Single payor in vermont

[Lokhtar]

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http://www.boston.com/bostonglobe/e...vermonts_single.html?p1=Well_MostPop_Emailed5

I'm surprised there wasn't a thread here for this - so I thought I'd create one.

 

[DoctwoB]

Very interesting. This should be a great test to see if a well-designed and thought out single player plan can mesh with American expectations of getting care immediately and having absolutely everything done regardless of cost. There are a lot of questions that weren't addressed in that article though.

1. Whats to stop very sick uninsured people across the US from moving to Vermont for free health care (and bankrupting the system)?

2. What happens if people form vermont require care in another state? Would the state plan offer reimbursements high enough for out of state hospitals to take them?

3. The guy mentioned that there would be evening in reimbursements between PCPs and specialists, while keeping the overall pie size the same? Whats to stop massive flight of specialists to other states? (his explanation of them being attracted to the quality of life in Vt and thus willing to take a lower salary seems optimistic at best)

4. Just how comprehensive this theoretically money saving universal coverage is.

It will be very interesting to see how this plays out. I'm not against single payer in theory, but in practice any government designed system may have massive unintended consequences, so this should be informative. It is also one of the good things about the US, in that the states and local governments can be laboratories of democracy and try these things out.

 

[Lokhtar]

Very interesting. This should be a great test to see if a well-designed and thought out single player plan can mesh with American expectations of getting care immediately and having absolutely everything done regardless of cost. There are a lot of questions that weren't addressed in that article though.

1. Whats to stop very sick uninsured people across the US from moving to Vermont for free health care (and bankrupting the system)?

2. What happens if people form vermont require care in another state? Would the state plan offer reimbursements high enough for out of state hospitals to take them?

3. The guy mentioned that there would be evening in reimbursements between PCPs and specialists, while keeping the overall pie size the same? Whats to stop massive flight of specialists to other states? (his explanation of them being attracted to the quality of life in Vt and thus willing to take a lower salary seems optimistic at best)

4. Just how comprehensive this theoretically money saving universal coverage is.

It will be very interesting to see how this plays out. I'm not against single payer in theory, but in practice any government designed system may have massive unintended consequences, so this should be informative. It is also one of the good things about the US, in that the states and local governments can be laboratories of democracy and try these things out.

Great questions.

1. No idea, that's a great question. Probably a long period to qualify - I'd think like five years.
2. No idea again, probably they'd pay upto VT rates/procedures, and after that you're on your own.
3. Yup, we'll see how that plays out. Maybe it'll result in PCPs having more responsibilities/doing more procedures (kind of how it was initially envisioned) while specialists handling only the truly complicated cases. But obviously this is pure conjecture. It'd be interesting to see what happens.
4. Yup

 

[Slack3r]

http://www.boston.com/bostonglobe/e...vermonts_single.html?p1=Well_MostPop_Emailed5

I'm surprised there wasn't a thread here for this - so I thought I'd create one.

Do you need to change your pants?

 

[Lokhtar]

Twice.

 

[Lokhtar]

If anyone is interested, here is the report by Professor Hsio which is the basis for the Vermont single payer: http://www.leg.state.vt.us/jfo/healthcare/FINAL VT Draft Hsiao Report.pdf

Vermont basically hired him to do an analysis and write a report on the best approach for Vermont and these were his findings.

 

[MOHS_01]

Does anyone remember how well Medicare held to projections? How many years it was before the program came back to Congress hat in hand for more funding?

 

[Lokhtar]

Does anyone remember how well Medicare held to projections? How many years it was before the program came back to Congress hat in hand for more funding?

Yup, I don't expect this to really hold to funding levels either until we can have a mature conversation about things like end of life services. It's really unfortunate.

 

[bravotwozero]

yup, i don't expect this to really hold to funding levels either until we can have a mature conversation about things like end of life services. It's really unfortunate.

noooezz! Death panellsss!! Nooeezz!

 

[JaggerPlate]

I skimmed the article, but it seems like they hired an economist to set up a state wide Health Maintenance Organization where the coupling of payment and services is tied to the state government (instead of a 'private' entity) and physicians are still rewarded for staying below the allocated amount paid for each individual into the coupled system (a point often masked by the guise of 'preventive care, avoiding the 'unnecessary' additional tests in a fee-for-service model, and allowing the PCP to act as the gateway for specialization care').

I could be missing something (I'll probably read the full article later), but I don't see how expanding a HMO program on a statewide level is going to reign in any sort of costs or efficiency when a. patients generally have issues with government intervention into health care and b. the exodus from HMO MCO plans to PPO MCO plans within the past decade has been enormous and attributed to a general dislike of the restrictions placed on HMO patients and the highly interrelated relationship between non-clinician, financial roles in determining care.

