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In Pt 1 we presented a basic introduction to the concept of Single Payer, as a preferred form of Universal Health Care Coverage, outlining one particular example, that of Physicians for a National Health Program.

This week we will cover some basic FAQs that commonly come up in discussing this topic.

But first, let us recite our mantra....

      EVERY OTHER DEVELOPED COUNTRY IN THE WORLD
      ALL THE OTHER WESTERN CAPITALIST DEMOCRACIES
      EVERY SINGLE ONE

      ...has SOME form of universal health coverage for their citizens.
      Only the United States does not.  

      They differ from each other in how they do this, and the mechanisms
      and details do matter...
      Canada is different from the U.K., is different from France is
      different from Germany, Japan, Australia, etc.
      But only the United States does not have something.

Remember that whenever somebody starts to say, "yes... but..."

To go with their particular proposal, PNHP wrote up a "Frequently Asked Questions" page, primarily written (posted without authorship)by past PNHP President Dr. Deb Richter of Vermont Health Care for All; with permission I have further edited and added to it and post it below:

Is national health insurance "socialized medicine"?

No. Socialized medicine is a system in which doctors and hospitals work for the government and draw salaries from the government. The U.S. actually does have a sector with such a system - Doctors in the Veterans Administration and the Armed Services are paid this way. Examples also exist in Great Britain and Spain. But in fact most European countries, Canada, Australia and Japan they have government financing, or governement health insurance, but not socialized medicine. The government pays for care that is delivered in the private (mostly not-for-profit) sector. This is similar to how Medicare works in this country. Doctors are in private practice and are paid on a fee-for-service basis from government funds. The government does not own or manage their medical practices or hospitals.

The term socialized medicine is often used to conjure images of government bureaucratic interference in medical care (and of course for good old fashioned red baiting). That does not describe what actually happens in countries with national health insurance.

However, it does describe the interference by insurance company bureaucrats in our health system.

Won’t this raise my taxes?

Currently, about 64% of our health care system is ALREADY financed by public money: federal and state taxes, property taxes and tax subsidies. These funds pay for Medicare, Medicaid, the VA, coverage for public employees (including teachers), elected officials, military personnel, etc. There are also hefty tax subsidies to employers to help pay for their employees’ health insurance. About 17% of heath care is financed by all of us individually through out-of-pocket payments, such as co-pays, deductibles, the uninsured paying directly for care, people paying privately for premiums, etc. Private employers only pay 19% of health care costs. In all, it is a very "regressive" way to finance health care, in that the poor pay a much higher percentage of their income for health care than higher income individuals do.

One example proposal from PNHP would finance a universal public system this way: The public financing already funneled to Medicare and Medicaid would be retained. The difference, or the gap between current public funding and what we would need for a universal health care system, would be financed by a payroll tax on employers (about 7%) and an income tax on individuals (about 2%). The payroll tax would replace all other employer expenses for employees’ health care. The income tax would take the place of all current insurance premiums, co-pays, deductibles, and any and all other out of pocket payments. For the vast majority of people a 2% income tax is less than what they now pay for insurance premiums and in out-of-pocket payments such as co-pays and deductibles, particularly for anyone who has had a serious illness or has a family member with a serious illness. It is also a fair and sustainable contribution. Currently, about 46 million people have no insurance and millions more are underinsured.  Thousands of people with insurance are bankrupted each year when they have an accident or illness. Employers who currently offer no health insurance would pay more, but they would receive health insurance for the same low rate as larger firms. Many small employers have to pay 25% or more of payroll now for health insurance – so they end up not having insurance at all. For large employers, a payroll tax in the 7% range would mean they would pay less than they currently do (about 8.5%). No employer, moreover, would hold a competitive advantage over another because his cost of business did not include health care. And health insurance would disappear from the bargaining table between employers and employees.

Another consideration is that everyone would have the same comprehensive health coverage, including all medical, hospital, eye care, dental care, long-term care, and mental health services. Currently, many people and businesses are paying huge premiums for insurance that is almost worthless if they were to have a serious illness.

Won’t this result in rationing like in Canada?

Wake up. We already have rationing.  The U.S. Supreme Court recently established that rationing is fundamental to the way managed care conducts business. Rationing in U.S. health care is based on income: if you can afford care you get it, if you can’t, you don’t. A recent study by the prestigious Institute of Medicine found that 18,000 Americans die every year because they don’t have health insurance. That’s rationing. No other industrialized nation rations health care to the degree that the U.S. does.

If there is this much rationing why don’t we hear about it? And if other countries do not ration the way we do, why do we hear about them? The answer is that their systems are publicly accountable and ours is not. Problems with their health care systems are aired in public, ours are not. In U.S. health care no one is ultimately accountable for how it works. No one takes full responsibility.

Most of the rationing that takes place in U.S. health care is unnecessary. A number of studies (notably the General Accounting office report in 1991, and the Congressional Budget office report in 1993) show that there is more than enough money in our health care system to serve everyone if it were spent wisely. Administrative costs are far higher in the U.S.'s private sector insurers, than in other countries’ systems. These inflated costs are directly tied to our failure to have a publicly-financed, universal health care system. We spend at least twice more per person than any other country, and still find it necessary to deny health care.

Who will run the health care system?

There is a myth that, with national health insurance, the government will be making the medical decisions. But in a publicly-financed, universal health care system medical decisions are left to the patient and doctor, as they should be. This is true even in the countries like the UK and Spain that have socialized medicine.

In a public system the public has a say in how it’s run. For example, cost containment measures could be publicly managed at the state level by an elected and appointed body that represents the people of that state. This body decides on the benefit package, negotiates doctor fees and hospital budgets. It also is responsible for health planning and the distribution of expensive technology.

The benefit package people will receive will not be decided upon by the legislature, but by the appointed body that represents all state residents in consultation with medical experts in all fields of medicine.

What about medical research?

Most current medical research is publicly-financed (your tax dollar) through the National Institutes of Health and other government entities. Under a universal health care system this would continue. A great deal of drug research, for example, is funded by the government. Drug companies are invited in when it comes to marketing successful new drugs. AZT for HIV patients is one example. All the expensive clinical trials were conducted with government money. When it was found to be effective, marketing rights went to the drug company. This is a controversial practice because it means pharmaceutical companies enjoy significant profits on the back of taxpayer-financed research. It has been proposed that the taxpayer/government should rightfully share much more in the patent rights of medicines developed with publicly funded research have been proposed (the Hatch-Waxman act limits public sector licensing fees from the drug companies to less than what free market would be).  

The drug companies accept "price controls" from our own Medicaid system and Veterans Adminstration, as well as from Canada, France, Germany, Japan, etc.

Most of the drug comapanies' so-called research budget goes to copycats of other blockbuster drugs. And they spend twice as much on advertising as on research.

Medical research does not disappear under universal health care system. Many famous discoveries have been made in countries that have national health care systems. Laparoscopic gallbladder removal was pioneered in Canada. The CT scan was invented in England. The new treatment to cure juvenile diabetics by transplanting pancreatic cells was developed in Canada.

It is also important to note that studies show that the number of clinical research grants declines in areas of high for-profit-HMO penetration. This suggests that in fact, it is for-profit managed care that increasingly threatens clinical research. Another study surveyed medical school faculty and found that it was more difficult to do research in areas with high for-profit HMO penetration.

Won’t this just be another bureaucracy?

No. It will reduce the bureaucracy. The United States currently has the most bureaucratic health care (non-)system(s) in the world. Over 24% of every health care dollar goes to paperwork, overhead, CEO salaries, profits, and other non-clinical costs. Because the U.S. does not have a system that serves everyone and instead has over 1,500 different insurance plans, each with their own marketing, paperwork, enrollment, premiums, rules, and regulations, our insurance system is both extremely complex and fragmented. The Medicare program operates with just 3% overhead, compared to 15% to 25% overhead at a typical HMO.  "Medicare for All" would be a less bureaucratic, more efficient, less expensive sytem than what we have now.

It is not necessary to have a huge bureaucracy to decide who gets care and what care they get, if and when everyone is covered and has the same comprehensive benefits. With a universal health care system we would be able to cut our bureaucratic burden in half and save nearly $150 billion per year.

How will we keep costs down if everyone has access to comprehensive health care?

People will seek care earlier when diseases are more treatable (and affordable). We know that the uninsured delay or avoid seeking care because they are afraid of health care bills. This will be eliminated under such a system. Undoubtedly costs of taking care of the medical needs of people who are currently doing without will cost more money in the short run. But we are already paying for what is by far the most expensive group, those over the age of 65. And we will be spending proportionately less on administration to compensate.

In the long run, the best way to control costs is to negotiate fees and budgets with doctors, hospitals, and drug companies and to set and enforce an overall budget.

How will we keep doctors from doing too many procedures?

This is a problem in systems that reimburse physicians on an open-ended fee-for-service basis, which we already have less and less of. In today’s health system, another problem is physicians doing too little for patients. So the real question is, "how do we discourage both overcare and undercare"? One approach is to compare physicians’ use of tests and procedures to their peers with similar patients. A physician who is "off the curve" will stand out. Another way is to set spending targets for each specialty. This encourages doctors to be prudent stewards and to make sure their colleagues are as well, because any doctor doing unnecessary procedures will be taking money away from other physicians in the same specialty. Another way is to continue to develop expert guidelines by groups like the American College of Physicians, etc. to shape professional standards – which will certainly change over time as treatments change. This really gets to the heart of "how do you improve the quality of health care" which is a separate longer topic . Suffice it to say that universal coverage is a pre-requisite for quality improvement.

