it that if you are in Austin metro (population ~1.4 mill), you should try to avoid doing things that might result in the need for a neurosurgeon on the weekend (better to do those things near the trauma center in Temple (pop ~54000) -- an hour or two to the north on I-35).

    "Economic Survival Tops Texas Physicians' Concerns
    "Stagnant or declining reimbursement, combined with increasing practice costs, has left Texas physicians troubled about the economic viability of their practices. And those financial concerns are threatening both the quality of and access to health care for Texas patients, according to a new TMA survey.

    "Asked to name the biggest challenge facing Texas doctors, 31 percent of physicians participating in the 2006 Survey of Texas Physicians [PDF] said low or declining reimbursement. That was up from 28 percent in 2004.

    "Reimbursement issues displaced professional liability concerns as the biggest challenge. In the 2004 survey, 33 percent of respondents cited liability as the biggest challenge facing physicians. That number was down to 5 percent in 2006 as a result of medical liability reforms enacted in 2003 that led to substantial decreases in professional liability insurance premiums.

    "TMA conducts the physician survey every other year. The 2006 survey included responses from 1,617 physicians and has a margin of error of plus or minus 3.5 percent with a 95-percent confidence level.

    "While low and declining reimbursement ranked at the top, 13 percent of physicians cited economic survival as the biggest challenge. That was followed by the uninsured and underinsured, 11 percent; managed care/insurance issues, 9 percent; and quality of care/access concerns, 7 percent.

    "Fifty-five percent of physicians surveyed said their income had declined over the past two years, while another 29 percent said there was no change. Only 16 percent said their income had increased.
     
  21. _MDPhD_doc

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    It is wise to put your trust not in the government, but place it in the free-market system. Open up healthcare to the free market and you will see greater competition, which drives down costs, increases quality and makes healthcare more affordable FOR EVERYONE! Just ask yourself this... would you want the government in charge of your health... just think about how well the government handles your drivers license renewal at the DMV, and you will have your answer. Turning our healthcare over to the government is a dangerous solution to our healthcare crises.

    P.J. O'Rourke said it well when he stated in 1993, "If you think health care is expensive now, wait until you see what it costs when it's free."


    For those of you who think healthcare is a "right", I strongly encourage you to read this brilliant article in its entirety.

    http://www.frontpagemag.com/Articles/ReadArticle.asp?ID=26465
     
  22. OncoCaP

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    Ah yes, the Ayn Rand Institute. In this article, we are treated to argument by metaphor like "Haircuts are free, like the air we breathe, so some people show up every day for an expensive new styling, the government pays out more and more, barbers revel in their huge new incomes, and the profession starts to grow ravenously, bald men start to come in droves for free hair implantations, a school of fancy, specialized eyebrow pluckers develops--it's all free, the government pays." Yes, that's right folks. Getting a tumor removed is just like getting a haircut from a barber! This discussion on ideological grounds will get us nowhere fast.

    If you actually have a point to make, quote some figures, like the fact that our mostly private system costs us 2X of the single-payer systems AND does not provide insurance to 46 million Americans and 1 in 3 Texans between the ages of 19 and 64. Our costs are expected to double again by 2016, and the costs of private health insurance are rising faster than the actual cost of healthcare (we wouldn't want our health insurance company profits to go down, now would we?). Meanwhile 55% of Texas physicians reported lower reimbursements from insurance companies in 2006 (their income went down). Let's see, we are paying more for our insurance every year, but physicians are getting less every year. I wonder if private health insurance companies have something to do with that? The free market is doing what it does best: generating enormous profits (for insurance and drug companies ... physicians less so), skyrocketing our costs, and reducing the average quality and quantity of care that we get.

    While the private sector should and does play a critical role in healthcare, to suggest that getting the government out of healthcare will improve the situation is an assertion unproven in modern times. In fact, it appears that the industrialized country with the least fraction of government healthcare financing (the U.S.) has the highest costs and largest number of citizens declaring bankruptcy due to medical bills (50% of U.S. personal bankruptcies are due to medical bills or a health condition).

    I wholeheartedly support intelligent solutions (even if they are different from what I would suggest!). However, we can't have an intelligent solution if we are unwilling to look at our healthcare system in an objective manner.
     
  23. sirus_virus

    sirus_virus nonsense poster
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    I have a quick question. If we want to go to a single payer system, why should I pay the same as someone who smokes 6 packs of cigarretes a day, obese from overeating, seldom showers, and patronizes prostitutes frequently?
     
  24. _MDPhD_doc

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    Let me make it very clear... Our system needs reform. That is, by opening up our system up to the free market. A free market is CONSUMER AND DOCTOR DRIVEN CHOICES. You say our system a mostly private system? What? The largest inceases in our healthcare costs are from the government subsidized welfare programs of medicare and medicaid. Also, the vast majority of Americans have HMO's responsible for making their healthcare decisions...which means a third party is responsible. Nobody ever spends someone elses money as well as they spend their own. THat is why our system is expensive. Free market healthcare advocates that the patients and doctors are making decisions vs. our trusty government getting involved (remember Katrina?).

    Our system may have the largest number of people declaring bankruptcies due to medical bills, primarily because people don't have the ability to afford good health insurance. But that only means that we must have solutions that make it more affordable. I support a single payer system, but the patient should be the single payer. If you are suggesting that turning our healthcare over to the government will make it more affordable. Think again. The government doesn't create wealth, all revenues from the government come from the people it taxes. This idea that the government can waive a magic wand and suddenly make healthcare "free", is false and morally objectionable. Watch what happens to costs when patients have a greater role in sharing the healthcare decisions they make. THe best thing the government could do is get out of the way, except for those who actually, truly NEED IT.

    I ask you then... Why is it that every other sector subjected to the free market has fostered innovation, drastically improved quality, and at the same time driven down the costs of consumer products. Take the tech sector, while the quality of computers continues to get better, costs continue to decrease, and companies continue to innovate new products. This drives a perpetual cycle of better products at more affordable prices (Remember what computers or plasma TVs cost 10 years ago?). Now they are commonplace for almost all Americans.


    And yes, to have "intelligent" discussions we must look at our system objectively. Opening healthcare up to the free market is not an "idealistic" point of view. Capitalism , free markets, competition and individual liberties are exactly what has made America the most successful country in the world. So why would we abandon the same principles that made this country great when it comes to healthcare?
     
  25. OncoCaP

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    Agreed. We need reforms. However, most people believe that the reforms that are needed are the opposite of what you advocate. That doesn't mean you're wrong ... it does mean that there is a big difference on the kind of reforms that people like you and me are interested in.