Historically, HMO plans (and various other forms of Managed Care Organization theories) haven't played out well at all. Additionally, I'm unsure if the system has built in enough fail safes to avoid abuse and spiraling costs. Furthermore, I'd also be interested to see if the 65+ residents (again, this could have been covered in the article) are covered under this plan, as the medicare group is notorious for uncontrollable costs.

Frankly, I'd predict that the plan will fail, and, more immediately, I'd guess that there will be some sort of backlash and it will never get off the ground in a large format.

Although I'm very conservative on the issue, it's abundantly clear that the current model needs big tweaks and these types of experiments are interesting to say the least. I'll definitely be interested to see how this plays out. Thanks for the update Lok.

 

[Lokhtar]

noooezz! Death panellsss!! Nooeezz!

Yup exactly. It'll all be pulling the plug on grandmas and death panels. I mean in the previous law, the only thing the law said was the physicians would be paid to talk about end of life care....and of course that became death panels. So if we can't even handle talking about end of life care, there is zero chance to actually get to a point where we can make policy about it.

I skimmed the article, but it seems like they hired an economist to set up a state wide Health Maintenance Organization where the coupling of payment and services is tied to the state government (instead of a 'private' entity) and physicians are still rewarded for staying below the allocated amount paid for each individual into the coupled system (a point often masked by the guise of 'preventive care, avoiding the 'unnecessary' additional tests in a fee-for-service model, and allowing the PCP to act as the gateway for specialization care').

I could be missing something (I'll probably read the full article later), but I don't see how expanding a HMO program on a statewide level is going to reign in any sort of costs or efficiency when a. patients generally have issues with government intervention into health care and b. the exodus from HMO MCO plans to PPO MCO plans within the past decade has been enormous and attributed to a general dislike of the restrictions placed on HMO patients and the highly interrelated relationship between non-clinician, financial roles in determining care.

Historically, HMO plans (and various other forms of Managed Care Organization theories) haven't played out well at all. Additionally, I'm unsure if the system has built in enough fail safes to avoid abuse and spiraling costs. Furthermore, I'd also be interested to see if the 65+ residents (again, this could have been covered in the article) are covered under this plan, as the medicare group is notorious for uncontrollable costs.

Frankly, I'd predict that the plan will fail, and, more immediately, I'd guess that there will be some sort of backlash and it will never get off the ground in a large format.

Although I'm very conservative on the issue, it's abundantly clear that the current model needs big tweaks and these types of experiments are interesting to say the least. I'll definitely be interested to see how this plays out. Thanks for the update Lok.

Well, medicare is federal budget...so I don't think this would apply to that. There might indeed be some backlash, and while I'm the polar opposite in this politically compared to you, I'm interested in this too. The guy has been responsible for doing similar studies in other countries, and it'll be interesting to see if it gets off the ground.

The thing that's working for 'my side', so to speak, is that it only takes one. See, people can oppose it all they want and it can be defeated 99 times, but if you win just once, and people start getting benefits and realize it's not the end of the world, generally it's almost impossible to go backwards. Same thing with medicare, social security, etc. It's hard to go from non less coverage -> more coverage but pretty much impossible to go the other way. It becomes a political impossibility to cancel benefits like that because then people start voting based on actual benefits they are receiving instead of political rhetoric. No first world country ever has gone from universal coverage to anything less than universal coverage, even if everyone is constantly tweaking everything, and none ever will - and there's a reason for that.

 

[ccfccp]

I agree that this will be interesting to see. I'm curious how long it will be before the cost shoots through those projections. Didn't we already learn this lesson with Massachusetts? It did nothing to curb costs. It actually increased costs. And you're talking about these northeastern states that have low uninsured rates when compared to the rest of the country. Try generalizing these policies (that already fail to come close to making budget) to places like Texas and Florida.

 

[Lokhtar]

Massachusetts is not like this proposal. Romneycare (like Obamacare) is a big 'How can we pay you more money?' handout to the insurance companies. This is slightly different and actually is designed to be cost cutting, whereas Romneycare and Obamacare are not. Will it actually decrease costs? I have no idea - we'll find out. It may cut costs, keep them the same, have it grow but at a slower rate to the national costs, or shoot it through the roof.

But the premise is different so you can't take what happened with one to predict the other - and you'd have to be more hopeful regarding cost cutting since it actually tries addressing the issue unlike Obamacare or Romneycare (again, whether it is successful is another thing).

In any case, the bill is supposed to come to the state Senate this friday and supporters are hoping to have it ready for the Governor to sign in early May. The opponents are trying to slow the process down.