What will happen to physician incomes?

On the basis of the Canadian experience, average physician incomes should change little. However, the income disparity between specialties is likely to shrink.

The drop in income that a physician might experience under a single-payer system could be mitigated by a drastic reduction in office overhead and malpractice costs. Billing would involve imprinting the patient’s national health program card on a charge slip, checking a box to indicate the complexity of the procedure or service, and sending the slip (or a computer record) to the physician-payment board. This simplification of billing would save thousands of dollars per practitioner in annual office expenses.

How will we keep drug prices under control?

When all patients are under one system, they wield a lot of clout. The VA can purchase drugs for 40% discounts because they are a bulk purchaser. This is called monopsy buying power and it is the main reason why other countries’ drug prices are lower than ours. The same could happen with medical supplies and durable medical equipment. Canada, and all those other devloped countries that have national health coverage, also buy the same drugs we use, but at lower costs. The drug companies do just fine selling to them also. No reason we should pay more than everyone else, for the same stuff.

Why shouldn’t we let people buy better health care if they can afford it?

PNHP correctly points out that, whenever we allow the wealthy to buy better care or jump the queue, health care for the rest of us suffers (same with education and private schools). One need only look at the example of the nation’s health insurance program for the poor, versus the National Naval Medical Center in Bethesda, MD, that serves members of Congress. Access to care for the poor is deteriorating because Medicaid is a grossly underfunded health care program. Because it doesn’t serve the wealthy, the payment rates are low and many physicians refuse to see Medicaid patients. D.C. General Hospital in D.C., which serves the poor, is always on the brink of bankruptcy. Calls to improve Medicaid fall on deaf ears because the beneficiaries are not considered to be politically important. On the other hand, members of Congress have completely free access to care at National Naval, where the quality of care couldn’t be better.

Although HMOs are allowed under single-payer, they can only be nonprofit staff and group practice HMOs. This distinction is a big issue for activists in some places (e.g. Minnesota) because MN has a law that HMOs be nonprofit, so what happened was enterprising capitalists created nonprofit HMOs that existed only on paper, then subcontracted 100% of their function to for-profit entities. This is, in fact, how Dr. William McGuire (of UnitedHealth-stock-option-backdating fame) got started.

Regarding competing private insurance and system "buy-outs": Under PNHP's proposal private insurers are not allowed to cover anything that is covered by the public program. No one can "buy-out," because it immediately creates a two-tier system where private insurers skim healthy, profitable patients and leave everybody who actually needs care in the public system. An Australian researcher named Steven Duckett has done extensive research on this. In Australia, the government attempted to reduce waiting times by giving incentives for people to buy out of the public system, and the result was that it made waiting times far worse in the public sector. Private insurers can sell coverage for things not covered by the public plan (like some types of cosmetic surgery not for reconstructive or medically warranted purposes), and one of them can contract with the single-payer to process claims, as in Medicare.

My view is that one cannot have an opt-out system which would allow the for-profit sector to continue to skim of the healthy and wealthy.  The whole point of insurance is to spread the risk. Therefore, the pool of people paying and covered has to be universal, the whole U.S.  However, this being the U.S., the freedom to purchase some sort of supplemental is probably inevitable.

What will be covered?

All medically necessary care, including doctor visits, hospital care, prescriptions, mental health services, nursing home care, rehab, home care, eye care and dental care.

What about alternative care, will it be covered?

Alternative care that is proven in clinical trials to be effective will be covered, the same any other care. For example, spinal manipulation for some back conditions. Other treatments will be decided by the health care planning board or other public body. New kinds of treatments will be added to the benefits package over time as they are shown to be effective, including "alternative" treatments. Similarly, ineffective, harmful, or wasteful care can be removed from the benefits package, such as funding for a costly medication that is no better than aspirin for arthritis.

Isn’t a payroll tax unfair to small businesses?

PNHP correctly points out that the payroll tax is more costly to businesses who are not currently insuring their workers. However, it is much less THAN what they would pay for good private insurance for themselves and their workers. For most of the small businesses already providing coverage, the payroll tax will be much less expensive than what they are paying now.  Ideally, the payroll tax will be replaced in the future by a tax that doesn’t charge an administrative assistant making $17,000 a year the same percentage of salary as a CEO earning $175,000 a year.

Another ideal might be to do away with the system of separate payroll deduction system, notably regressive against working people in their current incarnation (and especially galling since tax cuts for the wealthy have, ever since Reagan, been paid for by "borrowing" from social security paid for regressively by theworking class). Pay for everything... military security, national security, social security, health care security all from the same universal (same rates for earned and unearned income) system of progressive income tax (well... keep the estate tax too). This would also more complete the separation of health care coverage from employment, jobs and business.

Can a business keep private insurance if they choose?

Yes and no. Everyone has to be included in the new system for it to be able to control costs, reduce bureaucracy, and cover everyone. However, business and anyone who wants to can purchase additional private insurance that covers things not covered by the national plan (e.g. cosmetic surgery, etc.).

Insurance companies will no longer be needed to decide who gets medical care and what kind of medical care, and would not be allowed to offer the same benefits as the universal health care system. Any allowance for this would weaken and eventually destabilize the health care system. It would undermine the principle of pooling the risk. Health care systems act as universal insurers. At any one time the healthy help pay for those who are ill. If private insurers are allowed to cherry pick the healthy, leaving the public health care system with the very sick, the system cannot help but fail. This is part of what is happening in U.S. health care now.

Another reason is that, if allowed, patients would enroll in the private system while they were healthy (and their premiums were low), and enroll in the public system when their care (and private premiums) became expensive. This, in fact, is what we saw happen to Medicare and HMOs. There, patients needing expensive care, e.g., a hip replacement, were encouraged to drop out of their HMO so traditional Medicare would pick up the tab. However, while they are healthy they enroll in the HMO for the modest additional dental and drug benefits.

What will happen to all of the people who work for insurance companies?

The new system will still need people to administer claims. Administration will shrink, however, eliminating the need for a large bureaucracy. The focus will shift to those who deliver health care. More health care providers, especially in the field of long-term care and home health care, will be needed, and many insurance clerks can be retrained to enter these fields. Many people now working in the insurance industry are, in fact, already health professionals (e.g., nurses) who will be able to find work in the health care field again.

How will we contain costs with the population aging and the advent of expensive technology?

Japan and Europe are already facing this problem head-on and doing fine. They have a much higher percentage of elderly than we do, and still spend less on health care by far... and with better outcomes.

The best way to approach this is to regard it as a societal problem, one that needs a solution with everyone in mind. Germany and Japan recently adopted single-payer long-term care systems to cover the long-term care needs of the elderly at home and in specialized housing. Germany is pioneering a program that pays family members to care for the elderly at home. Now that is family values!

What about ERISA? Doesn’t it stand in the way of implementing a universal health care plan?

No. ERISA (the Employees Retirement Income Security Act) prevents a state from requiring that a self-insured employer provide certain benefits to their employees. However, a single payer plan would not mandate the composition of employer benefit plans – it would replace them with a new system that would essentially be "Medicare for All". The state would require employers to pay a payroll tax into the health care trust fund. This is legal and is done now with taxes levied to pay for Medicare.

How will the Health Planning Board operate?

It can be either National or State-based. If State-based it could go somehing like this: The health planning board (the Health Care Administration) would be a public body with representatives from every legislative district. The representatives would be appointed by each member of the state house of representatives. The state would be divided into 7 regions. The appointed members from each region would elect one person among them to serve on the health planning board. The board would consult regularly with a medical expert advisory committee. The latter would advise the regional board members on what treatments, medications and services should be covered, decisions supported by medical science.  Or alternatively, a similar system with citizen and expert input could be done at the national level.

Since we could finance a fairly good system , like the Norwegian, Danish or Swedish system with the public money we are already spending (60% of health costs), why do we need to continue to raise the additional 40% (from employers and individuals)?

We could cover all the uninsured for the same amount we are currently spending, or even less! First you have to remember that the U.S. health care system already spend more as a percent of GDP on health than other countries.  There are three reasons why: One, we spend 2-3 times as much as they do on administration. Two, we have much more excess capacity of expensive technology than they do (more CT scanners, MRI scanners, mammogram machines than we need; concentrated to serve the wealthiest neighborhoods). Three, we pay higher prices for services than they do. There is no doubt that we do NOT need to spend more than we currently spend to cover comprehensive care for everyone.

But it would make the transition to a universal system very difficult at first if we spent less. That is because we have a tremendous medical infrastructure, some of which would likely retain its slightly larger than necessary capacity during the transition phase. Secondly, we would likely retain salaries for health professionals at their current levels. Thirdly, we are proposing to cover much more than most other countries do by including dental care, eye care, and prescriptions. And for these reasons we would need the extra 40% that we are already spending – but NOT more. Nevertheless, we could, and are proposing, to cover all the uninsured for the same (or less) total amount we are currently spending... but now with universal coverage, less rationing, higher quality, and better cost-control.