    Please provide a source for your statement about the largest increases in healthcare costs are from government subsidized medicare and medicaid.

    As I said above, our system has the most choice and the highest prices. Physicians can choose what insurance companies to accept and can even go cash-only. Consumers can see whatever physician they want to as long as they can pay for it. Thus, we have a kind of free market in our healthcare system and it has produced the largest costs and quality is mediocre because care you can't afford is not high-quality (because what you get is no care).

    Just so I understand where you are coming from, are you advocating turning healthcare into a complete free market with no licensing of physicians and no government subsidies whatsoever? What about prescription medications? Should those be over the counter? What about the FDA ... disband it and anyone can sell cancer medications on store shelves? I just want to make sure I understand your position.

    Not true. Every American is free to pay whatever physician to get care, as long as they are in agreement (physician accepting patients, etc.). If you want to see an out-of-network physician, go for it; it will come out of your own pocket as in a free market.

    Well, 46 million Americans have the opportunity you are talking about. They aren't doing very well.

    Oh, and yes, I remember Katrina, and yes, I'm rather impressed with how well our gov't handled it (along with the work of thousands and thousands of volunteers). I'm not suggesting that there were no problems, but overall, I'm impressed. Find a country that handled a disaster of similar magnitude by private or other means and did a better job. Maybe you would have preferred that the government do nothing? Well, at least we would have saved billions (nevermind the human toll).

    Also, before we start blaming the goverment for everything in Katrina, keep in mind that many people chose to live there despite the fact that it is near/below sea level and next to the ocean. Many people chose to stay even though they were told a hurricane was coming. While the government can do many things, in a free society people are free to make unwise choices (as many in NO did). Yes, the gov't came to help and continues to help to this day. Many people from NO have even had a chance to get their lives back together back home or in a new place. No, it wasn't perfect and almost nothing involving people and politics will ever be perfect. However, the gov't did do a lot for the people of NO and surrounding areas.

    It is often not a matter of being able to afford good health insurance. Millions of Americans do not qualify for individual coverage at all due to pre-existing conditions such as diabetes, obesity, or other issues. They can't buy it at any price if their employer did not provide it as group coverage. Take Blue Cross Blue Shield for example. When you apply, they ask you your height and weight. Those who are obese don't qualify for that company's health insurance ... that's 30% of the population that doesn't qualify right there. On top of that, my 1 & 2-year old boys are perfectly healthy and not obese (per their pediatricians) and they do not meet the height and weight requirements. Fundamentally, private health insurance companies have a profit motive, not a public health motive. Only the government is in a position to strongly advocate care and ultimately manage healthcare with help from the private sector and significant input from its citizens.

    I have already given you plenty of proof that single-payer systems are cheaper than private systems (and I can give you plenty more if you would just ask). The facts are not on your side. Quit trying to rationalize. Either provide the data or be wrong. Your ideological truism don't contribute to this discussion.

    Every other sector has enormous government involvement. I was in pharma, tech, and heavy industry. I can assure you that the gov't $$ spiggots are wide and open in every industry from personal computers and microchips to advanced materials. In fact, that plasma TV ... it wasn't made in the U.S. It was made in South Korea, China, or wherever at a factory financed by low interest government loans or artificial currency manipulation. As far as things that are made here, rest assured, our government is investing billions upon billions in R&D and various efforts to help business. Without the government's help, many industries would be utterly destroyed by foreign competition, patent violations, fraud, etc.

    Now I will grant you that there is significant innovation in the tech sector and that free markets and privatization have a critical role. For example, in a single-payer (government) system, private companies could bid on dataprocessing, fraud detection, process improvement, cost reduction, and call-center contracts, for example. Both could work together, but the government, whether at the state or federal level, would be ultimately responsible for the program and making sure that everyone had access to care. In fact, I advocate a two-tier system, with a single payer (ala Medicare that covers everyone, but with copays) and optional additional/supplemental private coverage. In this way, everyone has at least access to healthcare, and if it is a priority and they have the means, they can spend more of their own money to get additional care.

    Interestingly, the government has been the biggest innovator in American healthcare. NIH spends enormous sums on the development of cancer treatments, child health, and education of medical scientists. Without organizations like the NIH we would be much worse off. The IT infrastructure (EHR's, etc.) of the VA is signficantly more innovative that that of the average hospital. Every VA patient's records can be pulled up on a laptop and aid the physician in making fewer errors. This is not unique. Going to the moon was a government funded enterprise. Both government and private organizations have a lot to contribute to our society and well-being. To say that when the government stays out of a sector that it does better fails to face the objective facts. Even our long-distance bills are relatively cheap because the government forced the breakup of the original AT&T.

    This would be a much more intelligent discussion if you actually quoted some facts like statistics, case studies, and the like. We all love mom and apple pie, but it's not going to help us sort out what we need to do.

    We are not going to let people die outside the hospital because they cannot afford care. Whether we get a plasma TV or not is not a life and death decision but whether someone has access to diabetes care and medication is.

    Sorry to be so aggressive about this. Maybe I'll go back and edit my message for a better tone. I'm a firm believer in using objective facts when it comes to problems like this. If you would just give objective information a try, I think we could make more progress in a discussion like this.

    http://www.nchc.org/facts/coverage.shtml
    "Nearly 82 million people - about one-third of the population below the age of 65 spent a portion of either 2002 or 2003 without health coverage (1).

    "In 2004, 27 million workers were uninsured because not all businesses offer health benefits, not all workers qualify for coverage and many employees cannot afford their share of the health insurance premium even when coverage is at their fingertips(4).

    "Millions of workers don't have the opportunity to get coverage. A third of firms in the U.S. did not offer coverage in 2004 (2).

    "Rapidly rising health insurance premiums is the main reason cited by all small firms for not offering coverage. Health insurance premiums are rising at extraordinary rates. Over the past five years the average annual increase in inflation has been 2.5 percent while health insurance premiums for small firms have escalated an average of 15 percent annually (2).

    "Even if employees are offered coverage on the job, they can't always afford their portion of the premium. Employee spending for health insurance coverage (employee's share of family coverage) has increased 143 percent between 2000 and 2005. (5)

    "Lack of insurance compromises the health of the uninsured because they receive less preventive care, are diagnosed at more advanced disease stages, and once diagnosed, tend to receive less therapeutic care and have higher mortality rates than insured individuals (8).

    "Over one-third of uninsured adults say they did not fill a drug prescription in 2003 and over a third went without a recommended medical test or treatment due to cost (4).