 

[DoctwoB]

Massachusetts is not like this proposal. Romneycare (like Obamacare) is a big 'How can we pay you more money?' handout to the insurance companies. This is slightly different and actually is designed to be cost cutting, whereas Romneycare and Obamacare are not. Will it actually decrease costs? I have no idea - we'll find out. It may cut costs, keep them the same, have it grow but at a slower rate to the national costs, or shoot it through the roof.

But the premise is different so you can't take what happened with one to predict the other - and you'd have to be more hopeful regarding cost cutting since it actually tries addressing the issue unlike Obamacare or Romneycare (again, whether it is successful is another thing).

In any case, the bill is supposed to come to the state Senate this friday and supporters are hoping to have it ready for the Governor to sign in early May. The opponents are trying to slow the process down.

Agreed that this is different form Mass or current US health reform. That consisted of throwing more money at the current system to cover more people. This is about creating a state-based single payer, which, at least in theory could have the teeth to reduce costs while expanding coverage of basic services by limiting coverage of non-cost effective therapies and trimming end of life expenses. Not sure if this will work in practice, but at the very least its a good experiment.

 

[cpants]

Cost, access, and quality are in constant interplay with each other. If you increase access, cost will go up or quality will go down or both. There is no way around it. Politicians and dreamers who tell you something like universal single payor will improve quality and decrease costs are kidding themselves.

 

[Lokhtar]

Cost, access, and quality are in constant interplay with each other. If you increase access, cost will go up or quality will go down or both. There is no way around it. Politicians and dreamers who tell you something like universal single payor will improve quality and decrease costs are kidding themselves.

Not really. Overall costs may go up (but they don't have to), but if you remove much of the overhead/profits, streamline some processes, work out proper reimbursement and tackle issues that lead to crazy costs (e.g, end of life care), you can decrease costs per capita quite substantially.

You're thinking of it as in 'It costs $5 to cover someone. If we cover 10 more people, it'll costs $50 more.' Which is not really accurate when you're talking about fundamentally changing healthcare delivery for everyone, not just the new people who haven't had insurance.

 

[MOHS_01]

Not really. Overall costs may go up (but they don't have to), but if you remove much of the overhead/profits, streamline some processes, work out proper reimbursement and tackle issues that lead to crazy costs (e.g, end of life care), you can decrease costs per capita quite substantially.

You're thinking of it as in 'It costs $5 to cover someone. If we cover 10 more people, it'll costs $50 more.' Which is not really accurate when you're talking about fundamentally changing healthcare delivery for everyone, not just the new people who haven't had insurance.

That is only true if you accept and acknowledge the authoritarian construct required for its implementation. This requires price fixing and rationing -- and as long as you are comfortable with this it is a great system. I, however, am not; I do not feel those who labor within the system should be commandeered and subjected to such one sided conditions and believe the "we'll take from you, by force, and then decide to whom, when, and where we wish these funds to be distributed" way of doing things to be wholly immoral... and I further find the advocates of such a system have earned any contempt thrown their way.

 

[cpants]

Not really. Overall costs may go up (but they don't have to), but if you remove much of the overhead/profits, streamline some processes, work out proper reimbursement and tackle issues that lead to crazy costs (e.g, end of life care), you can decrease costs per capita quite substantially.

You're thinking of it as in 'It costs $5 to cover someone. If we cover 10 more people, it'll costs $50 more.' Which is not really accurate when you're talking about fundamentally changing healthcare delivery for everyone, not just the new people who haven't had insurance.

This is the argument you constantly hear, but it is not valid. Yes there are inefficiencies in the current model. However, I find it extremely hard to believe that replacing private companies with a government bureaucracy will eliminate these inefficiencies and lower costs. That would be completely unprecedented. Almost any government-run service is extremely administratively costly and inefficient. I am all for eliminating unnecessary care and expensive administrative inefficiencies, but that could be done without completely changing the health care model, so it isn't very good justification for single payer. Furthermore, in a politician controlled system, there is little to no motivation to control costs. Politicians are in this to get reelected, not balance budgets (see current crisis).

 

[Angulimala]

This requires price fixing and rationing

Doesn't the URC already "fix prices," so to speak? What makes an app'y generate more resource units (=higher price?) than a discussion between a Palliative Med doc and a patient?