How much of the health care dollar is publicly financed?

Previous calculations of the percentage of the health care dollar that is publicly financed were estimated to be around 50%. That was from federal and state taxes to fund Medicare, Medicaid and the VA. 30% was out-of-pocket and 20% from employers.

Estimates differ depending on how they factor in certain costs. For example, recent studies put the tax subsidy offered to employers into the public spending column. A tax subsidy to help employers buy health insurance for employees means the public helps pay the bill. Another factor is that many employees pay the full cost of the premiums for their health insurance at work – not the employer. Newer analyses of these factors put the public financing estimate at 64%, out-of-pocket at 17% (for uncovered services, premiums not paid for by an employer) and employers’ contributions at 19%.

Why not MSAs?

Medical savings accounts (MSAs) and similar options such as health reimbursement arrangements are individual accounts from which medical expenses are paid. Once the account is depleted and a deductible is met, then medical expenses are covered by a catastrophic managed care plan, usually a restricted PPO plan. Individuals with significant health care needs may rapidly deplete their accounts and then be exposed to large out-of-pocket expenses. They would tend to select plans with more comprehensive coverage. Since only healthy individuals would be attracted to the MSAs, higher-cost individuals would be concentrated in the more comprehensive plans, driving up premiums and threatening affordability. By placing everyone in the same pool, the cost of high-risk individuals is diluted by the larger sector of relatively healthy individuals, keeping health insurance costs affordable for everyone. Also, since healthy individuals cannot possibly predict whether or when they would develop significant health care needs, they would eliminate that potential financial risk by being included in the comprehensive pool with everyone else.  Two pretty good diaries have debunked MSAs recently.

Why not use tax subsidies to help the uninsured buy health insurance?

Various conservatives (Dems & Repugs) and business groups have propopsed achieving universal health care by requiring people to buy health insurance (like you have to do for car insurance), with the possibility that there could be tax subsidies for the poor.  There are many problems with these plans (the only benefit being more privatization with public dollars going to the pockets of insurance companies).  The major flaw of tax subsidies in general is that they would be used to help purchase plans in our current fragmented system. The administrative inefficiencies and inequities that characterize our system would be left in place, and we would continue to waste valuable resources that should be going to patient care instead. In spite of tax subsidies, moderate and lower income individuals would be able to afford only those plans with very modest benefits, and with higher cost sharing that might make health care unaffordable. Instead of perpetuating our current inequities, tax policies should be used to create equity in contributions to a system in which everyone is assured access to comprehensive beneficial services.

If the tax subsidies are granted to individuals, employers would be motivated to drop their coverage, and most individuals covered would have merely rotated from employer coverage to individual coverage. The net reduction in the numbers of uninsured would be close to negligible. If the tax subsidies are granted to employers, a major shift in funding passes from employers to taxpayers without significant improvements in the inefficiencies and inequities of our current system. We can use the tax system to create equity in the way we fund health care, but we should also expect equity and efficiency in allocation of our health care resources. That is possible only if we eliminate the private health plans and establish our own publicly administered system.

Won’t competition be impeded by a universal health care system

Markets don't work for some things, and health care is actually a classic example of an inherently not free market: Patients are NOT in position to be full informed and free independent consumers; entry into the market by providers is not free, etc. Health care insurance is a classic example of where the "for profit" model is an inherent failure. Not only does it not work well; it cannot work well. For the insurance company the main incentive is to not provide care; it is their fiduciary responsibility to maximize their profit, and this means denial of care.  Their profit is your no care. Add to this their higher administrative costs, compared to our examples of public care such as Medicare, and we can see why single-payer is an economic necessity.

Advocates of the free market approach to health care claim that competition will streamline the costs of health care and make it more efficient. What is overlooked is that competitive activities in health care under a "free market" system have been wasteful and expensive and can be blamed for raising costs.  Not only have they NOT contained costs, they have raised costs. In fact it has been shown that in some states where competition among insurers and HMOs is fiercest, such as California, costs are higher than the national average.

There are two main areas where competition could exist in health care. Among the providers, and among the payers. When, for example, hospitals compete they often duplicate expensive equipment in order to corner more of the market. This drives up overall medical costs to pay for the equipment. They also waste money on advertising and marketing. The preferred scenario has hospitals coordinating services and cooperating to meet the needs of the public. Reserchers at Dartmouth, and others, have repeatedly found that having more providers, generates more demand rather than lowering costs.

Competition among medical care providers can be beneficial in terms of improving the quality of medical care. Take for example, three primary care doctors in a certain area "competing" for patients for which they will receive equal reimbursement from every patient. The doctor who is most competent in different areas will attract the most patients in that area. One doctor may make house calls to see the elderly. Another may be very good at mental health care. This is competition based on quality not on price. Competition among insurers (the payers) is not effective in containing costs either. Rather, it results in competitive practices resorted to by private payers such as avoiding the sick, cherry picking, denial of payment of expensive procedures, marketing, etc.

The called so-called Managed Care-HMO "insurance" companies, have nothing to do with free market, particularly when they move to capitation.  They are not really doing insurance in the classic sense of spread the risk, since they are skimming the healthy and wealthy and paying out on a fixed capitated bases.  They really are "guarenteed for-profit" middlemen, skimming their profit off the top, and putting all the risk on the patients and providers.  This, along with the administrative nightmare of dealing with different rules and paperwork of dozens of companies, and repeated denials of care, is why so many physicians now support change.

Why not make people who are Higher Risk pay Higher Premiums

Experience rated insurance requires higher risk people to pay higher premiums. This approach says that people who have had cancer or other problems in the past, or who have chronic conditions like diabetes and hypertension, must pay more because they are at higher risk of getting cancer again or having a stroke or other health problem. Experience rating allows insurance companies to "cherry pick" the healthiest people and either refuse to insure the sickest or, what amounts to the same thing, charge prohibitively high rates.This approach makes no sense. The whole point of insurance is to spread the risk so that everyone is covered. If you raise premiums – and thereby exclude from coverage – those people unfortunate enough to have been sick in the past, you defeat the point of both insurance and the health care system. Genetic conditions, childhood diseases, accidents, injuries and income distribution (or how much equality there is in a society) play a much bigger role in people’s health than so-called "lifestyle" factors. It costs much less to care for a smoker than a driver who has a paralyzing accident. (Of course, we need public health and education programs to try to prevent both!).

Community rated health insurance is the socially fair approach. It spreads the risks evenly among all the insured. It removes the punitive element. It does not discriminate against the very sick, nor against those of us who are at higher risk because of our age (say, over 50) or our gender (females have higher health expenses in their 20’s and 30’s than men do).

It appears that for what should be a broad social service an insurance-based approach does not work. For it to work at all society is asked to surrender all control of the system and what is left is both discriminatory and unaccountable to anyone. At some point in our lives all of us without exception have needed or will need some level of health care. Health insurance is unlike any other form of insurance. We all are involved in it. It is profoundly intertwined with social principles of decency and fairness. A system that punishes the sick is neither. Any reform of the health care system must begin from a principled approach.

Originally posted to DrSteveB on Thu Nov 30, 2006 at 07:00 PM PST.

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    N in Seattle, JWC, i dunno, pb, jazzmaniac, Upper West, elizsan, April Follies, MadRuth, eugene, vivacia, ferg, ogre, SarahLee, natasha, Trendar, Alice in Florida, tiggers thotful spot, badger, pHunbalanced, melvynny, ScientistMom in NY, RunawayRose, Lahdee, Coldblue Steele, Sherri in TX, baffled, rhubarb, GayHillbilly, jdld, movie buff, freelunch, elfling, exNYinTX, Just Saying, jancw, vrexford, doorguy, bronte17, mmacdDE, sfgb, OCD, eweedin, CoolOnion, biscobosco, Cool Blue Reason, chuckvw, cosmic debris, roses, dgb, javelina, lmaddison, Boxers, josephk, egarratt, michael1104, thingamabob, rioduran, pexio, WeatherDem, hhex65, Dallasdoc, Winnie, God loves goats, terran, hoolia, desmoinesdem, Black Maned Pensator, Catte Nappe, Tillie630, annetteboardman, lcrp, alizard, barbwires, svotaw1992, Anne Hawley, tigerjade, rapala, la motocycliste, maybeeso in michigan, bloomer 101, tribalecho, el dorado gal, JanetT in MD, drbjs, SherwoodB, RobotsRUs, ignorant bystander, PBen, Simplify, sidonie, devadatta, reflectionsv37, Blissing, EconAtheist, blue jersey mom, Brother Dave, illyia, gkn, wardlow, FightTheFuture, wiscmass, JanL, murasaki, roubs, grapes, DisNoir36, motherlowman, Do Tell, cm dem, emeraldmaiden, Big Eddie Calzone, meliorist, Magnifico, SuburbanBlue, kck, CAL11 voter, vome minnesota, A Siegel, southernphilosopher, NearlyNormal, chemicalresult, AndyS In Colorado, blitz boy, workingmom OH, doingbusinessas, zeke7237, toys, Dreaming of Better Days, kurious, bstotts, Snarcalita, louavul, Lesser Dane, Land of Lincoln Dem, lev36, Riddle, AntKat, DBunn, flagpole, Cronesense, maddogg, dmh44, PhantomFly, ksp, Tailspinterry, jetskreemr, offgrid, CT Treehugger, FishOutofWater, Mary Mike, profmom, Jimdotz, ilex, Unbozo, Elizabeth Ann, chicago jeff, gmac51, mtspace, splinterbrain, thursdays child, pioneer111, Progressive Chick, Dar Nirron, Chris 47N122W, furiouschads, Hens Teeth, Me Again, Niniane, Irlandesa, Blackacre

    if this continues to be as popular as the prior diary was, I'll be happy to continue the series.