    "Studies estimate that the number of excess deaths among uninsured adults age 25-64 is in the range of 18,000 a year. This mortality figure is similar to the 17,500 deaths from diabetes within the same age group (7).

    "Increasingly, the uninsured are more likely to be hospitalized for an "avoidable condition" - problems that could have been prevented had a person received appropriate and timely outpatient care (10).

    "Hospitals provide about $34 billion worth of uncompensated care a year (11).

    "The uninsured are 30 to 50 percent more likely to be hospitalized for an avoidable condition, with the average cost of an avoidable hospital stayed estimated to be about $3,300 (11).

    "The increasing reliance of the uninsured on the emergency department has serious economic implications, since the cost of treating patients is higher in the emergency department than in other outpatient clinics and medical practices (8).

    "Getting Everyone Covered will Save Lives and Money

    "The impacts of going uninsured are clear and severe. Many uninsured individuals postpone needed medical care which results in increased mortality and billions of dollars lost in productivity and increased expenses to the health care system. There also exists a significant sense of vulnerability to the potential loss of health insurance which is shared by tens of millions of other Americans who have managed to retain coverage. Every American should have health care coverage, participation should be mandatory, and everyone should have basic benefits.
     
  26. Gut Shot

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    You should actually pay more, because that person's overall consumption of healthcare resources is likely to be less than someone who lives an extremely long life.
     
  27. OncoCaP

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    Unders a single payer system, I would be in favor of higher taxes or other penalties for people who smoke (in a way they already pay for it with cigarette taxes, which might be ok). Obesity is more difficult. Perhaps if a person who is obese would need to enroll in some kind of weight control program to avoid paying penalties and higher taxes. However, many Americans would probably find such penalties to be unacceptable. I'm not sure a "cheeseburger and fries" tax similar to the tax on cigarettes would get public approval. Maybe better access to healthcare and better promotion of exercise and healthy eating would make a difference.

    Now as far as showers and prostitutes ... maybe we could bring back public bath houses and get OSHA to set up health inspections and certifications for sex workers like they do in the Netherlands and Germany :laugh: :rolleyes:
     
  28. thewarehouse

    thewarehouse Member
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    This is disgusting- So the 46 million people without health insurance should die or lose their "crappy 4000 square foot house" so you can make more money.

    You're right- all your hard work in becoming a "good" surgeon was "pretty much wasted" because it didn't lead to an extra mercedes in your driveway. You should have saved all that hard work and lived a life of mediocrity. I mean none of us really "just want to help people" anyways, so why put in any extra effort trying?

    My vote goes to any system that can help alleviate the health care disparities plaguing lower- and middle-class Americans who, despite working, can not provide adequate health care for their families. While a lot of people will agree with me, the truth about these systems is that it's going to take sacrifice in the way of lower salaries for health care professionals, reduced overhead in health plan administration, and funding from businesses and the government. From the several courses I've taken in health policy and health care, three things have become clear: our system is heading for a train wreck, one in six people is on the brink of medical or financial disaster because they are without insurance, and certain cuts need to made in order to alleviate this, whether we like it or not.
     
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  29. monday_best

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    Now, that deserves a standing ovation. :D
     
  30. Miami_med

    Miami_med Moving Far Away
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    #1: Go ahead and quote the Socialist Party, as they are espousing similar positions to the ones proposed on this thread.

    #2: The basic principles of economics apply to ALL industries. The fact that you find a comparison between haircuts and medicine unpalatable doesn't mean that there is no comparison. They both follow scarcity and other basic economic principles (that is unless you are ready to debate the supply and demand curve). At a low price, demand is high.

    #3: We DON'T have a truly private system in the US. We have a bizarre mixed system that is mainly beholden to a variety of special interest groups. You are probably correct that a single payer system would be cheaper than the current disaster that is US healthcare. It wouldn't necessarily be of higher quality, but it would be cheaper. I've never espoused the current system. That doesn't prove that either are a good idea. Our free market system as a percentage of our MUCH SMALLER GDP in pre-1965 was less than 5%. That's 1/2 of most of our European neighbors.

    Ah, back into the fray :rolleyes:
     
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  31. Miami_med

    Miami_med Moving Far Away
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    Have fun working for free. I think that being rewarded for good work is a good thing. Would you scream the same thing if the LA dock workers went on strike. Their service is a "public good." They make the same wages as some primary care docs with essentially no education. I'm just trying to be clear as to whether your position is Marxist across the board, or if it is just limited to medicine.
     
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  32. Miami_med

    Miami_med Moving Far Away
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    Careful with this one. You forgot that healthcare is a magic happy place that doesn't follow any of the same rules as any other industry. Scarcity doesn't apply to healthcare. Supply and demand DEFINITELY do not apply to healthcare. We as physicians should sacrifice ourselves constantly and expect no personal benefit in return. If you want to be paid for your work, you are evil. If you want to get paid for doing a better job, you're evil. If you think that people should be responsible for the consequences of their actions, you are REALLY evil.

    The real solution is the super tax on all choices that the government deems as bad. We'll make sure to include everything that is politically unpalatable in this group. Things like smoking and drinking will definitely make the list. Equally dangerous, but more elite, activities such as skiing or boating will be excluded. Being president is the most dangerous job in America. We should tax the heck out of that guy.

    There, I have prophylactically saved you from your emotional flogging :D
     
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  33. Gut Shot

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    ...but if you bombard us with false dichotomies you're just a douche.
     
  34. thewarehouse

    thewarehouse Member
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    I think most of your response is directed towards everyone else, but while you're on the subject of sociological theorists, I'm going to agree with you about getting Marxism out of our system entirely, starting with the right to an attorney. You're absolutely right- why have socialized access to an attorney? If someone's accused of something and can't afford an attorney, let 'em sit in jail for the rest of his life. What commie thought it'd be a good idea to sneak that amendment into the bill of rights?

    No; but I think we're a little at odds about what it means to do a better job. If doing a better job means developing the practice of medicine so that it can help people with diseases other docs can't even touch, then you deserve to get paid for all the patients you're going to help that would otherwise be untreatable. But I believe that anyone who thinks that a doc with a great track record of replacing knees needs to make seven figures instead of six while other people lose their houses to pay for treatment after a stroke is a little misguided in their decision to pursue medicine.

    And, my personal favorite:

    If you need a mansion, a yacht, and a Ferrari to feel a sense of "personal benefit," then you've gotta be compensating for something.
     