And rationing is something that will have to be discussed eventually--whether or not it's in the form of "pull the plug on grandma" is up to the discussants. Resources are not unlimited. I think when people realize that just by having a discussion about end-of-life preferences, care gets better and costs less, most of these scary thoughts about rationing will go away.

http://www.ncbi.nlm.nih.gov/pubmed/19273778
^discussions=cheaper & better care
http://www.ncbi.nlm.nih.gov/pubmed/21054172
^ (palliative medicine=better & less costly care)
http://www.webmd.com/cancer/news/20080604/end-of-life-discussions-may-ease-dying
^URL is self-explanatory

 

[MOHS_01]

Doesn't the URC already "fix prices," so to speak? What makes an app'y generate more resource units (=higher price?) than a discussion between a Palliative Med doc and a patient?

Yes, we do operate in a system of relative price fixing. The difference is in the method of relative price determination and the overall magnitude of the impact. To answer the question that you pose more directly: cost and risk -- orders of magnitude different. There are many legitimate grievances with the current pricing structure -- but arguments designed to equate E&M with surgical procedures will fall on their face if held to any level of scrutiny.

And rationing is something that will have to be discussed eventually--whether or not it's in the form of "pull the plug on grandma" is up to the discussants. Resources are not unlimited. I think when people realize that just by having a discussion about end-of-life preferences, care gets better and costs less, most of these scary thoughts about rationing will go away.

This is not what is being discussed, however. What is being discussed is nothing more than an authoritarian styled technocratic/plutocratic chimeric vision of how people's lives should be dictated.

 

[Lokhtar]

This is the argument you constantly hear, but it is not valid. Yes there are inefficiencies in the current model. However, I find it extremely hard to believe that replacing private companies with a government bureaucracy will eliminate these inefficiencies and lower costs. That would be completely unprecedented.

Will it? I have no idea. That's the point of trying stuff like this. Can it? I think it's the only way that can...otherwise we will never have an actual societal discussion on issues like end of life care.

 

[Angulimala]

Yes, we do operate in a system of relative price fixing. The difference is in the method of relative price determination and the overall magnitude of the impact. To answer the question that you pose more directly: cost and risk -- orders of magnitude different. There are many legitimate grievances with the current pricing structure -- but arguments designed to equate E&M with surgical procedures will fall on their face if held to any level of scrutiny.



This is not what is being discussed, however. What is being discussed is nothing more than an authoritarian styled technocratic/plutocratic chimeric vision of how people's lives should be dictated.

You're right, there is more to "price" than just cost. What's the Calculus of Harm? (Rhetorical).

Are you saying that we're not discussing the right things? Or that discussing "rationing" at all in the current climate equates to the subjection of the poor to the tyranny of the wealthy medical technocrats?

I tend to think that this kind of rationing is actually giving people more options, not less. I'd be surprised if anyone was lobbying to have people forcibly removed from vents...they're just looking to educate people and offer alternative options.

 

[Sneezing]

End of life care is quite simple. We wouldn't be in this mess we are in if it weren't for government intervention with things like EMTALA.

Get the government out of healthcare and end of life solves it self. No money, no insurance, no care. Have money or insurance and either are willing to be spent on extending your life for a few precious months (to simply delay the dying process) then go ahead.

Like MOHS hints at, I'm pissed to think that others out there feel they can choose how my taxes should be spent and go as far as to dictate what I can and can't get in a service industry.

The thing I do feel gracious in is knowing that as all these horrible leftist schemes take over, it only increases the demand for actual quality of health care which will be purchased on a real free market.

 

[Lokhtar]

it only increases the demand for actual quality of health care which will be purchased on a real free market.

Good luck with that one.

 

[Sneezing]

Luck isn't needed. Look at the trends that are happening right now. Emphasis is placed on how primary care is key to this accountable care organization scheme which is nothing more than capitation revisted. In the dawn of the monumental mistake we are seeing the re-emergence and strengthening of the traditional patient-physician cash only relationship. 'Concierge' practices are growing. As these PCPs find the balance to how many can be supported, there will be a need for equivalent specialists who practice in the same fashion. Eventually the market will level out to a two tiered system of the inefficient government system and the true free market system.

Congratulations. The pursuit of the liberal socialist ideal will do nothing more than clearly define two seperate health care systems.

 

[Lokhtar]

It's not happening. The same way that there isn't a free market alternative to medicare for people over 65 (not much of one). And it goes against things going on in every single other first world country. I'll bet anything it won't happen. But hey, I can't see the future - we'll find out.

 

[Sneezing]

I hope it goes against everything else that's going on first world countries. The thing that seperates America from the rest is innovation.

Ireland, spain, greece, etc are all being bailed out. France, UK and Germany are their supporters. The thing is, they are broke, too. Those countries can't handle the financial burden of a government run health system. Who is going to bail them out? They let the notion of healthcare be seen as a right. We can still fight it and keep it at bay. America originally didn't see healthcare as a right nor should it ever. If we don't we will forever be saddled with a crippling weight that will limit our ability to fund innovation and ultimately cause the demise of our country as we slip into the void of mediocrity.