    Lots more myth busting to do.

  •  This is AMAZING stuff. (21+ / 0-)

    Very well written and argued.

    The key issue, I think, is the funding for such a system. You're right that taxes are already going to health care in huge amounts and that we could use that money more efficiently in a national, universal system.

    I do think it's worth paying attention to the problems in other countries regarding funding. In virtually every one of the countries with a universal system, there are major debates about funding right now. A lot of it is driven by conservatives seeking to gut the public sector. But it bears watching.

    I'm not part of a redneck agenda - Green Day

    by eugene on Thu Nov 30, 2006 at 07:05:13 PM PST

    •  The other key issue: funding and budgeting (16+ / 0-)

      Control of budgeting for a single-payer government administered system is a big potential problem.  In our age of corporate control of government, having Congress control health care insurance as part of the normal budgeting process is a prescription for disaster.  Insurance companies, Big Pharma, and large health care providers would have every incentive to destroy the system for their own gain.  

      Funding and budgeting have to be taken out of Congress' hands.  Dedicated revenue streams and an independent, insulated administrator are essential.  The Social Security Administration offers a viable model, and has proven immune to corporate cooptation for many decades.

      Kudos to DrSteveB for this excellent series.  The issue of insulating the health care system from undue influence may be in his plans.  If not, I offer this idea.

      -4.50, -5.85 In a time of universal deceit, telling the truth becomes a revolutionary act. --Orwell

      by Dallasdoc on Thu Nov 30, 2006 at 07:42:31 PM PST

      [ Parent ]

      •  What about such interests on the provider side (4+ / 0-)

        In our age of corporate control of government, having Congress control health care insurance as part of the normal budgeting process is a prescription for disaster.  Insurance companies, Big Pharma, and large health care providers would have every incentive to destroy the system for their own gain.

        I agree, but I want you to address the other side, namely the desire of organized medicine and dentistry to also destroy the EGALITARIAN ASPECTS OF THE SYSTEM FOR THEIR PERSONAL BENEFIT AS WELL.  It has been the AMA that has been the primary opposer to national healthcare since 1950, and just why is that so??  If we do enter a new system of national healthcare run on an egalitarian basis, should the old forces that propped up the failed old healthcare system from the provider side also be force to be dismantled as well.  

        If you can relate horror stories about government budgeting as a threat to the new system becasue of vested interests, I can also provider many horror stories about how organized medicine and dentistry help scrap beneficial changes in the old system as well!  Deal with that as well in your planning please.

        Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

        by truthbetold on Thu Nov 30, 2006 at 08:13:03 PM PST

        [ Parent ]

        •  The AMA is conservative and stupid (16+ / 0-)

          They opposed Medicare tooth and nail, but now would give up their golf club memberships sooner than Medicare.

          Conservative forces like the AMA do not represent all medical providers, though like all vested powers they are averse to change.  Change must come despite those who value the status quo, and there will be plenty of health care providers fighting for change.  DrSteveB's diary is based on the Physicians' National Health Plan, after all.

          Just as we can't generalize about Southerners, we can't generalize about doctors or dentists.  Only a relatively small minority of doctors belong to the AMA, and as many of us oppose their actions as support them.

          -4.50, -5.85 In a time of universal deceit, telling the truth becomes a revolutionary act. --Orwell

          by Dallasdoc on Thu Nov 30, 2006 at 08:18:49 PM PST

          [ Parent ]

          •  People Generalize about Southerners (1+ / 0-)
            Recommended by:
            Dallasdoc

            Unfortunately, prejudice appears in many forms. It looks like the "rich, greedy doctor" stereotype just poked up its beady-eyed little head.

            •  Fear of change as swell (2+ / 0-)
              Recommended by:
              Odysseus, lcrp

              I don't know what you are trying to say here, but if you study the history of attempts at universal healthcare in America since 1950, you will find dentists and physicians overwhelmingly opposed to it. Take from that what you will, but any public health professional over the last 30 years who has tried to deal with the unfair disparities in our system will tell you privately that the private sector professionals have not been helpful in making egalitarian changes for whatever reason!

              Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

              by truthbetold on Thu Nov 30, 2006 at 08:47:02 PM PST

              [ Parent ]

              •  Medicare Fees are Unreliable (1+ / 0-)
                Recommended by:
                Dallasdoc

                And Medicaid is even worse.  Doctors are afraid that politics will cause payment instabilities - based on hard, cold experience.

                And the issue of abortion is been a real problem when you have single payer.

                •  I don't understand what (0+ / 0-)

                  you are trying to say here now. Are you for or against a universal system with equal access to proven effective care for all and payment not a barrier to care, and/or do you really think such a system can come about without government control and regulation??

                  Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                  by truthbetold on Thu Nov 30, 2006 at 09:22:31 PM PST

                  [ Parent ]

                  •  I am telling why docs are afraid of single payer (3+ / 0-)
                    Recommended by:
                    elfling, terran, lcrp

                    The government is a notoriously unreliable funding source because politicians play games with funding.  I know this from hard personal experience as a geoscientist who has been on both the research and government side. MDs have legitimate concerns about single-payer program stablity. Those concerns are not reasons to oppose single payer. However, single payer must not be micromanaged by politicians.  Program stability must be built into the design.  Medicare Part D is an eample of how not to design a program. What a f#$*^n mess.

                    I support single payer, but I do so with my eyes open.

                    •  two sides to every issue! (1+ / 0-)
                      Recommended by:
                      terran

                      However, single payer must not be micromanaged by politicians.  Program stability must be built into the design.

                      You are sounding like a conservative now.  I suppose is it okay for providers to limit their numbers and control all scopes of practice so that many people cannot afford care and access, like 46 million!  However, it is not okay for polticians to tinker with the professional's demands for great wealth.  

                      I know many people here seem to want to believe that all the ills of our current system are due to politicians and lawyers and insurance companies, and corporate greed but never the providers choices and acts. However, I personally blame providers THE MOST of anyone for the current state of the healthcare system in America because it developed under their watch.  They may have lost some control today, but it was their greed and lack of a universal social mission that allowed things to evolve under their noses to the current state of affairs.

                      If providers in 1950 had set a REAL national mission of access to proven effective care for all, we would see nothing like the crap we see now. Other countries had such missions and vision and look at them.  You get what you design, and we design a chaotic, unaccuntable system, and we got it!

                      Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                      by truthbetold on Fri Dec 01, 2006 at 07:08:42 AM PST

                      [ Parent ]

                      •  Now I'm Conservative (2+ / 0-)
                        Recommended by:
                        elfling, ilex

                        Conservatives rightly have concerns about unintended consequences of government action. I try to examine complex problems from multiple perspectives including conservative prespectives. I think that mulitfaceted thinking is necessary to solve complex problems effectively.

                        You may be right that greedy doctors deserve the most blame for the present sorry state of affairs in American medicine. Now what are you going to do about it?  Personally, I think that assigning blame doesn't help resolve anything about our medical system, but that's just my opinion. I think we need to look towards  finding solutions, not affixing blame. That's what Dr. Steve is doing and I strongly support him.

                        FWIW - 9.25 , - 8.97

                      •  1950 was a long time ago (1+ / 0-)
                        Recommended by:
                        elfling

                        We need to look at where people are at today, not hold grudges based on yesterday. It's time to stop playing the blame game and move forward.

                        "All governments lie, but disaster lies in wait for countries whose officials smoke the same hashish they give out." --I.F. Stone

                        by Alice in Florida on Fri Dec 01, 2006 at 11:50:20 AM PST

                        [ Parent ]

                      •  Stability is valuable (1+ / 0-)
                        Recommended by:
                        Dallasdoc

                        for both patients and providers. From the provider side, it's not necessarily about getting rich, but knowing that if you've just invested in renting a better office, that you can expect to be able to cover that additional expense for years to come.

                        From the patient point of view, stability comes in believing that what was covered last month will be covered this month, and in a similar fashion, that the trusted doctor will still be around for the coming years, etc.

                        He's right: building a system that is stable is important.

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

                        by elfling on Fri Dec 01, 2006 at 02:04:27 PM PST

                        [ Parent ]

                    •  not really true.. (5+ / 0-)

                      In fact, Medicaid & Medicare pays relatively easily, cleanly. Less refusals than private. Do need to remember that Medicaid is administered by States, so much more variable.

                      Just to be clear, Physicians are way way down on the list of opposition to single payer or other universal coverage. Just are not as powerful as they used to be, not as powerful as insurance companies, drug companies, hospital association.

                      Also, many doctors support single payer, or other universal coverage methods, and % that do so increasing.

                      •  But you get what you sow! (0+ / 0-)

                        Also, many doctors support single payer, or other universal coverage methods, and % that do so increasing.