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  35. OncoCaP

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    The pathetic arguments for a private (free market) healthcare system leave me no choice: I must argue for my critics' side just to have a discussion that rises above namecalling, strawman arguments, mindless analogies, and ideological chatter.

    If I was my own critic, here are some reasons I would give as to why we should go to a free market system in healthcare. Mind you that I don't agree with this point of view, but I value an objective assessment and letting the facts guide us as we look for reform and improvement. I can argue even for a position that I don't agree with when appropriate. I believe that any professional or college student who is serious about this subject (or any other controversial subject) should be able to argue objectively both sides of the coin. Being able to do so demonstrates understanding of the trade-offs of a particular policy vs another and shows the objectivity to be able to pick the best option based on the facts rather than being confined to narrow ideology and perspective by habit, lack of knowledge, or just plain arrogance.

    Here is an objective argument for free market healthcare reform (not surprisingly from "Reason Magazine"). I added a few points I came up with on my own at the end.

    http://www.reason.com/news/show/34816.html

    1. Let's assess the uninsured "crisis." Who are the people uninsured for a year or more? It turns out that 60.5 percent are under the age of 35, and 80.2 percent are under 45. Furthermore, 86.1 percent of those uninsured for a year consider their health to be "good" to "excellent," and they are not wrong. Consider the risk of death faced by those under 35. In 2000 there were 134,419,000 Americans in this age bracket. Of the 2,404,598 Americans who died that year, 112,005 were under 35, or about 4.6 percent. Using death as a crude measure for serious health risk (can't get more serious than death), the under-35 uninsureds were risking one chance in 1,200 of dying from whatever causes in 2000. And while 60.5 percent seems like a high number, keep in mind that the rate of the uninsured among the population as a whole remained small—only 7.3 percent of those under 19 were uninsured for the whole year; the 19-24 bracket was at 14.4 percent; and the 25-34 group came in at 12.3 percent.

    "So the vast majority of those who died under age 35 died with health insurance. But it may be specious to emphasize such correlations anyway. After all, we don't blame the 1,801,459 deaths of people over age 65 in 2000 on the fact that they are the beneficiaries of the federal government's Medicare program.

    "But how many die prematurely from lack of health insurance? The United Steelworkers of America gives an estimate of 18,000. That's bad, but let's put the number in perspective: In 1999 there were 29,199 suicides, and a year later 41,821 people died in traffic accidents. So the health care "crisis" does not mean that America's streets are clogged with folks pushing tumbrels yelling, "Bring out your dead!" Americans are not dying in droves due to a lack of health insurance.

    2. The government is a big part of the problem in healthcare, the single biggest cause. "[P]hysicians are being turned into paper-pushers handling mass quantities of government and private health insurance paperwork, while being limited in the tests and drugs they can order for their patients. Physicians are also being squeezed by federal government restrictions on what they can charge their patients. This means that doctors typically lose money on Medicare and Medicaid patients, which forces them to raise prices on their privately insured patients to make a decent living. If everyone was covered by these programs, many physicians would go out of business overnight, worsening access to care for everyone.

    The current system does not operate like a free market at all. Patients and physicians have little incentive to consider cost in making healthcare diagnostic and treatment decisions, so this results in an unstable system that quickly spins out of control. The government rules and mandates are what is screwing up private healthinsurance. If it wasn't for those books of rules, maybe private health insurance could actually offer low cost options.
    "ince patients are not paying for medical services directly, they have no incentive to curb their use of the services provided. This dysfunctional incentive structure leaves that burden on both government and corporate third-party payers who have to raise taxes and prices to cover their uncontrolled medical expenses. And health insurers have to meet myriad state and federal mandates that expand paperwork and prevent them from offering lower-cost alternatives. The system is so complicated and screwed up that policy makers, the public, physicians, insurers, and corporations may well entertain a radically simple solution to the problem just because the status quo is so absurdly annoying. ....

    3. There are some great examples of free market healthcare that are working. One of them "... is the rise of "boutique" medicine, in which patients agree to pay primary-care physicians an annual fee, in return for the physicians' agreeing to limit their number of patients and make themselves available on a 24/7 basis. The fees can also cover expenses like antibiotics, exams, and in-house diagnostic testing, in addition to the easy access. I don't have exact statistics, but maybe the average poor American spends $10 a day on cigarettes, beer, lottery tickets, mood rings, spinner hubcaps, and who knows what all ... that's $300 per month or $3600 per year in discretionary spending. If they instead bought a health insurance policy or a "boutique" policy with that or just saved the money for an unexpected expense such as an illness, they would be able to afford the care that they need. The fact that many poor or working poor Americans choose to spend their money a certain way is their choice. We are not their parents (in most cases) and should not feel like we need to compensate for their life choices whether good or bad. Let's let Americans live the life they choose to live instead of always bailing them out like an enabling parent.

    4. (Point added by me) Average wait times for procedures are much less in the U.S. In the U.S. in 2001, only 5% of Americans had to wait 4 or more months for elective surgery (http://www.oecd.org/dataoecd/31/10/17256025.pdf). Compare that with 23% in Australia and 38% in the U.K. with the supposedly better systems. Further study would no doubt show that excessive wait times for diagnosis and treatment have a human toll that might even exceed the toll we face with America's uninsured and underinsured.

    5. (Point added by me) Hospitals and providers will work with patients and charity programs are available. For those patients who cannot afford care, there are payment plans available. I know a family that has no health insurance, and, for that matter no money to pay a physician. Yet, they go to a physician when they need to and he provides care to them for free. Yes, it isn't ideal, but for patients who are honestly trying to get care on very little money, there are solutions. Our uninsured are not dying in our streets. Those who are willing to lift a finger can find care.

    6. (Point added by me) Just because healthcare is costing Americans a lot doesn't mean that there is a problem. We have a greater level of wealth than many other countries and choose to spend more on our health. Americans want the latest and best drugs and we don't want to wait months or years to see a specialist. Maybe Americans are just less likely to turn down heart bypass for a person in their 70s than a Spaniard is; our values are different, and we put our money where our mouth is. We have a right to make our own priorities and copying what the rest of the world is doing is not the American way. Maybe we spend more on entertainment, computers, clothes, and cars, for example, but this is not necessarily a problem. We just have a lot more discretionary spending than they do because it's a free country and we don't tax our citizens at 50% like Scandanavian countries. All their citizens have left is money for bear and snooker. Many of them can't afford a house or a car. Is this how we want to live? We have money for cigars, liquor, Girl Scout cookies, poker, and outrageous yard ornaments. We have money to spend on crazy stuff because we are not taxed to death. It's the American way; don't mess with it. We also save less than many other countries.(http://www.euromonitor.com/Spending_Choices_Discretionary_Income_Patterns_to_2015) It's just who we are, not necessarily a problem with our healthcare system. Let us be Americans instead of turning us into French or Germans. If we wanted to be European, we would move there.