I don't want to be Canadian. I don't want to be British, or French, or German or any other first world country. I want to be an independent, free American who suffers the consequences of his own poor choices and benefits from the fruits of his own labor. I want there to be incentives for me to work hard and take risks. I want these same opportunities to exist for my future children. Wasting our tax dollars on a government health system is a direct threat to that and ultimately the Freedom America stands for (and what lures in immigrants).

 

[Angulimala]

I hope it goes against everything else that's going on first world countries. The thing that seperates America from the rest is innovation.

Ireland, spain, greece, etc are all being bailed out. France, UK and Germany are their supporters. The thing is, they are broke, too. Those countries can't handle the financial burden of a government run health system. Who is going to bail them out? They let the notion of healthcare be seen as a right. We can still fight it and keep it at bay. America originally didn't see healthcare as a right nor should it ever. If we don't we will forever be saddled with a crippling weight that will limit our ability to fund innovation and ultimately cause the demise of our country as we slip into the void of mediocrity.

I don't want to be Canadian. I don't want to be British, or French, or German or any other first world country. I want to be an independent, free American who suffers the consequences of his own poor choices and benefits from the fruits of his own labor. I want there to be incentives for me to work hard and take risks. I want these same opportunities to exist for my future children. Wasting our tax dollars on a government health system is a direct threat to that and ultimately the Freedom America stands for (and what lures in immigrants).

I see where your head's at and you've got a well thought-out argument.

But I'm gonna pick a few nits.

First off, some people argue that there's no such thing as someone who benefits solely from his own choices and the fruits of his labor, since we are born into positions forced upon us by social forces and pure luck. I probably wouldn't have gotten into the schools I went to if I'd been born in a lower tax bracket. I would have had to work = less time to study. You're talking about opportunities for your children, but if you want them to grow up in a world where they earn by merit and reap what they sow, we have to remove the structures that place them in a position to succeed based mostly on random chance. We can support the freedom America stands for by helping people get on their feet (with healthcare) so they can pursue the American dream.

Sure there are a few bad apples who bomb out and go bankrupt after attending Ivy League colleges, just as there are poor people who manage to excel against all odds. The existence of exceptions doesn't invalidate this argument.

Secondly, I don't think that it's a waste to spend money on health care. Society is only as strong as it's "weakest" members. Are there people who abuse EDs, unemployment, etc.? Absolutely. Is completely cutting off all social services the way to solve the problem? I doubt it.

There's got to be a middle ground between this fend-for-yourself eat-or-be-eaten mentality, and forcing physicians into indentured servitude. That's not fair. Neither is forcing people into poverty because they can't pay medical bills.

We can still innovate! This Vermont health care plan *is* innovation! If it fails, someone will come up with a better idea.

 

[Sneezing]

I like your counter argument.

Seeing vermont as an innovation experiment is worthwhile. I take issue when the whole country is swinging in that direction.

Butterfly effect. No one is truely independent without the aid and assistance of others. However to say that assistance should come from government handouts is wrong. Assistance should be given by proper exchange of resources. I.E. I will help fund your college if you give back to our charity organization when you become able as a well to do widget maker. Our religious organization will help fund your training in widget artisanry as long as you tithe and support the less fortunate in our flock.

Spending our nations money to cater to the weakest links means we can't maximize the strength and integrity of our strongest links. We are faltering by cattering too many resources in our education system and now healthcare system by trying to strengthen the weak links. Why not stick with the original philosophy of having different chains of different strength performing different functions?

Getting out of the metaphor, I believe the abusers you describe above are becoming a cultural mindset, a way of being, and an acceptance of a greater mediocrity. We are passing the point of a few parasites here and there requiring societies good graces, but now a full fledged intestinal worm about to make us malnourished.

People can pay for medical bills there are ways. There are many stories, many nuiassances and many what ifs. Get government out of health care and prices will come down. Make people take more responsibility for their bills and health consequences and good dietary/life choices will surface. Right now we are saying it is okay to be obese, it is okay to smoke, it is okay to drink and do drugs. It is okay to not exercise, it is okay to not take your pills, because, hey, I'm only paying $20 so I don't value what is given to me for *free*.

My posts are only going to take on a more rambling diatribe from here, because the issue is more than just vermont. Its social, its political, its financial, its mores, and in summary I only see disaster where our country is heading and it saddens me.