                        But why didn't their professional predecessors demand and support universal coverage and quality of care standards from the begining.  Could it be that it would be harder to sell snakeoil with such rules way back when????  Sure, now the healthcare system greed parasites are well established and the providers may not be able to get these parasites back into their bottles, but providers must accept much evolutinary blame for this IMO.

                        Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                        by truthbetold on Fri Dec 01, 2006 at 07:24:00 AM PST

                        [ Parent ]

                        •  Exactly, What do you mean by quality of Care? (1+ / 0-)
                          Recommended by:
                          ilex

                          I support evidence-based medicine, but "quality of care" measures aren't necessarily based on evidence. Conformity for its own sake is not a good thing.  

                          Patients deserve the right to make their own choices within rational limits. "Quality of Care" TM could deny the rights of individuals to make personal choices about their health. "Quality of care" measures are potentially a can of worms for both patients and doctors.

                          •  Patients should alway have the (0+ / 0-)

                            ability to say no, but providers should only have the right to recommend and perform procedures that are recognized by a competent system as effective.  The average in the trenches provider is no researcher and basically does what he has been taught!  

                            How evidenced-based procedures are actually performed is also a part of quality care, and much more transparency in the process needs to be introduced.  Such methods as always having another provider or auxillary present and under oath to tell the truth about what happened, or at the extreme end of this spectrum, even to the point of video taping everything!

                            Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                            by truthbetold on Fri Dec 01, 2006 at 01:06:43 PM PST

                            [ Parent ]

                          •  What?? (0+ / 0-)

                            Such methods as always having another provider or auxillary present and under oath to tell the truth about what happened, or at the extreme end of this spectrum, even to the point of video taping everything!

                            That makes absolutely no sense whatsoever.

                            Democrats - We refuse to caucus in the missionary position.

                            by SaneSoutherner on Fri Dec 01, 2006 at 02:24:42 PM PST

                            [ Parent ]

                          •  why? (0+ / 0-)

                            What do you not understand about forcing or proving accountability on such a crucial social system?

                            Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                            by truthbetold on Fri Dec 01, 2006 at 04:12:16 PM PST

                            [ Parent ]

                      •  We don't disagree (2+ / 0-)
                        Recommended by:
                        elfling, ilex

                        We are talking about slightly different problems. Medicare billing is a big pain in the ass because they have so many ever-changing rules and are so damned picky but that wasn't and isn't my point. I agree that dealing with one payer, no matter how many ever changing rules, is easier than dealing with dozens or hundreds of payers and plans.  Yes,I have actually done  medical billing and accounting for a private practice. I'm not making things up based on reading the internet.

                        The bigger picture issue of program stability is paramount. A 5.1% reimbursement cut was scheduled to take effect in January 2007 as of Sept. 15. Has this cut been taken off the table?

                        Political micromanagement is a real potential problem in the U.S. What I am emphasizing is the need for a program that is independent of day to day politics.  Single payer cannot succeed if it is vulnerable to being held hostage by radical reactionaries, religious nuts and Republicans.

                        •  An Addition (0+ / 0-)

                          Single payer cannot succeed if it is vulnerable to being held hostage by radical reactionaries, religious nuts and Republicans.

                          And greedy provders through their professional orgs!!

                          Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                          by truthbetold on Fri Dec 01, 2006 at 08:28:12 AM PST

                          [ Parent ]

                          •  The AMA represents big Pharma (3+ / 0-)
                            Recommended by:
                            Dallasdoc, ilex, SaneSoutherner

                            as much or more than it represents MDs. Sure, there are greedy docs., but at 30% membership, the AMAs's power does not come from physicians. The AMA's power comes from the huge, enormous, gargantuan profits of big pharma which is one of the owners of the Republican party. And don't forget Joe Lieberman.

                            But, rant away about the AMA.  It deserves the criticism. So do doctors who do unnecessary procedures and charge outrageous fees. Just don't blame the 70% of docs who don't support it for the AMA's actions.

                          •  Doctor income is far less than.. (0+ / 0-)

                            insurance profits.  Doctors average take-home pay (i.e profits - after paying all the staff, overhead, etc) accounts for about 10% of each health care dollar.  Insurance profits (after all their much higher overhead, etc) accounts for about 30% of each dollar.

                            Are there a few greedy doctors in the country? Sure. But even so, doctor greed takes a very small slice of the pie.  And they are at least delivering actual health services in return for their "greed".  Insurance produces no actual useful health product, and makes three times the profit of doctors.

                            It's already been pointed out that 70% of the physicians in this country are not AMA members.  So I'm unsure why you think that doctors are a hugely significant part of the problem.

                            Democrats - We refuse to caucus in the missionary position.

                            by SaneSoutherner on Fri Dec 01, 2006 at 02:20:49 PM PST

                            [ Parent ]

                          •  YOU MISS THE POINT!! (0+ / 0-)

                            There are not enough providers for a universal system to work giving everyone equal and adequate access to proven and effective care.  For a start, much work has to be done on defining what is quality-effective care and on inducing providers to provide only such care on an accountable basis.  

                            In a Fee for Service (FFS) free market environment, it was to the financial advantage of providers to limit their numbers and to monopolize the field through scope of practice laws.  Under a universal system this won't have as much meaning, but old habits die hard, and we do not know we can get a univeral system. If by a miracle we ever do get there and we want it to succeed, we need it to just offer proven effective care, and everyone has to have decent access to that proven care. We are far from having the social system in place for gettting these things accomplished.  

                            Again, if the new system is going to have any chance of meeting a successful healthcare mission, it must have social controls that force a definition and provision of only effective and value-based care, and the provider numbers and their ascope of practice must be put in independent hands from the provider orgs!

                            Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                            by truthbetold on Fri Dec 01, 2006 at 05:24:47 PM PST

                            [ Parent ]

                •  And insurance companies (5+ / 0-)

                  are great at paying their claims? Since when?

              •  To quote Bob Dylan.. (6+ / 0-)

                ..the times they are a changin'.  More and more docs are seeing how unwieldy and to no one's benefit the current system is. Many more than 10 years ago are all in favor of Universal health care.  

                Many more docs recognize the AMA as the good old boys club that it is - more concerned with their own power than representing the actual interests of doctors.  

                The AMA does not represent most docs in this country. Don't be deceived by the membership rolls, and here's the dirty little secret why:

                The AMA cooperates with big insurance. A doctor often is required to be a memeber of the AMA in order to participate in insurance plans.  Docs who would choose to withhold those hefty dues to the AMA because they dislike it and don't wish to support the AMA's values cannot do so and still contract with some major insurers.

                So they join the AMA with that financial gun to their head.

                Democrats - We refuse to caucus in the missionary position.

                by SaneSoutherner on Fri Dec 01, 2006 at 04:31:02 AM PST

                [ Parent ]

            •  There are some of those (3+ / 0-)
              Recommended by:
              April Follies, Dallasdoc, ilex

              but I don't think they're the majority.

              I think a lot of doctors would love it if the drug companies were prohibited from consumer advertising. They must be completely frustrated when people come in absolutely sure that they have something that can be cured by some new drug.

              They can't really tell them they're idiots, that the drug has very specialized uses, and that they (or their kid) should try something less expensive and proven FIRST, then see if they need this other drug.

              Plus not allowing consumer advertising would give the drug companies more money to spend on research - which is what they keep saying they do so much of.

              Advertising to health professionals, at conferences, in trade publications, even consumer advertising in health related publications, that would be fine.

              Just get rid of the crappy, expensive, TV ads.

        •  The AMA Sucks (10+ / 0-)

          But it is the Republican Party that has scuttled single payer plans, not the AMA.  The AMA is not as powerful as the insurance lobby, IMO. Insurance companies have billions and billions to loose.  HMOs are parasites which compete for healthy patients by denying care to sick people. They are the big losers in single payer, not MDs.

          Don't blame all doctors for the AMA. A substantial percentage of doctors don't join it.

      •  why congress? (0+ / 0-)

        i frequently get this kind of response when i talk about healthcare reform: you want to put the federal government in charge of it?

        my response:  who said anything about the federal government?

        personally i think the system should operate at the state and local level, and the feds shouldn't meddle.  kind of like schools.

        yes, it's nice to have as big a risk pool as possible, and if we could do that while keeping control at levels where the decision-makers are more visible and accountable to local people, that would be the way to go.  if that doesn't work out, the state should be a big enough risk pool.  our states are pretty much equivalent in size to many european countries.

        l'audace! l'audace! toujours l'audace!

        by zeke L on Thu Nov 30, 2006 at 08:36:08 PM PST

        [ Parent ]

        •  Look at Medicaid (10+ / 0-)

          The variability in competence, generosity and judgment between the states is breathtaking and scary.  I think putting states in charge would negate the monopsony virtues of single payer.  We'd have 50 payers, and national suppliers could carve most of the smaller ones up.  Federal-based solutions, properly structured, would allow the best advantages to a single-payer system.