    7. (Point added by me) Much of the uninsured crisis is simply due to people who want to take their chances on their health because smoking a pack of cigarettes now or drinking a beer is just worth more it in terms of quality of life for them. Who are we to question their choices? Besides, the U.S. gov't is already spending $100 billion on the uninsured, so why should they? If the U.S. government quit interfering so much with our healthcare system and let Americans buy prescription drugs we need from Canada or Mexico without treating us like drug dealers because we want to save a couple hundred dollars our costs would go down as well. Even the uninsured who do not qualify for health insurance are not powerless. They can make decisions that benefit their health (such as not smoking) and work with those providers who do provide payment plans or charitable care.

    8. (Point added by me) People are not dying in the streets now and will not be dying in the streets under a free market system. Those who truly have a need will be treated by physicians. That's how physicians and nurses are ... they care about people. They are not in it just for the money. The compassion is there and it does not need to be mandated by law. When we create arbitrary laws like EMTALA, we get a lot of abuse. Most of the people who are making use of EMTALA do not have an emergency. In the words of Uncle Panda: they just want to spend their money on beer instead of a primary care physician. After all, if you can get a service for free, whether it's medical care of free lawnmowing, you would need to be an idiot not to take it. Without such heavy-handed rules we could see that people in the medical profession are not heartless capitalists. They are people who chose this profession to make a difference in the lives of others. They are willing to help; let's give them that chance. The few bad apples should not ruin the entire system for everyone. Let's deal with them separately. We shouldn't have every American under police surveilance because a few choose a life of crime. Similarly we shouldn't punish all physicians with dysfunctional laws just because some physicians chose not to provide proper care. Single-payer and other government financed systems would just increase the number of such bone-headed rules and mandates, further increasing costs and worsening the quality and access to care.

    9. (my point) We wouldn't need to throw out the entire system to improve the situation. We could perhaps test eliminating certain mandates and see if the cost and quality of care improves. This is more difficult to do with a system such as single-payer, where you typically don't see benefits until you have broad long-term implementation. If single-payer, two-tier, or a similar system turned out to be a disaster, it would not be as easy to recover from such an experiment as restoring a mandate or rule that turns out to be necessary out of practical necessity. We wouldn't need to implement a full-blown free-market system. We could make incremental changes and work with the public and assess progress. The risks of trying free-market changes would be much smaller than testing out a single-payer or two-tier system. Let's try free-market improvements first, and, if it unexpectedly doesn't work, we could always try a big government solution later. The trouble is that many of our politicians essentially want to buy votes by providing another government benefit to the voters (and, as usual, not informing them of the costs such as increased wait times and reduced care options). Reason is not prevailing; let's advocate a more rational and practical approach.
     
  36. USCTex

    USCTex Minding My Own
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    Well, it is a "kind of free market," I suppose we can concede. However, you can't write the current funding set up, off as merely physician vs. payer competition. This sort of cabal - with nearly 50% of funding coming from a single payer[1], almost all other sources setting their prices off the reimbursement rates of Medicare, and without any price/reimbusement transparency - would never be allowed by the SEC in the private sector for any other industry.

    And it is difficult to argue that, in a true free market sense, something like an emergency craniotomy isn't UNDERVALUED.


    A lovely notion, and reasonably true right now. But even if we avoid single payer and go to a two-tier system it isn't a terribly realistic notion. You start increasing the tax-burden to fund public health care and it prohibits people from seeking out and paying for their own private care.

    Two points about inflating the number of uninsured.

    1) 46 million is a easy and well repeated number for the media. However, a huge number of policy wonks concede that the Current Population Survey directly understates those with coverage at any time time[2] [3]. It is likely they under report those enrolled in Medicaid and because of the way the question on insurance is posed get negative responses from those currently insured but have had been uninsured in the past year (it is a point in time survey)

    Everyone should go look at KaiserEDU's tutorial on the difficulties in Counting The Uninsured. The CPS is the major survey for counting the uninsured with several smaller ones including MEPS and SIPP.

    2) Undercounting the uninsured doesn't tell half the story however. It speaks nothing to those who choose to forgo insurance or about the lack of personal responsibility amongst patients in this country.

    Yes there are ALWAYS antecedal stories about the single mother who pulled herself up by her bootstraps and then loses the farm because her son gets a brain tumor. Heart tugging but simply not part of the facts. And yes more than 30% of the uninsured are below the poverty level (which is in and of itself a joke of a measurement of true cost of living anymore, I admit) [4]

    Those being conceded, non-partisan respected estimates put the percentage of uninsured who are either a) able to afford insurance or b) eligible for public assistance (mostly Medicaid) and aren't enrolled at more than 40% [5] [6].

    The bleeding heart counter argument is that ANYONE uninsured is too many. Who cares if the numbers are inflated, is what you're probably saying right about now. Maybe, but it is important to understand the true magnitude of the problem so we can know how outraged to be.

    Let me make it clear, it is difficult to put my personal greed at the heart of my opposition to further government subsidies -- I've got my track record and ideals to the contrary. My distinction, and I don't think it is hair splitting, is that whatever I feel my moral obligation to the less fortunate I refuse to put it on anyone else. Which is exactly what any form of wealth distribution does. Public funds need to be used only for items beneficial to nearly all. And while, as it is for everyone determining what taxes should be spent on, the definition of what nearly all means is very subjective I can say that the bar needs to be very low and health care certainly doesn't fit under it.

    You're playing into the 'personal responsibility' crowd's hands. And I'm not merely taking about those who get lung cancer with a 15 year smoking history. Another two points to make:

    1) This is probably the sickest country in the western world. What I mean by that is that independent of health care access or quality this country is sick. In 2006 Banks, et al found that independent of coverage status Americans were sicker than their English cousins [7] [8]. The PI's conclusion in interviews? Lifestyle factors, especially in childhood were to blame on America's poor health.

    This country is the fattest in the western world [9]. And it has one of the longest histories of growing obesity. It has one of the highest rates of trauma and violent injuries. The point is the casual relationship isn't we spend more and get less (which isn't actually a relationship at all) it is we live unhealthy by choice, so we're sicker, because we're sicker we spend more on health care, and because we're sicker we die sooner. Those increased costs drive insurance premiums and leave more American uninsured.