 

[Lokhtar]

I hope it goes against everything else that's going on first world countries. The thing that seperates America from the rest is innovation.

Ireland, spain, greece, etc are all being bailed out. France, UK and Germany are their supporters. The thing is, they are broke, too. Those countries can't handle the financial burden of a government run health system. Who is going to bail them out? They let the notion of healthcare be seen as a right. We can still fight it and keep it at bay. America originally didn't see healthcare as a right nor should it ever. If we don't we will forever be saddled with a crippling weight that will limit our ability to fund innovation and ultimately cause the demise of our country as we slip into the void of mediocrity.

I don't really want to argue the philosophical point of which system is better (I've done that enough). I was simply disagreeing with your assertion that it's going to result in a two tier system, one which will be free market.

It won't. It hasn't with medicare. It hasn't in other first world countries. And it won't in the future. Healthcare will never, ever be a free market system in the US. Whether that's a good thing, or a horrible thing, I'm sure we'll disagree on, but that really wasn't the point.

But as I said, while I'd bet anything that what I'm saying will be true, I can't see the future, and we'll just see what happens.

 

[bronx43]

Luck isn't needed. Look at the trends that are happening right now. Emphasis is placed on how primary care is key to this accountable care organization scheme which is nothing more than capitation revisted. In the dawn of the monumental mistake we are seeing the re-emergence and strengthening of the traditional patient-physician cash only relationship. 'Concierge' practices are growing. As these PCPs find the balance to how many can be supported, there will be a need for equivalent specialists who practice in the same fashion. Eventually the market will level out to a two tiered system of the inefficient government system and the true free market system.

Congratulations. The pursuit of the liberal socialist ideal will do nothing more than clearly define two seperate health care systems.

I agree with your sentiment and philosophy that democratic welfare states are ultimately doomed to fail. It's a simple fact of life that resources aren't infinite, and much of what the American health care system is expending is pure sunk cost - free market or otherwise. Health care in its current state, like many other things, is largely governed by the law of diminishing returns. The more upmarket you go, the less benefit you actually extract per unit of resource input. It only takes a simple stroll through the ICU to see this first hand. And like you said, this level of service should only be provided by those who have produced enough in life to be able to expend their wealth on practices of such low yield. Allowing everyone access to expenditures of this caliber will inevitably result in the collapse of a nation's finances.

With that said, I don't understand why you keep bringing up "concierge" medicine. This is nothing more than a niche market, and as far as I know, there isn't any data showing these cash only practices to be growing in number. Especially as the economy continues to go into recession, the number of individuals capable of paying that much money for the service of one physician will keep on dropping. That isn't to say that I don't agree a two-tier system is possible - it is, but only with specific changes to legislation. Honestly, I don't see anything other than the collapse of this nation in the coming decades, as our real productivity and expenditures become ever more disproportionate.

 

[Charles_Carmichael]

I don't have much to say, but I'm really interested to see how things turn out in Vermont over the next few years. Good pilot study! 😀

 

[Lokhtar]

http://www.nationaljournal.com/heal...es-bill-for-single-payer-health-care-20110427

 

[shaggy alfresco]

http://www.cbsnews.com/8301-503544_162-20066495-503544.html

 

[filter07]

Why pass a law you haven't figured out how to pay for? Seems a bit backwards.

 

[Pharmavixen]

I don't want to be Canadian. I don't want to be British, or French, or German or any other first world country. I want to be an independent, free American who suffers the consequences of his own poor choices and benefits from the fruits of his own labor. I want there to be incentives for me to work hard and take risks. I want these same opportunities to exist for my future children. Wasting our tax dollars on a government health system is a direct threat to that and ultimately the Freedom America stands for (and what lures in immigrants).

You're worshipping false gods - there is no free market really, and never was. The gov't has its fingers in every industry. For health care, providing a judicious amount of basic coverage for everybody is not only humane, but also avoids being penny-wise, pound-foolish; where folks don't get minor ailments txed, and they become more expensive major problems eg sequalae of untxed HTN and T2DM.

As far as the personal motivating factor of having to pay your own medical bills goes, my experience is this: I work in a jail, seeing people whose personal care habits are (does it need to be said?) disastrously bad. My observation has been that when somebody has to get his feet chopped off because he was too busy dealing in crack (or whatever) to look after his T2DM, the fact that his medical bills got totally covered isn't that much solace, really.

Anyway, totally curious to see how this Vermont thing works out.

 

[womp]

This was what our federalism was all about, each state can experiment based on their own circumstances, so that the country can eventually identify best practices. If Vermont falls flat on its face, well, we'll know. If it works as advertised, then other similar New England states can follow, and pretty soon the whole country can adopt it.