          -4.50, -5.85 In a time of universal deceit, telling the truth becomes a revolutionary act. --Orwell

          by Dallasdoc on Thu Nov 30, 2006 at 08:41:00 PM PST

          [ Parent ]

          •  man, (1+ / 0-)
            Recommended by:
            d7000

            ya gotta throw them big econ words in there to mess me up.

            however - the variability between what the states cover is due to their people deciding that's what they want to have covered.  overally i think that's a good thing.  

            i expect it's somewhat dysfunctional for medicaid, because most voters aren't on medicaid, and so don't care.  put everyone on the same statewide system, and i think you'll see lots of voters taking a keen interest in what goes on in their state capitals again.  plus it gives us more variability to test out what works and what doesn't, without facing the enormous inertia of washington.  if it's working great in kentucky and problem-ridden in ohio, the folks in ohio don't have to look far to see an example that works and beat up on their legislators.

            as to national suppliers, i recommend we the people carve them up first.

            l'audace! l'audace! toujours l'audace!

            by zeke L on Thu Nov 30, 2006 at 08:56:52 PM PST

            [ Parent ]

          •  I'd like to see state boards (2+ / 0-)
            Recommended by:
            Dallasdoc, ilex

            but just for oversight. I'd rather Congress set some ground rules, and allow for some state/regional customization. I'd see it as more asset allocation than  deciding on what's included in the coverage.

            If you set up a capital projects budget, so much per person, you could put that in an account for the state/regional board to determine where/what should be built/remodeled/upgraded/purchased. They can look at demographics, talk to the people, the local govt, the medical community, administer the project, etc.

            The physical buildings/equipment need to be managed locally, but the general guidelines should be the same for everybody, everywhere.

        •  Social Security is federal (3+ / 0-)
          Recommended by:
          Dallasdoc, ilex, Hens Teeth

          and it's a whole lot more successful than it would have been if run by the states.

          "All governments lie, but disaster lies in wait for countries whose officials smoke the same hashish they give out." --I.F. Stone

          by Alice in Florida on Fri Dec 01, 2006 at 11:54:16 AM PST

          [ Parent ]

        •  It might sound reasonable (2+ / 0-)
          Recommended by:
          Dallasdoc, Hens Teeth

          unless you live in a state that is incredibly stingy with any kind of aid like Texas.  I think if it was state by state you might still have a multi-tiered system with some kinds of treatment covered in some states but not in others.  

          Should women in "conservative" states be denied access to birth control and family planning because the noisiest of their neighbors object?

      •  I don't think this is as much a problem w/ s-pay (1+ / 0-)
        Recommended by:
        April Follies

        In our age of corporate control of government, having Congress control health care insurance as part of the normal budgeting process is a prescription for disaster.  Insurance companies, Big Pharma, and large health care providers would have every incentive to destroy the system for their own gain.  

        I don't think this is a big problem with a universal single-payer solution, for 3 reasons:

        1. with everybody on the same plan, the political process should work.  If Congress tries to cut funding, everybody screams at them.  This isn't like Medicaid or even Social Security, where only a minority currently receive benefits.  This is every single person in the country.  Indeed, this issue would be a lot like income tax - the only thing that currently touches everyone in the country - except in reverse: any reduction in services or funding would be met with a huge outcry.
        1. Insurance companies will not exist under this model, so they won't be a threat.  Big health care providers will game the system like big military contractors, and yes, just like with the military we need strict oversight to stop fraud and waste.
        1. Social Security is not insulated at all.  I don't really believe that in our system there is a way to truly 'insulate' any source of money.  Basically, any act of Congress that's signed by the President is law and can override any previous act of Congress.  So any 'insulation' created one year can be immediately overridden the next year.  

        Social security is untouchable for precisely the reason I stated in #1: the political process.  Case in point: the public outcry that killed Bush's privatization boondoggle.

    •  Yup, you already debunked several of my (8+ / 0-)

      preconceptions. And I work in the healthcare industry--though not on the finance side.

      I keep thinking what a boon it would be to ER docs to not have to treat all the stuff that should be treated in a clinic visit --but isn't, cause patiants can't pay for a doctors appt. So people go to the ER, where they have to be treated, just for a sore throat, for instance.

      And that really boosts costs for everyone.

      Democrats promote the Common good. Republicans promote Corporate greed.

      by murasaki on Thu Nov 30, 2006 at 08:04:26 PM PST

      [ Parent ]

      •  Hours of operation, too (0+ / 0-)

        If you work 9-5 and you are not able to take a day off from work, when are you going to take your child to the doctor? If your child is in school/daycare and you're at work it's easy to not realize you have a sick child until Friday afternoon, and even if you have flexible hours, you probably can't be seen (or even set up an appointment) until Monday.

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

        by elfling on Fri Dec 01, 2006 at 02:10:23 PM PST

        [ Parent ]

  •  The Single Humanizing Issue for US (11+ / 0-)

    The US has a great operating document -- the US Constitution

    separation of church and state -- great idea

    right to free speach  -- great idea

    and many other great principles contained within that document and the 'liberal' traditions of this country

    BUT -- the US NEEDS universal health care -- it is so deficient a culture without this one very humanizing aspect ... imo

  •  Thank-you so much (11+ / 0-)

    for this series.  I've really come to believe in the last year or so that universal coverage via a single payer system is coming to this country.  And it will be the corporations that will insist upon it.

    What's different today is that yesterday we had the election....and the Democrats won.-G.W. Bush, 11/8/06

    by jazzmaniac on Thu Nov 30, 2006 at 07:06:34 PM PST

    •  True (3+ / 0-)
      Recommended by:
      April Follies, Tailspinterry, ilex

      It is a win-win for business and the workers.

    •  I don't know why they haven't already (5+ / 0-)

      It is something that GM and Ford have noted makes them much less competitive with foreign cars.  But their solution is to blame the unions and try to cut costs that way.  They need to be advocating for a government solution that is a single payer system (a situation when government IS the solution, ain't it great?).

      •  Believe me, (2+ / 0-)
        Recommended by:
        April Follies, annetteboardman

        the big corporations will soon be advocating for just such a system.  They will also attempt to pay absolutely nothing towards financing this system, and for that we must be vigilant.

        What's different today is that yesterday we had the election....and the Democrats won.-G.W. Bush, 11/8/06

        by jazzmaniac on Thu Nov 30, 2006 at 08:35:31 PM PST

        [ Parent ]

        •  but that's OK (5+ / 0-)

          the idea that employers should be financially responsible for healthcare costs is simply a hold-over from our current dysfunctional system.  there's no reason they really should be paying for it directly.  

          just have them fork over the amount they currently budget for health-plan expenses by putting it in our paychecks, replace the premiums we pay with a fair, progressive healthcare financing tax (which will probably be less than the premium) and we're fine.

          of course, we need to close the corporate tax boondoggles so they start paying their fair share all around, but that's another topic.

          l'audace! l'audace! toujours l'audace!

          by zeke L on Thu Nov 30, 2006 at 08:43:07 PM PST

          [ Parent ]

        •  For the large corps (3+ / 0-)
          Recommended by:
          April Follies, ilex, Hens Teeth

          it will either be a wash or SAVE them money. They already pay a fortune for healthcare, for benefits coordinators, for clerks to deal with the paperwork, etc.

          They want to cut costs - well, universal health care would cut their costs. And it wouldn't require them to sell assets, cut factory workers, or change production.

          Though they need to change production, and make some things that people actually want to buy.

  •  Excellent analysis and research (3+ / 0-)
    Recommended by:
    JanL, AntKat, Tailspinterry

    Hotlisted and recommended; thank you for posting.

    In loving memory of Wimpy, my furry, four legged, feline friend. March 25, 1989 - October 27, 2006

    by CTLiberal on Thu Nov 30, 2006 at 07:08:25 PM PST

  •  Loving this series (7+ / 0-)

    thanks so much. My family remains financially viable today because my least healthy relatives all happen to live in Canada ( I live in the US). So even though I don't live in Canada, I've financially benefitted from their system.

    Writing, photography, cartoons and more in A Cold & Snowy Place.

    by decembersue on Thu Nov 30, 2006 at 07:12:00 PM PST

  •  take this information... (8+ / 0-)

    pare it down a bit and start an email chain, tell your friends, tell your family, tell anyone who will listen. Universal Healthcare needs as many voices as possible, because when the push finally happens the insurance companies will be clawing for dear life to save their cash cow, and we need to have defined universal healthcare on our terms.

    absolute freedom for one individual undoubtedly limits the freedom of another.

    by jbou on Thu Nov 30, 2006 at 07:15:46 PM PST

  •  The money quote: (9+ / 0-)

    Rationing in U.S. health care is based on income: if you can afford care you get it, if you can’t, you don’t.

    This would incense public opinion in most countries, but a big segment of the US population is perfectly OK with this.

    -2.38 -4.87: Maturity - Doing what you know is right even though you were told to do it.

    by grapes on Thu Nov 30, 2006 at 07:18:09 PM PST

    •  Medi Cal reimbursement = estate tax on the poor (2+ / 0-)
      Recommended by:
      April Follies, elfling

      It works like this(somewhat simplified): If you have nothing left except your home, the Government will allow you to get on Medicare (in California, Medi-Cal)which will pay for in home care and nursing home care. When you die, your childen, who you hoped would inherit your home, find instead that they have inherited the bill for your care. Medicare is a loan. In many cases, the tax bill is $40,000-$100,000.

      The mantra is that "those who use services should pay for them." This is not true of large corporations who benefit from roads, airports, police services, community garbage and water.

