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View Diary: When Can We Expect Health Care Reform (Whoever Wins)? (369 comments)

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  •  Cost containment (8+ / 0-)

    We know, for sure, the best way to contain health care costs. And that is with a universal system.  Krugman has been doing a fine job pointing this out.  Our candidates need to do a better job of saying this; when McCain says we need tax credits and a competitive system, he is advocating a strategy that we know has failed. The gatekeeper role of the insurance company raises costs and creates perverse incentives.

    This may have been a debatable proposition in  1992. There was progress being made by insurance companies in lowering cost of care provision, mostly by converting inpatient procedures into outpatient procedures. But that progress stopped long ago.

    We know, for sure, that universal plans are cheaper, because we're surrounded by countries that have such plans.

    I know there is some choir preaching going on in this, but we simply don't push back strongly enough on "it will cost more to make the system universal."  It won't, if you follow atrios' advice and just send everybody a membership card.

    The trouble with any of the incremental plans that involve insurance companies is that cost containment will fail, which will be used, in turn, to argue that we need more cost containment.  "More cost containment" in a privatized system means "less care provided." they will use the "cost containmnent" argument to further restrict care access, increase co-pays and cherry pick the 20 somethings who don't get sick.

    In many ways, the Republican proposals are subsidies to get healthy people into the system in order to increase insurance company profit. Clinton's and Obama's intermediate plans do much the same thing.

    if this must be done incrementally (and I can read numbers as well as the next person), then better to start squeezing the age limits on the current publicly funded programs, lowering the medicare eligibility age, raising the SCHIP means test ceilings, and get more people into taxpayer funded programs. Toss the insurance companies, and their 12 percent subsidy out of the Medicare program, and start talking about how great Medicare is.

    If Clinton and Obama can get this camel's nose under the tent, I'll be very impressed. Because under plans involving private insurers, they will not have access to the information flows needed to figure what is happening, and will have few mechanisms to address the perverse incentives of for profit health care gatekeepers.

    Come see Greg Mitchell on Thursday Virtually Speaking

    by JayAckroyd on Sun Mar 02, 2008 at 06:43:14 AM PST

    •  the SCHIP battle has been fought by proxy (2+ / 0-)
      Recommended by:
      ferg, JayAckroyd

      exactly for that reason.... funded by decreasing Medicare advantage, the privitazation model.

      And call it sequential, not incremental.

      "Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho Marx

      by Greg Dworkin on Sun Mar 02, 2008 at 06:51:03 AM PST

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    •  Mainly Because ..... (0+ / 0-)

      the insurance giants have an insatiable appetite for huge profit . Like a shark they have to maintain a feeding frenzy to hold their body weight which any top heavy organization must do .

      •  It's really simpler than that (2+ / 0-)
        Recommended by:
        elfling, LillithMc

        The responsibility to their shareholders is to make profits.  the best way to make profits is to have a large healthy insured population who do not seek care. One of the things that drives me a little crazy about the republicans take on this is their focus on moral hazard--that somehow people will decide to behave in ways that cause them to go see a doctor.

        So insurance companies have incentives that are perverse with respect to the public policy goal of broad coverage for all citizens.  They are a bad means to implement that policy goal, because  their gatekeeper role leads to citizens inadequately, or not covered at all, except through expensive, inpatient procedures that take place late in the development of an illness, as in an ER.

        There was a comment above that remarked on France providing universal basic health care through taxpayer funding, with private companies provide additional coverage for procedures or pharmaceuticals not fully reimbursed by the government.

        This is obviously the right model; there are procedures that are simply ineffective, and should not be covered by the state system.  Moreover, in a system like this one, the state has access to procedural and outcome information, and can therefore perform assessments of what is and what is not efficacious.

        What is most efficacious in a public health sense--getting people to make better lifestyle decisions--doesn't fit at all well into our insurance model. In the currrent system in the US, there is a significant disincentive for a doctor to see a patient who is trying to control a diabetes or obesity problem.  The copays aren't worth the doc's time.  And the roster fee covers about two visits a year.  While this is going on, of course, the doc is spending significant money getting reimbursed for valid procedures, at high costs.  (My PCP is in a dual practice, and has to have two full time administrators.)

        Also, much of these efforts properly take place outside the medical system per se.  I think it's worthwhile to think the health care system as infrastructure, which is fittingly the role of government to provide. It needn't provide everyone a Maserati, but it should provides roads and traffic lights.  Competitive systems don't do infrastructure provision well, because duplication and redundancy.

        Come see Greg Mitchell on Thursday Virtually Speaking

        by JayAckroyd on Sun Mar 02, 2008 at 08:53:22 AM PST

        [ Parent ]

        •  I For One ... (0+ / 0-)

          certainly agree with all of your above statements . If people can afford to see a doctor at regular intervals that doctor can certainly advise them of the error of their ways in maintaining a healthy body . When this doctor/patient relationship is allowed to thrive people will take the health issues more seriously resulting in prevention before care .