    Don't get me wrong, America runs one of the least efficient health care systems in the world. This explanation, at most, contributes a relatively small part to America's health care expenses. But it is significant, and whatever the size of that contribution shouldn't people be taking some personal responsibility before they ask for hand outs?

    2) This country has the most consumer debt in the world. More than 2 trillion dollars [10]. The Urban Institute's analysis of those who could afford health insurance (cited in Health Affairs above) didn't even consider this. As I already admitted above, more than 30% of the uninsured fall below the poverty line, so this discussion doesn't include them.

    Plenty of evidence exists that this isn't survival debt, it is merely Americans not living within their means. Americans are working to pay off the dimes they spent on that new television or pair of shoes or tupperware and yet at the same time they're clamoring for health care reform with further subsidization of their health care expenses? They can't even show the common sense or strong will to cut up that pre-approved credit card offer so that they might have some money to budget for their health care expenses.

    This is an example of a growing entitlement culture. I mean, for all the lavish praise laid on universal health care, in many ways why would we want to follow europe down this road of socializm and guarantees. Take a look at what an entitlement culture has done to their unemployed figures...but at least those unemployed don't have to worry if they get sick I suppose[11].

    No, this complaint doesn't apply to all but it does change the frame of the debate. If you concede the above then back off your single payer talk. Start discussing a public assistance program with strict eligibility rules based on income...call it Medicaid-For-All. Then we can have a discussion, with those who should be able to afford insurance out of the picture.

    A legitimate common complaint. Although I can't find nor have I ever seen any numbers on this, which makes me dubious, because people cite it all the time.

    If this is your primary complaint then stump for mandated community rating for private insurance. Sure, I might not like over government regulation of the insurance industry, but I promise myself and just about every other libertarian would buy it more than a single payer idea.

    What? There's no globalization of health care. If your point is that government is already involved in the market so why shouldn't it be in health care...well the answer is easy. There's a huge difference between the way the market SHOULD work and the way it must pragmatically work. If the government doesn't HAVE to be involved in health care to protect it, then it shouldn't be. No one wants to leave our manufacturing industries out to dry, so we look for ways to assist them. But in an ideal world China would let its currency float so its export products weren't artificially cheap, etc.

    As I said above, this is an inadequate compromise. Proponents of a two-tiered system should not pretend it is the best of both worlds - covering all while protecting liberty. Increased tax burdens prohibit many of those who want private insurance from affording it in a two tier system. The UK has a private insurance market which is not very utilized. It is my contention that the lack of utilization is due to inaffordability, not with satisfaction with the National Health System. Indeed, in 1999 only 61% of UK residents were satisfied with the NHS [12].

    Obviously the UK's tax burden is large and its socialized system puts unique pressures on the private insurance market. But it is certainly an example of what can happen to the reality of 'private insurance choice' in a two tier system with a large tax burden.

    Well, maybe you'll take my response a little more seriously. :)

    Almost assuredly all facts derived from the Current Population Survey and other census bureau surveys. Not a criticism, just a point. As cited above you should go check out some critiques of them...although they only lower the magnitude of the problem. The problem still remains the elephant in the room.

    Sadly this misses the point, as does basically my entire post up until now. :)

    For all I've cited and all you've cited, the argument over government funded health care is really one of political philosophy and morality.

    Libertarian proponents may get side tracked, or more likely are scared of appearing heartless, and go out and cite all sorts of figures or make all sorts of arguments trying to display the free market as a pragmatic solution.

    I concede right now that single payer and socialized medicine system, while sacrificing choice and increasing waiting times, are cheaper and in terms of common imprecise measures (don't get me started on comparing infant mortality and life expectancy figures...what a joke) of health care quality are at least equal with the American system or a true free market system.

    I concede that the safety net in this country is inadequate to provide the uninsured with the same medical attention and quality that the insured have, and that the uninsured die at a higher rate and with live their lives with a lower quality of life.

    And after those concessions, I wipe the tear away and promise to do my personal best to correct those WITHOUT FORCING SUCH ON ANYONE ELSE.

    I simply cannot defend wealth distribution. Correcting inequalities is simply not the role of government. There's several winding roads I can take to come to this conclusion. Lets take an obtuse one.

    A) A progressive tax system and government funded health care redistributed wealth.

    Everyone can agree to that.

    B) Wealth distribution denies some of liberties.

    IF, you believe in property rights then you almost have to agree with this. Implicitly you're choosing some right to a quality of life level over property rights.

    C) The quality of life level or the level of health care guaranteed is subjective.

    There is a huge amount of indefensible subjectivity in determining wealth redistribution. Oh you get this health care covered but not this other procedure. Oh you get health care but not a roof over your head.

    At first it seems like a pragmatic determination, because you don't have the monies. But remember if you wanted to you could go and take more money in taxes. What you've done is weighed property rights against the rights to health care and come up with a scale - oh it is okay to take this much from the wealthy to guarantee this much health care for everyone, but it isn't okay to take more than that.

    There are of course reasons you made the choices on the tax rate and on which procedures would be covered and on how many MRI machines there would be or why you spent the money on health care rather than on housing the homeless. There are economic and social factors in this determination but from a solely philosophical point of view the determination (no matter what it turns out to be) is subjective and illogical. At least in my mind.

    The only seemingly sound and defensible positions are either a) no redistribution of wealth or b) equal redistribution of wealth guaranteeing all the same quality of life.

    I've made a circumstantial argument (probably with many fallacies in it) which concedes that complete redistribution of wealth has a logical road to it. Throw out the idea of individual property rights and throw in some collectivism and you have ideal communism. Short of you advocating that, I think government subsidized health care has to be condemned.

    ---------------------
    1) Wall Street Journal Graphic From CMS Data
    2) Urban Institute On Counting The Uninsured
    3) Heritage Foundation On Counting The Uninsured
    4) Kaiser Family Foundation, "Health Insurance In America"
    5) Health Affairs Blog
    6) Health Affairs Article (Subscription Required)
    7) USA Today On Study
    8) Study In JAMA
    9) Forbes' Fattest Countries
    10) MSN On Consumer Debt Circa 2003
    11) Challenge Magazine On Europe's Unemployment...All The Way Back In 1998
    12) European Foundation National Health Care Systems Satisfaction
     
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  37. OP
    OP
    def jeff

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    OncoCap,

    For someone playing devil’s advocate, you provided some pretty convincing and rational arguments.;)
     
  38. OncoCaP

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    Excellent points USCTex! :thumbup: You provide a number of practical solutions and improvements we can work with and reasons why a single payer or two-tier system might not be the best approach. I'm open to well-reasoned alternatives.