  •  Manpower and their income (1+ / 0-)
    Recommended by:
    fladem

    Secondly, we would likely retain salaries for health professionals at their current levels

    I want you to tell us why this should be so?  I also want you to explain why physicians should have a monopoly on care through supposed state controlled and enforced limited scope of practice acts and control of the limited number of training slots when in fact organized professional societies are the real controllers in favor odfhigher profits for their members!  

    It sounds like you want to have your cake (high income) and eat it too (less competition from more types of providers and more of them!)  This will inevitably lead to too few providers and ques with rationing in favor of high provider salaries.  Try talking about determining and meeting manpower needs to do the job well including increasing the scope of practice of many types of auxillaries that both exist now and those we can only imagine!  Who controls such manpower-scope of practice decisions in the new system??

    Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

    by truthbetold on Thu Nov 30, 2006 at 07:33:57 PM PST

    •  understand what you are saying (6+ / 0-)

      reality is likely that for top earners (surgical subspecialties, invasive cardiology)... pay comes down. In fact it has already for some under managed care

      As to supply... actually current situation is more complicated than what you are saying, in terms of who gets to determine how total number of medical school slots per year, many residency training slots there are in each specialty.

      •  Not sure this is an answer? (0+ / 0-)

        Let me ask you this.  Under the current system the AMA and the ADA (Dental org) are quite obviously really financial orgs that have as their primary interest the maintenance of low provider numbers with exclusive scope of practice control so that their members can make a lot of money.  In fact, I personally blame these professional societies for much of what is wrong in the American healthcare system of today because of their stubborn insistence on greed over overall health mission.  

        In your new system, do you still see a need for organized professional societies similar to the old AMA, and ADA, and if so, how would their roles be different in the new system from their roles in the old system??  Would they be forced somehow to help in the overall health mission, or still be allowed to act as adversaries to universal health disparities elimination in truth??

        Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

        by truthbetold on Thu Nov 30, 2006 at 07:50:57 PM PST

        [ Parent ]

        •  The AMA serves big bus., not MDs (3+ / 0-)
          Recommended by:
          SarahLee, gkn, Tailspinterry

          Professional Societies don't determine the number of residencies or med. school slots. The AMA makes money in the disability insurance business and in controlling medical coding.  It is heavily linked to big pharma. The AMA is a right wing organization that is heavily invested in the status quo. However, you overestimate its power.

          Professionals are free to join or not join professional organizations. I am a member of the American Geophysical Union, but it doesn't make me rich. Doctors can join the AMA, but it will likely cost them far more than it benefits them. Unlike the AGU which costs me a paltry $20.00, the AMA is pricey.

          •  Sad truth is, the residency program that I (5+ / 0-)

            work along side, though it does have an effective cap, actually trains as many foreign nationals as it does American docs. That has to do with who gets into med school, too. And the sad truth is, that in areas of higher ed, many kids from US aren't making the cut. Foreign universities are often topping ours in turning out well-educated, qualified graduates.

            Democrats promote the Common good. Republicans promote Corporate greed.

            by murasaki on Thu Nov 30, 2006 at 08:15:32 PM PST

            [ Parent ]

            •  Consider this! (2+ / 0-)

              actually trains as many foreign nationals as it does American docs. That has to do with who gets into med school, too. And the sad truth is, that in areas of higher ed, many kids from US aren't making the cut.

              Schools can collect their fees by running at full capacity while still staying on the provider-side good graces by simply training foreigners who will then have to leave the country. It is a win-win situation for the schools and the profession in terms of limiting US providers while still allowing the schools to fill their slots.  It stinks in many ways!

              Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

              by truthbetold on Thu Nov 30, 2006 at 08:37:15 PM PST

              [ Parent ]

            •  Oh please (1+ / 0-)
              Recommended by:
              southernphilosopher

              How many applicants are there for each seat in Med School?

          •  AMA ~30% of physicians (4+ / 0-)

            AMA is down to ~30% of American physicians... continuous drop since opposed Medicare and Medicaid in 60s. Also very regional... even lower on coasts, more in middle and south; more in burbs and rural. But everywhere lower than people think.

          •  I disagree strongly (0+ / 0-)

            Professional Societies don't determine the number of residencies or med. school slots.

            I assure you that the AMA and the ADA have GREAT indirect power over the Boards that determine scope of practice and over the state and private sector plans for slots for training and type of training in professional scools.  I have been there, and it takes a very bold and independent legislator to go against these orgs as the system has been structured in the past! In fact, it just does not happen much, so let the blame fall where it needs to. If you are going to radically demand a new system, open your eyes and look at everything that was disfunctinal in the old system.  There is a hell of a lot!

            Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

            by truthbetold on Thu Nov 30, 2006 at 08:21:43 PM PST

            [ Parent ]

            •  there is a fair amount of regulation (4+ / 0-)

              with opening up residency slots.

              agreed there are lots of political players.

              obviously docs have strong role, just saying, unlike simple view of it JUST being a conspiracy by docs to control the number in the "guild." Not so simple anymore.

              But yes, this material originally developed for/by PHYSICIANS for national health progra, so emphasis is not same as it is say for "Medicare for All" which in fact is what I personally think is best approach.  Also some of the PNHP material is a little dated, based on Clinton plan and fallout thereafter.

            •  Med Education is Very Expensive (3+ / 0-)

              Many med schools are state funded. They get huge subsidies from the states. To increase the number of slots in med school, more subsidies or higher tuitions will be required. This is not an AMA issue.

              Right now, the most urgent priorty is more nursing ed slots, not more med school slots. We aren't training close to enough nurses to care for our aging population. We send recruiters to other counries, like the Phillipines, to take their nurses, leaving those countries with a nursing shortge.

              •  Strongly, strongly disagree (1+ / 0-)
                Recommended by:
                fladem

                To increase the number of slots in med school, more subsidies or higher tuitions will be required. This is not an AMA issue.

                I agree that more subsidies might be needed, but there has always been more applicants than slots! The number of slots and the scope of practice is determined by a convoluted dance between exisitng providers and legislators.  The AMA or the ADA representing providers has great power over the legislators in every state.  Not complete power, but great power.  

                You can blame greedy insurance companies and lawyers for all the problems if you want while leaving the good docs out of the blame game, but I absolutely assure you that you would be making a huge greedy mistake!  No new egalitarian system can work without vesting control of the scope of practice and the number of provders from the foxes that have given us the crappy system we have now!

                Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                by truthbetold on Thu Nov 30, 2006 at 08:54:53 PM PST

                [ Parent ]

                •  Increasing the number of doctors (2+ / 0-)
                  Recommended by:
                  April Follies, ilex

                  Does NOT decrease costs according to research I have read over the years. It's too late for me to Google it up, but it's there. The Feds had funding programs to increase the number of doctors, but they went into sub specialties and costs increased.  Low paying primary care specialties are not popular so residencies go unfilled by American trained MDs. That's why so many India trained Docs are in primary care.

                  What do you propose?

                  •  WRONG (1+ / 0-)
                    Recommended by:
                    SingleVoter

                    The Feds had funding programs to increase the number of doctors, but they went into sub specialties and costs increased.  

                    I went to prof school in the early 70s during the 40% increase in medical and dental providers incentivized by the federal capitation program to increase physicians and dentists. That program greatly increased graduating class size from about 1968 to 1980. It was such a success that the professions through their various school alumni groups threatened a massive protest because of a fear of too many providers. Must have that guarantee to be able to make those big incomes you know. Anyway the schools complied, especially in dentistry, and dropped their enrollment back to 1968 levels.

                    BTW, as a consequence to this story, the graduating classes, again especially in dentistry, for the last 25 years have been smaller than during this federal capitation period, and when this increased cohort of providers starts retiring soon, we will have an added stress of too few providers because of this decrease over the last 25 years due to provider greed and pressure.

                    As for induced demand as a reason why more providers does not lower costs, well that may be true but it has more to do with the lack of standards and accountability to them in the professions that allows privders to get away with such acts.  With increased number of providers due to both more training slots and more types of provders with expanded practice acts along with accountability to good evidenced-based standards, the law of supply and demand could work in the healthcare consumers favor for a change!

                    Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                    by truthbetold on Fri Dec 01, 2006 at 06:48:21 AM PST

                    [ Parent ]

                    •  How much does a family practice doc earn? (2+ / 0-)
                      Recommended by:
                      April Follies, ilex

                      It's not very much in relation to the education and responsibility.  

                      Disease is a liberal plot.

                      by otto on Fri Dec 01, 2006 at 07:37:59 AM PST

                      [ Parent ]

                      •  It depends on many things (0+ / 0-)

                        such as location, willingness to work, and not the least the ethics of the provder to a point.  I believe the most ethical provders may well make the least in a fee for service system, which by its very nature and definition is corrupted because of induced demand capability and information assymetry in the healthcare world.  

                        Any healthcare system reform should either reward providers for healthly results or salary them only but still reward healthly results. I mean that is what it should be all about.  Before anything like this can happen, evidenced-based guiudelines and standards of care must be found and put in place, and then accountability to these enforced.

                        BTW, I have no problem with increased income for those that work longer or harder, as long as the ethics and results of their labor are clear. Finally, in a socially sensitive area such as healthcare, part of the ethics of all provders should/would be to adher to a healthcare system mission, which first must be set.