    •  Cost containment (2+ / 0-)
      Recommended by:
      DemFromCT, absurdist

      "More cost containment" in a privatized system means "less care provided."

      True. The problem is this is also true in a public system. The British state run system for example, puts far too much emphasis on cost control. In some respects it is successful in that.  On the whole they do get similar outcomes to us, at near half the overall cost. But, a modern OECD nation should really do better than getting similar outcomes to us.

      This is why I think the battle over single payer is also the wrong battle. In theory a government run system could be better; but in practice it's effectiveness will always depend on who controls the government.

      I'd rather see more individuals be empowered to opt out of for-profit care, without compelling it. And I would like a lot of that non-profit care to come from outside of the government, from competitive, entrepreneurial non-profits.

      Provide basic government coverage. And put suitable restrictions on private  insurance, like outlawing cherry picking, requiring them to take all comers. And especially provide consumers with information to help them make better decisions.

      •  Cost containment or cost effectiveness? (2+ / 0-)
        Recommended by:
        acerimusdux, beemerr90s

        I can imagine a plan where certain therapies are discouraged because they aren't as effective as other inexpensive therapies.  I remember hearing about a study (by Columbia Medical School?) about the relative effectiveness of different hypertension therapies, and a simple diuretic (at 12 cents per day) was just as effective as the $100/wk pills being pushed by Big Pharma.
        If you don't want to take a diuretic, you can pay for the other therapy from your own pocket, or through an insurance plan (paid by your employer).

        Don't be a DON'T-DO... Be a DO-DO!

        by godwhataklutz on Sun Mar 02, 2008 at 07:40:24 AM PST

        [ Parent ]

        •  Yes (1+ / 0-)
          Recommended by:
          beemerr90s

          That's the idea; but it shouldn't be compelled, but rather encouraged through incentives.

          The case the right will always use to scare people off on government health care is the cancer patient or other serious illness who can't get the  treatment they want in Canada or Britain. Of course the right only looks at one side, and not all of the ways the Canadian or British system is preferable to what we have. And in some cases those treatments may really be not cost effective. But I think it is important that people ultimately not be forbidden from making their own decisions there.

          Here is another recent example in Britain:

          One such case was Debbie Hirst’s. Her breast cancer had metastasized, and the health service would not provide her with Avastin, a drug that is widely used in the United States and Europe to keep such cancers at bay. So, with her oncologist’s support, she decided last year to try to pay the $120,000 cost herself, while continuing with the rest of her publicly financed treatment.

          By December, she had raised $20,000 and was preparing to sell her house to raise more. But then the government, which had tacitly allowed such arrangements before, put its foot down. Mrs. Hirst heard the news from her doctor.

          "He looked at me and said: ‘I’m so sorry, Debbie. I’ve had my wrists slapped from the people upstairs, and I can no longer offer you that service,’ " Mrs. Hirst said in an interview.

          "I said, ‘Where does that leave me?’ He said, ‘If you pay for Avastin, you’ll have to pay for everything’ " — in other words, for all her cancer treatment, far more than she could afford.

          Officials said that allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.

          It's stories like this which they will use to try and attack the idea of any government provided care. So it's important that we are clear that people always should still have the freedom to make their own decisions without it impacting any government provided care.

      •  I Don't Think ... (0+ / 0-)

        the intent of the Single Payer proposal is to induce not-for-profit care , instead to reign in administrative costs . Think of bundling all the nations insurance costs (not health care costs) and hold that thought . Then think of bundling all of the nations health care costs (without insurance applied ).
        Then think of small government community agencies administering payment to health care providers from proceeds that everyone pays into on a fair share basis .No one scenario will change the quality of care except the one where the "private" for profit insurance company determines the quality by attrition of allowed services .

        •  I do (1+ / 0-)
          Recommended by:
          ferg

          HR 676 requires that all participating providers be public or non-profit. Essentially it is trying to massively re-engineer the entire health system into a non-profit system.

          Beyond a certain level there is of course no meaningful savings attained simply by bundling more people into one pool. A small nation doesn't have any higher per person administrative costs than a large nation. There are likewise no administrative advantages in pooling people at a national level rather than a state level, or in some cases even a county level.

          In a nation of 300 million, it is likewise impossible to find any great administrative advantages in having one payer rather than three hundred or a thousand. Any marginal theoretical advantage in administrative efficiency would surely be offset manyfold by the inherent inefficiency of all monopolies, public or private.

          •  the major advantage of one payer (0+ / 0-)

            is that it simplifies the billing dramatically.

            Of course, most of that advantage could be obtained with multiple payers if they all used exactly the same forms, if they all paid the same rate for the same services, and if all you had to do was change the address you sent them to. Of course, that's dramatically different than what we do today, where insurance companies "compete" by being obscure about what they cover when for who.

            Fry, don't be a hero! It's not covered by our health plan!

            by elfling on Sun Mar 02, 2008 at 11:26:58 AM PST

            [ Parent ]

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