Universal Health Care

[rs2006]

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Hi all,

I hope all is well for everyone in the forum. I recently attended a lecture discussing universal health care and just wanted to know how it would affect the various specialties in medicine-- are any specialties which one (a fourth year medical student, like myself) should consider more than others since they would be "financially resistant" to the impact Universal Health Care would have on docs? Also, any thoughts as to whether this could become a reality would be much appreciated. Thanks .

 

[island doc]

It will become reality for us all if President Clinton is back in the White House. (The next Pres. Clinton, remember 1992-93?)

 

[Solideliquid]

It will become reality for us all if President Clinton is back in the White House. (The next Pres. Clinton, remember 1992-93?)

I was listening to Neal Borts this morning, a popular republican. He is predicting that social medicine will eventually happen because most of the people in this country seem to think health care is a right, not a privilege. Meaning people believe they are entitled to health care and should not pay for it.

As to your question, I think (hope) psychiatry won't be hit hard, as the cost to run a psych unit/practice is low.

 

[skypilot]

We need to acknowledge the billions of dollars we are already spending to care for the poor in emergency rooms and establish Universal Health Care.

Manage the diabetics, kidney, heart disease and hypertension in a primary care office instead of dealing with the amputations and heart attacks in the ER.

Not to mention the plagues of TB, Influenza and other unimaginables that could be averted if we had a better system.

What we need is a good two tier system with Cadillac care for the insured and basic care system for everyone else.

 

[DrMom]

I was listening to Neal Borts this morning, a popular republican.

Just wanted to chime in to point out that Neal Boortz is a libertarian, not a republican.


carry on 🙂

 

[Solideliquid]

Just wanted to chime in to point out that Neal Boortz is a libertarian, not a republican.


carry on 🙂

DrMom-

You are totally right! I completely forgot about that, I always think of him as a Republican. LOL.

 

[Suppuration]

I was listening to Neal Borts this morning, a popular republican. He is predicting that social medicine will eventually happen because most of the people in this country seem to think health care is a right, not a privilege. Meaning people believe they are entitled to health care and should not pay for it.

First, while socialized medicine would provide universal heatlh care, the two are not synonymous. Socialized medicine implies government ownership of the health care delivery system. Universal health care means that everyone has access, regardless of the nature of the system.

Second, as Malcolm Gladwell pointed out, during the 20th century there were six significant efforts made to introduce universal coverage: during WWI, the Great Depression, the Truman and Johnson administrations, in the Senate during the 1970's, and of course the Clinton bomb of the early 90's. Each time the efforts failed. Things are going to have to get worse, a lot worse, before any real reform is undertaken.

 

[Sanman]

Universal healthcare will probably happen within our lifetimes. Especially now that the baby boomers are getting older and the AARP is pushing for more access to healthcare. If not, than it will at least move more towards socialization then it already has. As for what will be resistant to this possibility, I would suggest derm or plastics because last I checked Botox and boob jobs weren't a right. These will always be cash procedures. Anesthesiologists working for plastics will be good too. Psych will probably be hit too, except for the NY psychoanalysts in manhattan doing cash practices.

 

[Pingu]

I think canada has shown that universal health care doesn't work. People wait months to years for procedures that can be scheduled in days in the US. But yeah, put something under the control of the government, they are like super efficient and can ALWAYS get the job done.

But I think what best sums of the clinton plan is that back when he had his little heart episode and had to have an emergent CABG, it was pointed out that under his proposed health care plan, he would have died before he would have been able to get the surgery. (and yes, i know that as a rich/famous person he would have moved ahead in line, but still, you or i would be dead)

I don't think universal health care will affect me as a pathologist whatsoever, though. There will always be specimens needing a diagnosis.

 

[skypilot]

I think canada has shown that universal health care doesn't work. People wait months to years for procedures that can be scheduled in days in the US. But yeah, put something under the control of the government, they are like super efficient and can ALWAYS get the job done.

But I think what best sums of the clinton plan is that back when he had his little heart episode and had to have an emergent CABG, it was pointed out that under his proposed health care plan, he would have died before he would have been able to get the surgery. (and yes, i know that as a rich/famous person he would have moved ahead in line, but still, you or i would be dead)

I don't think universal health care will affect me as a pathologist whatsoever, though. There will always be specimens needing a diagnosis.

I think you are talking about socialized medicine not universal health care. And why wouldn't universal health care work? If there were two tiers it might work better for some than for others but at least everyone would get their vaccinations, their prenatal care, and their diabetes care before they ended up with whooping cough, a low birthweight brain damaged baby, or a diabetic shock. The money is certainly available, we are wasting more money than any other country and we still have 40 million uninsured people.

 

[Pingu]

And why wouldn't universal health care work? If there were two tiers it might work better for some than for others but at least everyone would get their vaccinations, their prenatal care, and their diabetes care before they ended up with whooping cough, a low birthweight brain damaged baby, or a diabetic shock.

Oh, you are probably talking about the same people who even when given free health care through medicaid are non compliant with meds (which are free) and are non-compliant with visits (which are free). They don't bring their kids in for shots and in fact, do very little with their children at all.

I think we need to face the facts that there are people in this country who, even if their medicine was provided to them on a platinum platter by a sexy nurse who lived only to serve them and their doctor gave house calls while arriving on a winged horse, would still get whooping cough, have a brain damaged baby, or diabetic shock. There are those who will not lift a single finger to help themselves and some (but not all) like it that way. I have in laws who will do nothing to help themselves because it gives them an excuse to not make something of themselves.

I don't think universal health care is the answer. I think we all need to buck up, take some responsibility for ourselves and our actions and accept the fact that bad things happen and sometimes nothing you can do will change that.

 

[docB]

As for the original question of what socialized medicine will do to practices my prediction is that pay for physicians will decrease by about half but it will likely become very difficult to sue.