None of this Obamacare "you'll know what's in it when it's passed" crap forced on all states.

I agree with your sentiment and philosophy that democratic welfare states are ultimately doomed to fail. It's a simple fact of life that resources aren't infinite, and much of what the American health care system is expending is pure sunk cost - free market or otherwise. Health care in its current state, like many other things, is largely governed by the law of diminishing returns. The more upmarket you go, the less benefit you actually extract per unit of resource input. It only takes a simple stroll through the ICU to see this first hand. And like you said, this level of service should only be provided by those who have produced enough in life to be able to expend their wealth on practices of such low yield. Allowing everyone access to expenditures of this caliber will inevitably result in the collapse of a nation's finances.

With that said, I don't understand why you keep bringing up "concierge" medicine. This is nothing more than a niche market, and as far as I know, there isn't any data showing these cash only practices to be growing in number. Especially as the economy continues to go into recession, the number of individuals capable of paying that much money for the service of one physician will keep on dropping. That isn't to say that I don't agree a two-tier system is possible - it is, but only with specific changes to legislation. Honestly, I don't see anything other than the collapse of this nation in the coming decades, as our real productivity and expenditures become ever more disproportionate.

My sentiments too. It's a depressing outlook though. I'm still hoping that technological progress can save the day with a deus ex machina.

 

[shaggy alfresco]

None of this Obamacare "you'll know what's in it when it's passed" crap forced on all states.

Which part of it do you dislike?

 

[MOHS_01]

Which part of it do you dislike?

It may be quicker to list the parts that one could possibly like while understanding both the implications and the ramifications of such a policy.


*crickets*

 

[shaggy alfresco]

It may be quicker to list the parts that one could possibly like while understanding both the implications and the ramifications of such a policy.


*crickets*

OK, I'll start. I love the high risk insurance pools where people with pre-exisiting conditions can get subsidized private health insurance. For example, my 31 year old cousin who suffers from a chronic back problem was unable to get private insurance but now has insurance for $283/month from Blue Cross Blue Shield in PA because of the high risk insurance pool. Now you tell me why that is a bad idea.

 

[MOHS_01]

OK, I'll start. I love the high risk insurance pools where people with pre-exisiting conditions can get subsidized private health insurance. For example, my 31 year old cousin who suffers from a chronic back problem was unable to get private insurance but now has insurance for $283/month from Blue Cross Blue Shield in PA because of the high risk insurance pool. Now you tell me why that is a bad idea.

Because it forces someone else to pay for his/her likely and expected costs and makes the cost for their level of coverage higher than it otherwise would be in the absence of said provision. In short it is a directed and intentional redistribution by edict; in no sane and intellectually honest world can this be construed as just. These subsidy monies are not free by any means; they must be taken from others.

Do not make the mistake of believing that I am saying that this is an easy problem to address, for I am not. I do believe, however, that the means should never contradict the ends -- and if the ends include justice and equality in the eyes of the law any deliberate intervention on the part of the law that forces one party to be disadvantaged in order to advantage a counter party is contradictory to the ends.

 

[shaggy alfresco]

Because it forces someone else to pay for his/her likely and expected costs and makes the cost for their level of coverage higher than it otherwise would be in the absence of said provision. In short it is a directed and intentional redistribution by edict; in no sane and intellectually honest world can this be construed as just. These subsidy monies are not free by any means; they must be taken from others.

Do not make the mistake of believing that I am saying that this is an easy problem to address, for I am not. I do believe, however, that the means should never contradict the ends -- and if the ends include justice and equality in the eyes of the law any deliberate intervention on the part of the law that forces one party to be disadvantaged in order to advantage a counter party is contradictory to the ends.

Really? In no sane and intellectually honest world can any service that is paid for collectively be considered just? Have you thought the implications of that all the way through?

I don't believe many sane people would want to live in a society without police, roads, education, etc. Apparently you do, and good luck with that.

 

[MOHS_01]

Really? In no sane and intellectually honest world can any service that is paid for collectively be considered just? Have you thought the implications of that all the way through?

I don't believe many sane people would want to live in a society without police, roads, education, etc. Apparently you do, and good luck with that.

You assume far too much... and are, in essence, attempting to work the spreadsheet backwards as if someone gave you the answer and you are now attempting to construct the question. There are precious few justifications for the intrusion of state force into the healthcare arena, and these are largely limited to the domain of public health. Here is the Reader's Digest version since I have neither the time nor the desire to walk you through the entire process:


Billy's diabetes in no way burdens Johnny. Billy's flu or ebola does.

Johnny's cancer does not burden Billy. Johnny's smoking does.