    Have you looked at the European systems very much? Of those systems, which one do you like the best (if you were forced to choose, so to speak). For example, I have a good impression of the Austrian, Danish, and Dutch systems. Some of the reasons I like them could be copied in a private system. For example, by making sure everyone has at least the option to get coverage and the administration is consistent (there are fewer different forms and insurance companies aren't spending our healthcare dollars on figuring out how to reject high risk patients). You provide an alternative to the European systems.

    An advantage of the European systems is that they force a certain element of fiscal discipline in healthcare spending. That might be a problem in some cases, but I'm curious as to what you see as holding down costs in your preferred system or if you even see controlling cost as an important factor.

    I don't like the Canadian system because it is underfunded (a major weakness of single-payer and two-tier -- if the gov't underfunds the system, we are screwed). However, their drug prices are less because the gov't is involved in negotiating drug prices. Would you envision such negotiation of drug prices as an essential reform of our current system?
     
  39. OncoCaP

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    Thanks. :laugh: Yes, my goal really is not to win an argument. I want to understand the options and advocate the best solutions. I wish more people would do the same.

    I'm sure there is more than one great plan for U.S. healthcare financing. The tough part is comparing and evaluating them. We are not each other's enemies (hopefully). We all stand to benefit from a great healthcare system. There are tradeoffs and these need to be understood and managed.

    I realize that a great plan is only part of a solution. Excellent execution, incentives for excellence, smart political lubrication, and protection against fraud and abusers are some of the many details that can make or break just about any plan.
     
  40. indo

    indo Feed me a stray cat
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    You've essentially just said that the reason 46 million people don't have health insurance is because doctors get paid too much. I know of 1 person who opted out of purchasing health insurance but instead bought a new purse and a new car. Is that because doctors get paid too much?

    Halving physician salaries would reduce overall health care spending by 5%.


    In my analogy I was the BEST surgeon.

    You missed the point. The point was that if you create an environment where excellence above medicrity is no longer rewarded you will find excellent people leaving the environment (medicine) and going to an environment where excellence is rewarded (building 4000 square foot houses or business or dentistry or whatever).

    I used well-built houses vs manufactured homes because anyone with a pulse realizes that there is a quality-of-build difference between the two and thus a price difference between the two. The square footage is an inconsequential artifact of the analogy. Let it go. If a builder became the best builder in town by working hard and just being better at it than everyone else doesn't he or she deserve to get paid more? Where does the motivation to become the best at your job come from if not from a financial standpoint? Why should that builder bust his ass if he is going to be treated the same way as the builder who cuts corners and uses cheap materials and employs illegal immigrants?
     
  41. OncoCaP

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    Hi indo,

    I'm in favor of a two-tier system where physicians can also take cash instead of universal medicare or private health insurance (if they wish). It seems reasonable that they should have that freedom.

    Looks like the Centers for Medicare & Medicaid Services (CMS) agrees with you and is looking for ways to reward excellent physicians:

    http://www.healthimaging.com/content/view/4942/89/
    Health Imaging News | September 11, 2006 | Top Stories
    "The Centers for Medicare & Medicaid Services (CMS) last week announced a three-year program that will test whether hospitals can provide financial incentives to physicians for quality care will improve patient outcomes but not drive up costs. The program is known as the Physician-Hospital Collaboration Demonstration (PHCD).

    "The model would see hospitals paid its usual inpatient rate for the patient’s care, but would pay doctors a portion of the savings resulting from quality improvement and efficiency efforts that they have undertaken. Each payment would have to be documented and the care improvements and savings would have to be significant, CMS said.

    What do you think? Is it a good idea what the CMS is doing or would you suggest the best surgeon take cash only?
     
  42. Miami_med

    Miami_med Moving Far Away
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    Well, we don't have socialized legal system per se. Yes, you get an attorney if you are being tried for a felony. In this case however, the individual only has a problem because the government has put them on trial. This doesn't mean that they aren't guilty, but you have to give someone the means to navigate the legal system if you are thrusting them into it against their will. With regards to ALL OTHER legal matters, you must hire your own attorney. We don't give people free attorneys to file lawsuits or do real estate deals or write corporate contracts. Most of the attorneys who push for socialized medicine would be horrified at this idea. Anyone can choose to not access medical care. It would be a stupid idea not to if you have a potentially fatal condition, but it is still a choice.

    No, the only real Marxist idea in the constitution (which of course pre-dates Marxism) is the Post Office. A nationalized company from the start with state support in tax dollars. Do you understand the ideas of Marxism?


    In a free market system, the doctor that helps the most people would be able to be reimbursed for doing so. I think that there is a value to being the best at knee replacements. Have you ever known anyone who needed one? Personally, I think recovery of neurological function is worth the loss of almost anything I own. I can also purchase private insurance to prevent this loss. I also don't think that we should tax other people out of their homes in order to pay for my stroke. I noticed that little elitist blurb at the end, where you again insinuate that the only reason to pursue medicine is to follow your ideaology.
    [/QUOTE]
    I'm glad you appreciated this one.

    I don't care if you buy a mansion or a trailer. That's not the point. People should be fairly compensated for the work that they do. The only way to determine a truly fair compensation is to determine what people are willing to pay for it. This can only be done in a free market. If this compensation is enough to buy a yacht, good for you. If it's enough to buy a trailer in Hicksville, then that is what you have earned. There is also nothing wrong with turning around and donating much of what you earn towards helping others in whatever cause you choose. You have still been compensated.

    By the way, not that the exact numbers are relevant in any way, but most doctors don't make seven figures. Have you been living in a box?
     
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  43. Gut Shot

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    Unbenownst to many, overall physician income was more uniform and modest pre-Medicare than any time since. When an older surgeon gets a tear in his eye while recalling the Golden Age back in the 1970's, he's remembering the slaughter of the Medicare cash cow.

    -From a 1993 NY Times article "Health Plan Is Toughest On Doctors Making Most"
     
  44. Gut Shot

    15+ Year Member

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    Excerpt from an excellent article (Part 1 of 4) from the 2005 Annals of Internal Medicine:

     
  45. Gut Shot

    15+ Year Member

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    Sorry, long…
     
  46. Miami_med

    Miami_med Moving Far Away
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    There is some truth to what you are writing. Without the government, some specialties would lose money. There are all sorts of misallocations already, specifically because of government involvement. A switch to a free market system would likely cause a narrowing of the difference in pay between specialties, while concominantly causing a wider range of pay within the specialty. This is probably great if you like IM or FP and not so good if you want to be a dermatologist.