 

[f_w]

Again, universal healthcare does not equal 'socialized medicine'.

Nobody in his right mind intends to replace the largely private healthcare delivery system in the US with a goverment run system (model: the old NHS). There are healthcare systems out there where a private delivery system is combined with some means to make sure that everyone is covered (e.g. switzerland with its three-tiered state/private payor system).

In the US, already 44% of healthcare expenses are underwritten by the goverment. So we are already willing to accept goverment provided healthcare on the payor side, why do some people still act as if the US has a 'completely private' healthcare system ?

There are numerous ill effects on public health from the group of patients unable to access regular healthcare due to their inability to obtain coverage. Few of them indeed fall into the group that wouldn't use healthcare if it was delivered to them on a silver platter, but many are just in that 'gap' between medicaid eligibility and a job that provides coverage. This 'you are poor, its your own fault' conservative propaganda is just a slightly more intelectualized way to ignore an unpleasant issue.

Why don't we offer some sort of medicare eligibility for low-income workers and the unemployed at a cut-rate ? Because it costs too much money ? Some estimates say it would cost about 90bil per year to extend some basic coverage to the 30mil or so citizens who don't have insurance right now (accounting for the fact that some of them probably wouldn't elect to get coverage, even if offered). As long as this country apparently has 240bil per year to blow on a 'elective war', money can't really be the issue. (also, if the medicare prescription drug benefit had been structured in a more efficient way, the money saved could have probably covered the uninsured)

 

[Elysium]

There's also a large number of people that don't fall into the indigent "not lifting a finger" category. Think of people who graduate from college and are looking for work. There is sometimes a year gap before grads gain employment. There are people who work freelance (film people, actors, etc) that don't have an employer to give them benefits that would probably buy into a universal health care system. I have one friend that's 40 and has never been insured because he's a free lance actor and substitute teacher. He has to go to the ER for health care, even though he's college educated and comes from a "white collar" background.

I'm all for people to have better access to health insurance to defray the cost that consumers have to pay insurance companies and local and state taxes to pay for bankrupted ERs and academic hospitals.

 

[docB]

We have parallel private/public system here in Australia and I think it works pretty well. There is universal coverage; however, you can buy private insurance which enables you to go to a private hospital and see your private physician.

In general, I think the Australian system works pretty well. We spend a lot less per capital than the US (15% of GDP vs 8% of GDP) and our health outcomes are similar if not better. Also, you are not locked in. If you have money, you can opt out of the private system. Interestingly, most of the physicians I know say the public hospitals are better (they are kind of shabby but have the best doctors).

We would be unlikely to adopt that here because it does not meet the equality agenda of the American left. As was illustrated by the abortive Hillary plan (Hmmm. That's an interesting double entendre.) the main goal is to redistribute wealth and services to insure that no one can get out of the system. The idea is to "progressively" punish people as they produce more with increasing tax rates and denial of services. In this endevor forced equality is much more important than quality.

 

[San_Juan_Sun]

Only a medical student impression from rotation thought here:

It seems to me that the patients who have access to federal/state dollars for health care, seem to use those dollars much more freely than people who spend their own. I suppose that it to be expected.

It just seems to me that any expansion of entitlements creates a situation in which the entitled use more resources than the paying public. I would be willing to bet that this is a general principle, not healthare related only. It doesn't seem to me that universal coverage would be any cheaper, and I highly doubt that individuals who do not monetarily suffer the consequences of their poor health are less likely to perform preventative management.

I also highly doubt that our federal government could do anything other than make a huge mess out of a federal universal health system. State governments might make a better solution, unless they just are taking the federal dollars and adding a little more incompetence to the mix.

So what am I trying to say? I doubt we can offer universal health care without enourmous (and unanticipated) expenses. I doubt that our governemnt can adequately provide such services. And I worry that free health care ultimately enables people to eschew preventative (e.g. cheaper) health care.

On the other hand, I do beleive that some sort of safety net should exist. But after that, I have no freaking clue about what to do. It seems like most of us (myself included) are better at complaining about the problems than offering real solutions.

Fundamentally, I do feel that entitlement expansion is financially unsustainable (ask Starbucks) and can provide lots of negative unintended consequences. The intention might be good, but the execution stinks. Anyways, I'm rambling now. The sure sign of someone who doesn't have any answers to this mess. 😉

 

[f_w]

> It seems to me that the patients who have access to federal/state
> dollars for health care, seem to use those dollars much more
> freely than people who spend their own. I suppose that it to be expected.

So, in your vast experience, medicare beneficiaries just blow out the money while patients with commercial insurance are more frugal ?

There are already large publicly financed areas in the healthcare system. I don't think there is any proof to your assertion that public financing of your healthcare is the reason for wasteful utilization. (e.g. there have been studies looking at expenses/patient in the classic fee-for-service medicare scheme vs HMOs. For every $100 medicare spends, the HMOs spent $114.)

We all look at our medicaid patients who are indeed a piece of work to deal with (no mam, you can't have another albuterol spacer because one of your brood used the one we gave you as a toy). What the right wing ideologues forget is that the group of patients who are in the 'gap' are different. In order to be eligible for medicaid, you really have to sink to the bottom of the societal barrel. The patients we regularly have trouble to get adequate care for are the 35k/year-own-a-2bdrm-ranch working class guys. They are the ones who have to decide whether they can get that ankle pinned or whether they can replace the leaking furnace. The deadbeats don't care, they just have everything done and count on the hospital to write off the uncollectable charge. It is the ones who have something to loose who get screwed.

And the 'just buy health insurance' and 'take care of yourself instead of looking to the goverment' sermon is just complete bs. I am trying to get coverage for a middle aged relative. She runs a small business, but it just won't make enough to cover the $900 it would cost to get even an 80% coverage.