The only justification for the imposition of state force is in the protection of an individual's person and/or property as well as the regulator of real third party impacts (think clean water supply, environmental protection, etc in which the parties are not alway easily and clearly defined). Healthcare, in large part, does not meet any of these criteria save the specific example of communicable disease. Now you may choose at this point to employ the productivity/social burden of disease... but I would caution against it as this has been (repeatedly and soundly) cast aside as feel good hyperbolic emotional gibberish. If Johnny drinks and drugs himself into liver failure, poor Johnny, Johnny's family, and his co-workers -- but these continue to be individually limited burdens and most definitely do not reach the threshold necessary to sanction the use of force and theft from the many to somehow compensate for Johnny's stupidity. The logical end (and what anyone without blinders or the ostrich mentality) of any policy counter to what is laid out above is dictation of life and habit by the statesmen... for, after all, they are paying for it... are fiducially bound stewards of "public" monies (oxymoron, btw, as these are nothing more than monies confiscated)

Collectivism -- and those who advocate it -- are worthy of any contempt thrown in their direction.

 

[deleted87716]

Collectivism -- and those who advocate it -- are worthy of any contempt thrown in their direction.

Really. So, when Johnny is diagnosed with ALL (the most curable of the childhood leukemias), but his working-class family can't afford the treatment he needs, he's just SOL, right?

I don't think I'd enjoy living in your world.

 

[MOHS_01]

Really. So, when Johnny is diagnosed with ALL (the most curable of the childhood leukemias), but his working-class family can't afford the treatment he needs, he's just SOL, right?

I don't think I'd enjoy living in your world.

Again, you're assuming too much. The issue is with the application of force (which, as it turns out, is the mechanism by which government mandated collectivist schemes operate, btw), not the consensual pooling of funds. This does not preclude the purchase of health insurance. This does not preclude charity. It does not preclude the creation of the civil services mentioned previously (although it would change the funding of these services). On and on...

...although I imagine your point probably still stands as I have found that most would be uncomfortable living in a world where they are not coddled by a state willing to extract from others for self benefit. This is certainly true of most doctors -- you know, those who fight constant protectionist battles against NPs, PAs, DNPs, optometrists and the like.... those who support all forms of barriers of entry, certification status, etc.

And, just out of curiosity, are you familiar with the Shriners? Sure, they don't list ALL -- but it makes for a good model don't ya think?

 

[Dxr123]

Or....you can just cover all children so you don't have to rely on charity? Charity is a pretty ****ty model because you'll never get full coverage for everyone - it's sick that such a thing is needed in the US.

And healthcare ought to be akin to the civil services mentioned previously.

 

[MOHS_01]

y'all are right -- I must've been drinking. Theft and coercion are truly the only option in a moral society.

Explain to me how my labor can be converted to a "civil service" sans the forced annexation of said labor under penalty of law and then we'll have a starting point for discussion.

 

[MOHS_01]

Or....you can just cover all children so you don't have to rely on charity? Charity is a pretty ****ty model because you'll never get full coverage for everyone - it's sick that such a thing is needed in the US.

And healthcare ought to be akin to the civil services mentioned previously.

...and you're right, we probably should socialize all childcare costs. It is sad and sick that such a thing is needed in the US, but I guess it is what it is. But, however, they can go straight to he** come 18 -- that's when the gravy train ends, mister.

 

[deleted87716]

The issue is with the application of force

You appear to be using the term "force" when you really mean "the law" (e.g., taxation). They are not synonyms.

are you familiar with the Shriners? Sure, they don't list ALL -- but it makes for a good model don't ya think?

Charity is necessary only because our current system fails. If it didn't, the Shriners could do something else with their time and money.

I must've been drinking

If that's your excuse, it at least explains things. 😉

 

[MOHS_01]

You appear to be using the term "force" when you really mean "the law" (e.g., taxation). They are not synonyms.

I'm not the one who's confused, friend, for they most certainly are part and parcel. There is also a clear and palpable difference between law that protects ones person and property and law that expropriates one from the same. One requires force (or at least the implied threat thereof) to cause an action while one serves to prevent a harmful act upon a person. I'll leave it to you to determine the difference.

Charity is necessary only because our current system fails. If it didn't, the Shriners could do something else with their time and money.

Yes, they could. The same could more easily be said for the monies expropriated from individuals for any of these welfare (or militaristic) programs.

If that's your excuse, it at least explains things. 😉

While it is true that someone pi**ed in my Cheerios this week, I stand on pretty firm ideological ground. One side is offering up an apologists' argument for theft and social engineering while the other stands in defense of personal liberties once protected by our governing documents.