    Training program restrictions have also caused misallocations. The existance of ridiculously competative fields (such as dermatology or radiology) shows either an artificially high demand for the specialty in the secondary market place (thus driving up prices), an incorrect valuation of services (The government overpaying for services), or an artificially constrained number of training spots (Limits on residency training). These sorts of misallocations are BECAUSE of government involvement. They will only get worse if the government takes over completely.

    I do think that your article is a little misguided. Consolidation of health services, as it listed as the reason for decline in market forces, is also a market force. There can be backlashes and price variation in industry. What the article doesn't mention is that nearly 50% of the money in this market is still from the government.
     
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  47. monday_best

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    She didn't miss the point. You missed the point.

    Comparing providing excellent medical care to furnishing customers with exclusive, high-quality houses is really kind of a messed-up analogy, I agree. If you missed my response to you earlier:

    Like I said, I'm really bothered by the attitude that practicing medicine could be analogous to providing "boutique"/exclusive service. The idea skeeves me out. I do think physicians should be comfortable (and not suffering under crippling debt), but I hate the implication that medicine is just like any other business. It's fine to deny access to your custom, designer construction services or your cosmetic dentistry if people don't have the means, but I think people who want to get rich off of doctoring-- to the exclusion of people who need their services but cannot afford them-- are not really people I want as colleagues.

    At the same time, while I chastize you for your sense of entitlement, I realize that many Americans have no realistic sense of what they should be financially contributing to their health care, yet feel entitled to the best care even though they make irresponsible decisions.

    What can I say? The world doesn't get better if everyone thinks, "f*** the other guy, I'll do what's best for me." (Yes, huge idealist here, I know.)

    It says something about you that you need to be well-paid to want to achieve. I really don't think there's going to be a brain drain from medicine. Believe me, there are plenty of bright, bleeding-hearted people that would still be committed to medicine even in a single-payer system. Just look at academics. They could be making a lot more in private practice.

    Unfortunately, we need business-minded entrepeneurs and people with less "noble" motives (like getting rich) to drive/fund innovation and progress (even though this is a double edged sword), hence my original vote.
     
  48. foo

    foo Junior Member
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    Everyone covered for catastrophic coverage by government (paid by mandatory taxes), anything over $50,000. The government covers all individuals in the high risk pool.

    Obtaining health care insurance mandatory for everyone.

    Health care vouchers for private insurance coverage (tax exempt), subsidized by government for working poor and unemployed. Insurance companies prohibited from denying coverage to anyone (they are protected by the $50,000 max ceiling). Extra insurance premium cost for drug coverage.

    Insurance companies must cover all recommended preventative care. Families and individuals responsible for first $500 of costs.
     
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  49. OncoCaP

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    Excellent info, Gunshot. Your article clearly shows many of the ways that competition and market forces have failed us in healthcare and instead increased costs and made patients and physicians pawns to be played in a dysfunctional system. This article explains why a free market often fails to achieve benefits and required government intervention for the best results in our society. This isn't just unique to healthcare. The same could be said for public education and even public works. Efforts to privatize education and public works have failed beyond the small scale. It just turns out that because the government doesn't need to earn a profit and its employees are accustomed to being paid low wages in exchange for livable & stable jobs that these systems work well under government control.

    There are some functions that fit most appropriately under government supervision and control. As much as I hate to say it, many adults need "parenting" by the government and/or their employers for their own benefit. Some companies (e.g., health insurance companies) are also so notoriously maligning the public good that they need to be kept on a very short leash. Anyone who has been in management or leadership knows that this is true. Unfortunately it would be more expensive just to target a system for a subgroup of citizens. As the Europeans have proven over and over, a single simple system with private healthcare as an option provides a base level of care to everyone at the best price (with options for more care to those who want & can spend more). Left to their own devices some people will mess things up and then run around crying, blaming everyone but themselves.

    Only government intervention in healthcare can address the needs of many Americans who are unable to make it work for reasons that may or may not be their fault. Also, physicians largely go into medicine to treat patients not to living a fighting retreat against health insurance companies that have them outgunned and keep cutting their pay because they can. Government intervention provides a predictable process with the opportunity for public input and monitoring. By expanding Medicare to cover everyone and then providing some opportunities for private insurance companies to offer additional or less-wait-time care we could make healthcare work better. We would need to implement controls such as no opportunity to decline applicants but perhaps long waiting periods before full private (optional) benefits become "vested" over a period of 5 years perhaps. Community-based rates might also make sense. Other controls would be that insurance companies would need to use the public health insurance cards and billing systems to avoid creating more paperwork and maybe there would be a limit on the number of private insurance providers per state (3?) and private companies could bid for these slots on the basis of cost, range of services / products offered, and operational excellence.

    Miami_med: (do NOT answer these questions until you have finished whatever you want study and need a diversion ... this isn't worth losing points on your STEP or exam ;) ). Any ideas on how to increase the number of residency slots in fields such as derm and rad? Besides ending Medicare, ending Medicaid, laying off all military physicians, terminating all licensing boards, closing the FDA, closing all VA and public clinics, opening the practice of medicine to anyone who can pay $10 to get a sign made, and selling the operations to private companies do have any solutions at all? Do you see the need to do this all at once or would an incremental process work for you? If you had to pick one first step, what would it be?
     
  50. Miami_med

    Miami_med Moving Far Away
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    I'm pretty sick today, and I've got no exams until Monday, so I'm mostly sitting today out. Thanks for the concern though ;) .
    I've been on here about 10x as much as normal today.

    I'd say that an incremental change would be necessary. People have gotten used to the government telling them what is safe and who is qualified. As an aside, I have always said that there is ONE role for the government in medicine. That is helping to control infectious disease. This is because unlike CHF or Diabetes, highly infectious diseases are force that is transmitted from one person to another. Controlling severe infections is like policing criminals, and I am not a fan of anarchy. Aside from that, I'd like to close it all down slowly, allowing for the market to adapt to the changes. The impact would be too severe if it were done immediately, with people losing coverage in an environment that hadn't adapted new ways to cover them yet.

    The first step would be to undo the government prescription drug coverage disaster. It's new, so it isn't all that entrenched. The second step would be to simultaneously begin a plan to phase out Medicare and Medicaid over many years AND end all monopoly priveledges granted to hospitals. I'd give fair warning to charitable and religious institutions, allowing them time to develope plans to deal with those that will eventually lose coverage. I also think malpractice reform would have to come early in the process.
     
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