Nobody is saying that access to healthcare should be free and that the patient should be free from any financial responsibility (like it is in the medicaid system at this time). The system as it exists right now is highly inefficient and already costs record amounts of money. Compared with other areas of goverment spending, coverage for the working poor (or sometimes working lower middle class) would be peanuts.

 

[generalIM]

Here are some facts on our great healthcare system:

The leading cause of bancruptcy in the US is unpaid medical bills.

Children without insurance are far less likely to get care for chronic problems like asthma and recurrent infections. Lung caner patients without insurance are far more likely to die without having treatment attempted. Heart attack victims without insurance are less likely to get angioplasty or follow-up care.

The death rate is 25% higher for someone without insurance againsted age matched counterparts

The uninsured ARE SICKER and therefore cannot get better jobs to get better benefits

We are the only country that is industrialized to not offer some sort of universal coverage and yet we spend 5267 per capita vs 2193 in the rest of the countries and in terms of outcomes Canada and GB have better outcomes in many areas (cardiac care for one)

We go to the doctor less, get admitted less and are less satisfied with our health care than any other country (depsite our huge costs)

We spend more on paperwork, have lower immunization rates, higher infant mortality rates, and lower life expectancies.

We have fewer MRIs then Switerland, Japan austria and finland, fewer CT scanners than every other idustrialized nations

We do perform more angioplasties, but have equal or lesser mortality rates for cardiac disease

The list goes on and on

 

[generalIM]

Only a medical student impression from rotation thought here:

It seems to me that the patients who have access to federal/state dollars for health care, seem to use those dollars much more freely than people who spend their own. I suppose that it to be expected.

It just seems to me that any expansion of entitlements creates a situation in which the entitled use more resources than the paying public. I would be willing to bet that this is a general principle, not healthare related only. It doesn't seem to me that universal coverage would be any cheaper, and I highly doubt that individuals who do not monetarily suffer the consequences of their poor health are less likely to perform preventative management.

I also highly doubt that our federal government could do anything other than make a huge mess out of a federal universal health system. State governments might make a better solution, unless they just are taking the federal dollars and adding a little more incompetence to the mix.

So what am I trying to say? I doubt we can offer universal health care without enourmous (and unanticipated) expenses. I doubt that our governemnt can adequately provide such services. And I worry that free health care ultimately enables people to eschew preventative (e.g. cheaper) health care.

On the other hand, I do beleive that some sort of safety net should exist. But after that, I have no freaking clue about what to do. It seems like most of us (myself included) are better at complaining about the problems than offering real solutions.

Fundamentally, I do feel that entitlement expansion is financially unsustainable (ask Starbucks) and can provide lots of negative unintended consequences. The intention might be good, but the execution stinks. Anyways, I'm rambling now. The sure sign of someone who doesn't have any answers to this mess. 😉

The classic Moral-Hazard argument. So people go to the doctor because they can, not because they are sick. So insurance causes people to be more efficient with their money and health care. But uninsured Americans do go to teh doctor and on average spend about 1000 on health care, the average insured patient spends about 2400, if we assume the goal of insurance is to reduce waste, then we are all getting about 1400 of unneeded care.

I assume everyone here has insurance, how often do you go to the doctor?

The RAND Insurance company did a study by setting randome levels, copay 0, 10, 50 percent and monitored patients. Guess what, of course the fifty percent group went to the doctor less often, but they did not cut back on friviolous visits, the cut back on chronic HTN visits, DM visits, etc. Peopel in the higher Copay group had worse controlled HTN and poorer outcomes.

The solution is education and prevention - we save more money getting a melenoma early than we do treating it. You pay for insurance, why because in your younger years you do not go to the doctor, why pay? Because you want to be ensured that you have coverage when you are older. We need to share the burden of chronic illness.

Healthcare cannot be a free market (it cannot be capitalistic) because in a truly free market you need buyers who do not need to buy, but sellers that do not need to sell - this is not true in health care. We need to share the burden, especially with the boomers getting older.

 

[San_Juan_Sun]

So, in your vast experience, medicare beneficiaries just blow out the money while patients with commercial insurance are more frugal ?

LOL, so what do I get for prefacing my entire post with my admitted inexperience? Some jerk pointing it out again! Nice sleuthing there, genius.

But let's not belabor the point: in MY experience, it was the Medicare patients who continually harassed the doc and staff with mindless complaints, visits, checkups, med requests, etc. From the single office vantage point, it was these people who used the clinic like leeches. And they had no problem with it. Honestly, I can't count how many times the question about generics or brand names was answered with "Oh, it doesn't matter. Medicaid is paying for it anyways."

And I can remember several instances where guys over 50 had to get back to us on that colonoscopy or whatever, because they weren't sure about what their insurance would and would not pay for. There was a clear relationship between services used and who was footing the bill. At least in MY experience.

You may not like this, or like the fact that I don't have vast experience, but it's what happened. Drove the docs nuts.

There are already large publicly financed areas in the healthcare system. I don't think there is any proof to your assertion that public financing of your healthcare is the reason for wasteful utilization.

Absence of evidence is not evidence of absence. Besides, I was speaking generally about human nature, and just trying to discuss, rather than argue. As I made abundantly clear, I have questions I'd like answered before I would commit to massively straining our economy of universal health coverage. I don't think this is a crime. Excuse for for not engaging you in a Talking Points battle.

The patients we regularly have trouble to get adequate care for are the 35k/year-own-a-2bdrm-ranch working class guys. They are the ones who have to decide whether they can get that ankle pinned or whether they can replace the leaking furnace. The deadbeats don't care, they just have everything done and count on the hospital to write off the uncollectable charge. It is the ones who have something to loose who get screwed.

I agree that people with something to lose often get screwed. But here, you admit that deadbeats are a drain to the system. So remind me again my you are so miffed when I point out that Medicaid patients attempted to use more services in the clinic I was working at?

Also, since you're clearly a fan of quoting (well not really "quoting" as you don't bother to cite your nebulous sources), perhaps you can acquaint yourself with the number of deadbeats out there. I can assure you, it's a lot (and you certainly don't have to be "poor"). And when free stuff is being handed out, it doesn't matter if they have to take the bus or drive the new Tahoe to get it. Because if they can, they will (if it's "free").

And the 'just buy health insurance' and 'take care of yourself instead of looking to the goverment' sermon is just complete bs.

Since I never said "Just buy healthcare" I can only assume you aren't talking to me. Unless you're trying to put words in my mouth and getting ready to pound that Straw Man to smithereens.

Nobody is saying that access to healthcare should be free and that the patient should be free from any financial responsibility (like it is in the medicaid system at this time).

But here you have a problem with enforcement. If you're going to have truly universal coverage, you have to accept that many people won't pay. And unless you're going to create a huge Collections beauracracy, your ideals about "financial responsibility" are moot. I personally believe in being responsible for costs that I incur, and it seems you do too, but we both know that isn't how it always works in the real world.

The system as it exists right now is highly inefficient and already costs record amounts of money.

So let's put the government in charge? Are you seriously advocating this?

And then you respond with this:

Compared with other areas of goverment spending, coverage for the working poor (or sometimes working lower middle class) would be peanuts.

So it's already record breakingly expensive, and inefficient, but adding the working poor is going to be peanuts? Pardon me, but in my "vast experience" even I can tell you that untold billions added on top of other untold billions is not peanuts or efficient.

Seriously, I wonder a bit about the vitriole of of your position. If you expect to convince me (or anyone else) you'd better come up with good explanations and well thought-out advanatges to the system you propose. You don't win people over my mocking their experience. You do it by actually having a workable plan that answers concerns that people like me, even with my "vast experience" can point out.

 

[VA Hopeful Dr]

I'm not going to pretend that I know enough about medical economics to have an opinion on this. There is, however, something that I think is worth considering. Think about how many people already GET insurance (in one form or another) through the government. Medicare, medicaid, state, and federal employees all get governmental health care already. I would be willing to bet that somewhere between 1/2 and 2/3rds of Americans get governmental health insurance anyway.

Just a thought

 

[f_w]

> it was the Medicare patients who continually harassed the doc and
> staff with mindless complaints, visits, checkups, med requests, etc.
> From the single office vantage point, it was these people who used
> the clinic like leeches. And they had no problem with it. Honestly,
> I can't count how many times the question about generics or
> brand names was answered with "Oh, it doesn't matter. Medicaid is
> paying for it anyways."

Medicare = federal medical insurance program for the elderly. Pays for doctors visits, hospitalization, long term care but does NOT pay for medications (as of yet). Everybody over 65 who paid more than 40 quarters (10 years) medicare tax is eligible.

Medicaid = state/federal welfare benefit for people below federal poverty level. Pays everything without co-pay.

> As I made abundantly clear, I have questions I'd like answered
> before I would commit to massively straining our economy of
> universal health coverage. I don't think this is a crime. Excuse
> for for not engaging you in a Talking Points battle.

You, and other followers of your religious cult, tend to throw this 'it will cost HUGE amounts of money' argument out there without a shred of evidence that this will actually be the case. US consumers are not so much different from swiss or australian consumers. There is actual data to anticipate utilization patterns. The numbers thrown out by the cultists are hopelessly inflated. We know how much per patient the VA system spends, we also know what medicare and medicaid spend. I won't argue numbers with you here, but compared with overall goverment expense, extending coverage to the currently working uninsured would be a pitance.

> But here, you admit that deadbeats are a drain to the system. So
> remind me again my you are so miffed when I point out that
> Medicaid patients attempted to use more services in the clinic
> I was working at?

Because I wasn't talking about the deadbeats. They already get free healthcare, its called medicaid. I am talking about the people who try to make an honest living but don't happen to work for a corporation large enough to offer healthcare benefits.

> If you're going to have truly universal coverage, you have to
> accept that many people won't pay.

And here, your ideology takes over again. Offering goverment subsidized basic health insurance to people who won't be able to afford it on the free market does not equal 'free medical care'.

> The system as it exists right now is highly inefficient and already
> costs record amounts of money.
> So let's put the government in charge? Are you seriously advocating this?

Actually yes. Although it is not a popular opinion, the goverment is actually doing a decent job at a couple of things including mail distribution, dropping bombs overseas and healthcare. The VA system with all its buerocracy is consistently cheaper on a per-subscriber basis than the private sector while the outcomes are not better or worse. The medicare fee-for-service system administered by the goverment itself (through CMS and the regional carriers) is more efficient spending our money than the medicare HMOs.

> So it's already record breakingly expensive, and inefficient, but
> adding the working poor is going to be peanuts?

- It is inefficient because in the current system we are forcing people to go to the ED (ka-ching $650) for many things which could be handled in a community health center or better even private physicians office (for $45).
- It is inefficient because we keep DVT patients admitted on heparin drips because they don't have the cash to buy their Lovenox as an OP.
- It is inefficient because we re-admit patients on day 40 with clotted fem-pops who stopped their Plavix after the 30 day pack the inpatient socialworker had dug up ran out.

And again, I am not talking about the structurally unemployed welfare dependent medicaid clientele. These examples are normal folk.

By eliminating this kind of waste through expanded healthcare coverage, the overall expense for healthcare in this country is bound to go down rather than up. The goverment contribution might get higher, but through the lower healthcare expenses born by the employers it would easily be made up.

I do give you one point. Once the goverment offers medical insurance coverage, the private sector drops their employees like hot potatoes. I worked in a state where the state goverment offered access to their medicaid HMO for low-income workers at a reasonable fee. As a result, WalMart increased the health insurance premium for their minimum wage employees to a level that forced them to go into the state plan. So, if the feds started offering some sort of health insurance, the number of working americans who don't get coverage from their employer might go up considerably.

 

[f_w]

> I would be willing to bet that somewhere between 1/2 and 2/3rds
> of Americans get governmental health insurance anyway.

44% of US healthcare expenses are paid for by the public sector (through the systems you mentioned). I don't know how it divies by patient numbers.

(in most physician practices I know of, about 60% of the patients are medicare beneficiaries. The rest private, HMO and self-pay.)

 

[Suppuration]

An interesting article by Himmelstein and Woolhandler (and Wolfe), proponents of a single payer system, as detailed by Physicians for a National Health Program.

http://cthealth.server101.com/healthcare_bureaucracy_u_s__vs__canada.htm

"The U.S. wastes more on health care bureaucracy than it would cost to provide health care to all of the uninsured. Administrative expenses will consume at least $399.4 billion out of total health expenditures of $1,660.5 billion in 2003. Streamlining administrative overhead to Canadian levels would save approximately $286.0 billion in 2003, $6,940 for each of the 41.2 million Americans who were uninsured as of 2001. This is substantially more than would be needed to provide full insurance coverage."

"These potential administrative savings are far higher than recent estimates of the cost of covering the uninsured. For instance researchers from The Urban Institute estimate that covering all of America’s uninsured with an “average” private insurance policy would cost $69 billion annually (Hadley and Holahan, Health Affairs, May/June, 2003). Thus, the $286.0 billion in administrative savings could cover all of the uninsured, with $217 billion left over to upgrade coverage for Americans who are currently under-insured – e.g. to offer first dollar drug coverage to seniors."

To put it in perspective, $69 billion would be 4.16% of total health care expenditures in 2003. It would also equal 16.5% of our military budget in 2003, or 33.7% of what has been allocated to the Iraq war (through September 30, 2005).

 

[f_w]

"These potential administrative savings are far higher than recent estimates of the cost of covering the uninsured. For instance researchers from The Urban Institute estimate that covering all of America’s uninsured with an “average” private insurance policy would cost $69 billion annually (Hadley and Holahan, Health Affairs, May/June, 2003).


Great, someone who actually has references to back up his points. I would argue that you don't even need an 'average private insurance policy'. A basic one would do just fine.

Who says that your goverment policy has to cover viagra for sex-offenders or repeated liver transplants for incurable alcoholics (like medicaid does). Write a list of covered conditions, come up with a basic formulary, cover physician visits with a reasonable co-pay, cover hospitalizations and run the entire thing through the medicare regional carriers. I bet it would cost even less than these numbers that smarter people have come up with in the past (surely not the trillions and bazillions the chanting chorus of conservatives wants us to believe).


By the way. I don't believe in the single payor system (been there, done that). It might reduce the administrative cost, but with so much power in the goverments hand, the healthcare sector tends to become unattractive as a career choice. Choice is good. If you can afford A+ health coverage, you should be free to buy it.

 

[skypilot]

"These potential administrative savings are far higher than recent estimates of the cost of covering the uninsured. For instance researchers from The Urban Institute estimate that covering all of America’s uninsured with an “average” private insurance policy would cost $69 billion annually (Hadley and Holahan, Health Affairs, May/June, 2003).


Write a list of covered conditions, come up with a basic formulary, cover physician visits with a reasonable co-pay, cover hospitalizations and run the entire thing through the medicare regional carriers. I bet it would cost even less than these numbers that smarter people have come up with in the past (surely not the trillions and bazillions the chanting chorus of conservatives wants us to believe).

Exactly, getting the mundane everyday illnesses out of the ER will cost a lot less and work a lot better for everyone. Including docs! Don't worry, the wealthy insured patients aren't going to go away if we take care of this problem.

 

[banner]

Governmental universal healthcare will probably eventually come, but in order for success, rationing would be required. Is the public/politicians, already used to the Mardi Gras atmosphere of American medicine, ready to accept it?

The recent Terry Schiavo debacle would argue otherwise. While I know that she was mostly funded with private $$, our society seemed to have such difficulty letting a clearly braindead person die naturally. Such an adolescent view on medicine would likely persist in an American universal healthcare system.

Simply put, unless one has infinite resources, you can't "do everything" for everybody, which is something that Americans have been spoiled with. If you disagree, then just look around you're average ICU which are filled with people just taking up expensive space.

Are we ready for things like, no dialysis after age 55?

I am, but will society accept it? If we continue our current medical practices, any healthcare system (social or private) is doomed.

 

[banner]

Also, in countries where socialized/universal actually medicine works,people have a completely different culture and outlook. Americans are very individualized and really don't feel that they are part of any greater society. Places like Europe or Japan are very different culturally, and the common good is a recognized concept.

Don't believe me?
In Tokyo, if you leave your wallet on the subway, you are likely to have it returned to you by the stranger who found it. Leave the same wallet on the NYC subway, and what do you think your chances of getting it back are?

It has nothing to do with the types of train cars or tracks each nation uses, but
instead cultural attitudes toward society and "public places".

 

[f_w]

Pulled from the last discharge summary of one of todays patients:

Patient is a 45-year-old, female with a previous medical
history of sarcoid, hypertension, heart failure, cardiomyopathy and
obstructive sleep apnea, who presented with shortness of breath that
started approximately 2 weeks ago......nausea for the past 4 days; occasional cough but no sputum. She does not use inhalers at home. She does sleep on 3 pillows. She states she ran out of her medications inApril and secondary to no insurance has been unable to refill them. She states she started a new job lately and makes too much money to be qualified for medicaid and does not qualify for insurance through her new job. In the ED, patient's pressures were 215/121, pulse 114, respirations 13, ox 80% and glucose 182 .......

SOCIAL HISTORY:
Patient is married. She has 2 children. Her spouse is _____.
She works as a teacher's assistant at an academy.

 

[f_w]

> Governmental universal healthcare will probably eventually come,
> but in order for success, rationing would be required.

Not more or less than in the publicly funded part of the US healthcare system today. You can't get an annual colonoscopy on medicare, if you are 1 day short on your annual mammogram, you pay out of pocket etc. What do you think the 'utilization review' departments at the HMOs are doing already ? There is rationing left and right, so I wouldn't use it as an argument against publicly funded (and or mandated) healthcare coverage.

> Are we ready for things like, no dialysis after age 55?

The largest chunk of your lifetime medical expenses accrue in the last year of life, a good share in the last 90 days. We already cover these expenses through medicare, covering working age adults would only rarely include these expenses.

 

[skypilot]

The recent Terry Schiavo debacle would argue otherwise. While I know that she was mostly funded with private $$, our society seemed to have such difficulty letting a clearly braindead person die naturally. Such an adolescent view on medicine would likely persist in an American universal healthcare system.

Simply put, unless one has infinite resources, you can't "do everything" for everybody, which is something that Americans have been spoiled with. If you disagree, then just look around you're average ICU which are filled with people just taking up expensive space.

I agree but we have the brightest minds in the world in the U.S. Surely they can come up with a balance that would work. The fact that the largest chunk of your lifetime medical expenses accrue in the last year of life means that we have to get a better handle and acceptance of when the end of life is approaching if we are going to cover everybody without bankrupting the system.

But the money is clearly there, the system is now spending that money overtreating the well patients and the hopeless patients and ignoring the working poor.

The system has every incentive to keep the hopeless patients alive as long as they wring the very last dollar out of their insurance.

And there is no incentive to treat the working poor unless we provide them with coverage. Also consider that a high percentage of the uninsured are children. If the child was born poor and is trying to raise themselves up out of poverty, taking away all medical coverage when they start working is like sending them right back to the ghetto. The most vulnerable population in this country is the sick and injured.

 

[f_w]

> Also consider that a high percentage of the uninsured are children.

Which is largely due to the stupidity of their parents. Getting the kids insured is the easier part. There is for example CHIP which is low-cost health insurance available for kids if the parents are above the limit applicable for hard core medicaid. All it takes is taking your W2, your rent and your phonebill and actually show up at the CHIP office. Some parents are too dense for that.

 

[zeusdoc]

The problem with the healthcare system is that no-one pays for their medical care because we have no idea what things costs. Every procedure has an attached price, but is that what it really costs? No. Market forces of our capitalist society are not able to work because there are no choices for patients to make in terms of selecting care because nothing has a price.

Here's a solution: Just like every other good or service in America, if you want healthcare, then you pay for it. If I want a college education, I pay for it. If I want food...I pay for it. If I want gas to drive my car and heat my home.....I pay for it, a lot. Water to drink and make my lawn green....I pay for it. A latte in the morning before work....I pay for it (get the recurring theme) A gun to protect my home....yep, you guessed, I pay for it. When people have to spend their own money, all the sudden they are much better stewards of that money.

Where did the concept that healthcare is a "right" come from. Probably the same people who say we are the ONLY industrialized nation in the world without "universal coverage" and they quote all these facts about how our system is so inferior to those of other countries. My response: When has America ever tried doing things the way the "world" does them? We don't take siestas like the Spanish, we don't drive like the Brits, we don't "chill" like the Australians, and we sure as hell don't back down like the French. Secondly, what other country supports the burden of over 25 million illegal aliens? Last I checked, none of the Scandinavian countries have an immigration problem. And if the Sweeds have such great healthcare and lifestyle, why aren't more people moving there?

"Free" healthcare means no responsibility and an excuse to use (too frequently) and abuse the system. San Juan Sun is absolutely correct!! The people that abuse the system are not the ones paying for it. It's not a question of healthcare, it's human nature. Anytime something is offered for free, people are going to abuse it.

Just like there is public schools for children, there should probably be a program to cover all children up to a certain age. And as was posted earlier, education and prevention is the key. Get off the couch, quit playing video games, quit drinking soda and eating chips, quit your smoking and drinking. We all know that the #1 cause of preventable disease is smoking. #2 is alcohol. Never mind the quibble about medical errors, think of the disease that could be prevented if people stopped smoking and drinking.

As to the original question, the higher the specialized training, the less affected by universal healthcare.

 

[skypilot]

Here's a solution: Just like every other good or service in America, if you want healthcare, then you pay for it. If I want a college education, I pay for it. If I want food...I pay for it. If I want gas to drive my car and heat my home.....I pay for it, a lot. Water to drink and make my lawn green....I pay for it. A latte in the morning before work....I pay for it (get the recurring theme) A gun to protect my home....yep, you guessed, I pay for it. When people have to spend their own money, all the sudden they are much better stewards of that money.

"Free" healthcare means no responsibility and an excuse to use (too frequently) and abuse the system. San Juan Sun is absolutely correct!! The people that abuse the system are not the ones paying for it. It's not a question of healthcare, it's human nature. Anytime something is offered for free, people are going to abuse it.

Never mind the quibble about medical errors, think of the disease that could be prevented if people stopped smoking and drinking.

The problem with this argument is that we are already paying for the uninsured through emergency rooms, and unnecessary hospitalizations. Nothing is "free." And people cannot anticipate the $100,000 medical bills they might incur. That is why everyone needs to be insured ie. you pay in a little bit each month in anticipation of a huge bill that might come due some time in your lifetime.

And it is not a good idea to blame the patients for being sick. You will be a patient some day and it will be because of all the lousy vending machine meals and 24 hour shifts.

 

[skypilot]

> Also consider that a high percentage of the uninsured are children.

Which is largely due to the stupidity of their parents. Getting the kids insured is the easier part. There is for example CHIP which is low-cost health insurance available for kids if the parents are above the limit applicable for hard core medicaid. All it takes is taking your W2, your rent and your phonebill and actually show up at the CHIP office. Some parents are too dense for that.

Parents may be dense, poorly educated, or mentally ill. Or maybe they are too sick themselves to take care of this problem. Why should we try to rely on this population of people to administer a program that is administered automatically in other countries?

 

[Miklos]

Also, in countries where socialized/universal actually medicine works,people have a completely different culture and outlook. Americans are very individualized and really don't feel that they are part of any greater society. Places like Europe or Japan are very different culturally, and the common good is a recognized concept.

Don't believe me?
In Tokyo, if you leave your wallet on the subway, you are likely to have it returned to you by the stranger who found it. Leave the same wallet on the NYC subway, and what do you think your chances of getting it back are?

It has nothing to do with the types of train cars or tracks each nation uses, but
instead cultural attitudes toward society and "public places".

IMO, leftist propaganda.

Take a long look at just about any American community and you'll find that they are far more involved than Europeans in charitable causes. Religious organizations, charities, clubs, etc.. are so ubiquitous that we often forget to realize their presence. Walk into just about any company and you'll see at least one charity that is sponsored by it. Please note that all of this activity is VOLUNTARY.

Contrast this to "social" Europe, where giving money or contributing to charities is by comparison miniscule. Well, in their defense, they already gave in the form of their insane taxation -- that's why they cry so loudly for government to do something whenever something goes wrong. I much prefer the voluntary system, thanks.

Another important difference (regarding both Japan and Europe) is the cultural/racial homogeneity of the population. America has one of the most culturally/racially heterogenous populations on the planet by far.

 

[Miklos]

Parents may be dense, poorly educated, or mentally ill. Or maybe they are too sick themselves to take care of this problem. Why should we try to rely on this population of people to administer a program that is administered automatically in other countries?

Guess what?

Even if it is automatically administered, free of charge, etc.., that doesn't mean that the parents are going to bring their children to the doctor in time.

 

[f_w]

> Where did the concept that healthcare is a "right" come from.

I don't remember anyone in this thread arguing along this line. But because you brought it up:

We also don't have a 'right' to paved roads. Still, the federal goverment paves roads free for anyone to use. At some point, the feds have decided that a national highway grid is beneficial for interstate commerce and national defense and started funding it. The current medical system with its glaring inefficiency is hurting the competitiveness of the US economy. From a purely pragmatic point, you could justify fixing the system (you don't even have to sing the bleeding heart liberal 'right to healthcare' tune).

> Last I checked, none of the Scandinavian countries have an
> immigration problem. And if the Sweeds have such great healthcare
> and lifestyle, why aren't more people moving there?

Well, I guess you never checked (at least not in the last 20 years). While I don't have source statistics available off hand, I can just quote from a newspaper article here:

http://www.weeklystandard.com/Content/Public/Articles/000/000/005/271dgkju.asp

Of 9 million Swedes, roughly 1,080,000 are foreign-born. There are between 800,000 and 900,000 children of immigrants, between 60,000 and 100,000 illegal immigrants, and 40,000 more asylum-seekers awaiting clearance. The percentage of foreign-born is roughly equivalent to the highest percentage of immigrants the United States ever had in its history (on the eve of World War I).

> "Free" healthcare means no responsibility and an excuse to use
> (too frequently) and abuse the system. San Juan Sun is absolutely
> correct!! The people that abuse the system are not the ones paying
> for it.

If you look at your indigent medical student clinic patients, you might walk away with this impression. But I don't think that there is empiric proof that this applies to medicare beneficiaries, people who get automatic health insurance through their employer and other groups who don't pay for their healthcare out of pocket.

> Just like there is public schools for children, there should probably
> be a program to cover all children up to a certain age. And as was
> posted earlier, education and prevention is the key. Get off the couch
> , quit playing video games, quit drinking soda and eating chips,

As long as our highschools deem it fit to finance the football program for a chosen few by fattening the masses (through hallway vending machines), I think we have ways to go before the schools can be seen as an asset in the fight for health promotion.

But at least we are agreing on that point. Kids should be covered, regardless of the educational background of their parents. Some states are already doing that, but they have to fight the feds for every penny to do so.

 

[Miklos]

We also don't have a 'right' to paved roads. Still, the federal goverment paves roads free for anyone to use. At some point, the feds have decided that a national highway grid is beneficial for interstate commerce and national defense and started funding it. The current medical system with its glaring inefficiency is hurting the competitiveness of the US economy. From a purely pragmatic point, you could justify fixing the system (you don't even have to sing the bleeding heart liberal 'right to healthcare' tune).

I'm not certain that the analogy holds. Keep in mind that highways though heavily subsidized through other meansare also funded by gas taxes, tolls, etc... In other words, users pay for the convenience of using the infrastructure.

Well, I guess you never checked (at least not in the last 20 years). While I don't have source statistics available off hand, I can just quote from a newspaper article here:

http://www.weeklystandard.com/Content/Public/Articles/000/000/005/271dgkju.asp

Of 9 million Swedes, roughly 1,080,000 are foreign-born. There are between 800,000 and 900,000 children of immigrants, between 60,000 and 100,000 illegal immigrants, and 40,000 more asylum-seekers awaiting clearance. The percentage of foreign-born is roughly equivalent to the highest percentage of immigrants the United States ever had in its history (on the eve of World War I).

Yes, but what you forgot to mention was why/how most of those immigrants got to Sweden in the first place. They were needed as relatively inexpesive labor during Sweden's industrial expansion starting in the 60s and were invited 'guests'.

 

[generalIM]

If universal health care is such a bad thing, why do we the USA, were our health care is so superior to the rest of the world have worse outcomes compared with other industrialized nations. Sure there are problems with universal health care, but there are clear problems with our current system as well. 43,000,000 without insurance is a huge problem, compared with having a slightly longer wait to be seen in the ED.

Just because something is free does not mean people will use more of it, especially with healthcare, because people need health care - therefore regardless of cost people will eventually have to use it. The average uninsured person spends about 1000 dollars per year on health care so it is not like paying for it makes them never go, they just go less often and for less important things. People without health care are more likely to have complications from chronic diseases than those with health care. So what is saving more money in the long run, having more people see the doctor more often or caring for a person's complications?

The US government already subsidizes a vast amount of total healthcare in this country, through medicare, medicaid, VA, etc, so how much more can it cost assuming that the elderly (the argument made earlier that they use the most money and resources) are already covered? Perhaps we could reduce the amount if people were covered before and had few long term complications. Sure there are restrictions, but overall people on medicare are much happier with their health care than people with private insurance. Earlier some one argued you cannot get a colonscopy yearly, who the hell needs one? Or that if your Mammogram is a day early you pay for it (same is true with most insurance companies), so the argument is flawed because every system socialized, universal, private pay will have restrictions.

 

[generalIM]

IMO, leftist propaganda.

Take a long look at just about any American community and you'll find that they are far more involved than Europeans in charitable causes. Religious organizations, charities, clubs, etc.. are so ubiquitous that we often forget to realize their presence. Walk into just about any company and you'll see at least one charity that is sponsored by it. Please note that all of this activity is VOLUNTARY.

Contrast this to "social" Europe, where giving money or contributing to charities is by comparison miniscule. Well, in their defense, they already gave in the form of their insane taxation -- that's why they cry so loudly for government to do something whenever something goes wrong. I much prefer the voluntary system, thanks.

Another important difference (regarding both Japan and Europe) is the cultural/racial homogeneity of the population. America has one of the most culturally/racially heterogenous populations on the planet by far.

VOLUNTARY? Most people give because they get tax breaks because of it. So although techinically not forced, they do it to get something from it.

And our racial/ethnic hetergenous population is a strong argument for universal coverage. So that races and ethinicities are not discriminated against in terms of health care. Because although we do not like to talk about it, we do have huge racial gaps in our society, perhaps this way we can at least fix one of them.

 

[skypilot]

VOLUNTARY? Most people give because they get tax breaks because of it. So although techinically not forced, they do it to get something from it.

And our racial/ethnic hetergenous population is a strong argument for universal coverage. So that races and ethinicities are not discriminated against in terms of health care. Because although we do not like to talk about it, we do have huge racial gaps in our society, perhaps this way we can at least fix one of them.

Yes, people talk about poverty recurring generation after generation in familiies. This is one way to address it.

You can also address some of the problems with overuse of insurance through maintaining small co-pays which could be waived in an emergency.

 

[automaton]

Healthcare cannot be a free market (it cannot be capitalistic) because in a truly free market you need buyers who do not need to buy, but sellers that do not need to sell - this is not true in health care. We need to share the burden, especially with the boomers getting older.

wtf? you don't need food, water, shelter? last time i checked food was for sale, so were water and homes. we don't "need" to do anything, comrade.

 

[Miklos]

VOLUNTARY? Most people give because they get tax breaks because of it. So although techinically not forced, they do it to get something from it.

While I agree that people get a relatively large tax benefit from charitable contribution in the form of money, these are also available to a lesser degree in most Western countries (generally speaking, policy is too encourage charity). However, I hold that the straightforward tax benefit is outweighed by intangibles by far. Above all, people donate their time and effort as well.

And our racial/ethnic hetergenous population is a strong argument for universal coverage. So that races and ethinicities are not discriminated against in terms of health care. Because although we do not like to talk about it, we do have huge racial gaps in our society, perhaps this way we can at least fix one of them.

I categorically disagree. However, I have no desire to turn this into a race thread.

 

[Miklos]

Of the arguments presented in favor of universal healthcare, there are two I find that standout:

• People in the "middle" without insurance, that have jobs/assets seem to be caught in the grinder.
• That our healthcare dollars might be spent more efficiently, e.g. relying less on EDs and more on PCPs.

Regarding the first argument, American healthcare consumers are a curious lot. They'd like their healthcare system to:

1. Be gold-plated without rationing. Evidence for this is found by the use of advanced imaging techniques, procedures, brand-new drugs, etc..
2. Risk-free (or failing that, having the ability to collect a windfall from their physician). IMO, contractual law is not respected in medicine (by this I mean that the role of the physician is to explain the given benefits/risks, make their recommendation and receive informed consent from the patient.) It has been replaced by malpractice law (or the threat of a malpractice lawsuit). This has lead U.S. doctors to practice defensive medicine. The upside: lowest malpractice rate on the planet. The downside: significantly higher costs, expressed as malpractice premiums, unecessary/expensive testing, outrageous administration, etc..
3. Free/inexpensive. IMO, generall speaking, few of the insured realize how much their healthcare costs above that $10 co-pay (read this piece for some insight into their thinking). If they pay attention to their paycheck, they'll find an automatic healthcare deduction. What they don't realize, until they have to buy their insurance independently is that a very large percentage of their health insurance premium is a fringe benefit their employer provides. Why? Because it is not taxed.

You can't have all three. However, universal healthcare (IMO) is far from a panacea. At some point, we are going to have to have a debate about all of these issues and decide which way to cut. I don't think that as a country, we've even started yet.

Regarding the second argument, there might be some truth here.

However, to those of you who believe just that because something is "free", it won't be overused I think that you need to spend a little time in an inner city emergency room. Because EDs are required to see everyone (in California, legally one cannot even ask for evidence of an ability to pay before ED treatment!) they've become the cornerstone of healthcare for the indigent.

That's simply evidence of a rational choice.

Instead of paying a nominal amount to see a PCP in a community healthcare clinic, they chose to go to the ED. Sooner or later, hospitals are going to start closing their EDs as they can't afford to provide a free service. IMO, if you want to change this behavior, you've got change the rules radically. That means no longer providing a free ED and making low-level primary care (e.g. NPs, PAs) less expensive than the ED.