                        Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                        by truthbetold on Fri Dec 01, 2006 at 08:03:42 AM PST

                        [ Parent ]

                        •  Of course it 'depends' (4+ / 0-)
                          Recommended by:
                          Spit, April Follies, d7000, ilex

                          Everything does.  

                          A GP doesn't earn what people think they earn.  

                          It seems to me that you want to apply a system of checks that won't work within a system where there are outside factors.  

                          Do you know how much a GP makes?  I don't know for sure, but I would assume that they make up the greatest percentage of doctors.  It appears they start around 130k.  I don't find that to be an exceptionally large salary for someone with 10 years of post secondary education.  

                          I think doctor's salaries are the least of the concerns when it comes to the healthcare system.  

                          Disease is a liberal plot.

                          by otto on Fri Dec 01, 2006 at 09:33:55 AM PST

                          [ Parent ]

                          •  Many FPs make less than 130 K (0+ / 0-)

                            And pediatricians are paid less than you might think too.  Doctors doing heart procedures are paid very well, but doctors caring for patients with congestive heart failure are not paid well comparitively. Doctors are overpaid for many procedures and underpaid for caring for elderly and chronically ill patients, in my opinion.

                          •  Family Practice docs are in big trouble. (0+ / 0-)

                            They are not paid as well, a huge portion of the growing administrative burden falls on them, and  they are expected to be the "gatekeeper" for all the managed care, and the primary health educator for their patients as well as fixing what ails them.  Who wants that headache?

                            The number of those choosing a Family Practice residency has decreased by 52% in the last 7 years.  There are more FP residency slots every year that go unfilled, because no one wants that thankless (but important) job when they could go to a lucrative sub-specialty instead.

                            No, most FP's do not make tons of money.  I personally know plumbers who make more.

                            Democrats - We refuse to caucus in the missionary position.

                            by SaneSoutherner on Fri Dec 01, 2006 at 03:37:20 PM PST

                            [ Parent ]

                •  DOCTOR TRAINING (0+ / 0-)

                  I think all physicians should be trained as nurses first.

                  After four years of hospital practice they would be able to go on to medical school if they can pass the MCAT and have good evaluations for listening skills and compassion.

              •  If you want to train more medical personnel (2+ / 0-)
                Recommended by:
                April Follies, terran

                in ANY specialty, including nursing, you need three things.

                1. Facilities to train them in, including equipment.
                1. Faculty to train them.
                1. Students who have the foundation to do well in advanced math/science subjects.

                We're short on all.

                I work at a college. We have a nursing program, a radiology tech program, a surgical tech program, and a massage therapy program, among others. We have WAY more applicants than we can take. We also have many applicants who just can't handle the work - they're so far from ready, it would take them 2 yrs to just get to the point of handling chemistry and algebra.

                We're also short facilities. We have an agreement with the local hospital, so our students get clinical time there, and we have classrooms there. We don't have any more room. We're lucky that right now we have enough instructors, but that's always a concern too. And if by some miracle we got more space and could take more students, we'd have to get more faculty - which would not be easy.

                It's not just one thing. It's a combination of things that keeps the number of trained medical personnel down.

              •  We wouldn't need to train so many nurses if (5+ / 0-)

                we didn't burn them out so quickly. There are plenty of trained non-practicing RNs out there who leave the field because of poor working conditions.

                Giving nurses better conditions improves outcomes, too.

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

                by elfling on Fri Dec 01, 2006 at 09:09:50 AM PST

                [ Parent ]

    •  Because med school costs a fortune (4+ / 0-)

      and training absolutely sucks in terms of time/sleep deprivation/difficulty.

      No one's going to do it for 50K/yr.

      Politics is like driving. To go backward, put it in R. To go forward, put it in D.

      by gkn on Thu Nov 30, 2006 at 08:42:12 PM PST

      [ Parent ]

      •  If big money stays the driving (1+ / 0-)
        Recommended by:
        jd in nyc

        force behind becoming a provider, we will never achieve a good system with decent access for all and proven quality and effectiveness of what is done.  Never!

        Is it only physicians and dentist that deserve a guaranteed high salary?  Why??

        Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

        by truthbetold on Thu Nov 30, 2006 at 09:07:51 PM PST

        [ Parent ]

        •  Do a residency (6+ / 0-)

          and you'll understand why no one will do it for 50K/yr.  Would you work 90 hrs/wk for that when you could just as easily work 40 in another field to make the same amount?  I doubt it.  I wouldn't.  90-hour weeks suck.

          Money is not the driving force behind becoming a provider.  That's one of the major things they screen for in med school interviews, and the attitudes such people display during med school, if they get in, will rapidly get them labeled "unprofessional" and, quite possibly, get them kicked out.

          No, physicians and dentists aren't the only ones who deserve a guaranteed high salary.  That's inane.  Compensation for anything, however, should be directly related to the time/money/difficulty a person invests in order to enter that field.  To most people, that's common sense.

          I am so goddamn sick of this "doctors are only in it for the money" opinion that seems to be so prevalent around here.  Personally, I'm going into medicine for the research.  But it's not worth devoting my twenties and thirties to the training if I'm going to be paid the same as I would to be a lab tech.  

          Politics is like driving. To go backward, put it in R. To go forward, put it in D.

          by gkn on Thu Nov 30, 2006 at 09:32:20 PM PST

          [ Parent ]

          •  There is more to it than that (3+ / 0-)
            Recommended by:
            SarahLee, truthbetold, mmacdDE

            Your work as a physician or researcher would be more rewarding than your work as a lab tech. There are lots of people who spend many years in school and wind up with jobs with less than fantastic pay in order to be able to do work they find meaningful. They're called professors.

            I myself spent my 20's in grad school only to wind up with a starting job that paid less than 40K, with the prospect to make a whopping 70K or so once I got tenure. If I hadn't become sick of the politics in academia, I would still be there.

            The only real difference I see is that you guys in medicine work longer hours in your residency/training period. But there is no reason why that has to continue, is there?

            Look, other nations pay their physicians an upper middle class income, but one on the order of $100K per year rather than $200-300K per year like in the US. They still have an adequate supply of physicians, so it must not be true that if we lower the pay we won't have enough doctors. Maybe they take it easier on residents, I don't know, but I'm sure there is much we can learn.

            •  From what I hear (2+ / 0-)
              Recommended by:
              April Follies, terran

              they do take it a lot easier on residents.  Those residents also aren't in 260K of debt from med school, let alone undergrad.  And they do get paid 40K per year until they're done with residency, and while they're paying off their loans.  Then, they get out into practice, and pay up to 350K/yr in malpractice insurance.  I am not exaggerating that number (a neurosurgeon from Illinois I recently met paid just that.)

              Actually, I'm not sure I'll find medicine that much more rewarding than working as a lab tech, with the way it's going right now.  And I really doubt that I will in residency, if the residents I know are any indication.  The 90-hr weeks don't have to continue past that, but my dad still works a good 65 - and he's got his own residents to take care of some things.

              100K is reasonable - in fact, it's around what many non-surgical specialties make now.  I had someone on here tell me a while ago that his friend, who is a physician in Sweden, makes about US $25K per year, which is about as much as you make as a grad student here.  

              Let's turn this argument around a bit.  Why should attorneys make 500K?  Investment bankers make god-knows-how-much straight out of college?  Should we regulate that, too?  Surely, that money could be redistributed to the betterment of society, right?

              Politics is like driving. To go backward, put it in R. To go forward, put it in D.

              by gkn on Thu Nov 30, 2006 at 10:02:41 PM PST

              [ Parent ]

              •  And what about the LPN's? (3+ / 0-)
                Recommended by:
                April Follies, terran, ilex

                And the nursing home caretakers? They do difficult work all day, with minimal pay, lousy working conditions and few health benefits. I would like to see nursing home care providers paid a decent salary for the work they do. This is not possible in a for profit system.

                •  Of course they should be paid well. (2+ / 0-)
                  Recommended by:
                  April Follies, javelina

                  I've done palliative care, and it is tough work (although, oddly, one of the specialties I like best.) Once again, though, there is the debt/time training argument.  Show me a nursing home caretaker who paid 260K to train to do that, and I'll agree that they should make a doctor's salary.

                  That said, our whole nursing home system needs a massive overhaul.  It's absolutely ridiculous how poorly we treat our seniors.

                  And I'm not sure what you mean by a "for profit system."  I'm completely in favor of the diarist's plan, though I think there needs to be some carrot-and-stick maneuvering to get people to live a reasonably healthy lifestyle.  But if you mean that doctors shouldn't be paid a reasonable wage, I think you're wildly underestimating what our current expenditures could do.  Actually, your whole comment seems like a non-sequitur to mine...I'm not sure how they're related.

                  Politics is like driving. To go backward, put it in R. To go forward, put it in D.

                  by gkn on Thu Nov 30, 2006 at 11:49:47 PM PST

                  [ Parent ]

                  •  doctors should be paid a reasonable wage (2+ / 0-)
                    Recommended by:
                    April Follies, gkn

                    Doctors do actual work, that helps people, and train long and hard in order to do it. That is a given. However, in a for-profit system, capital moves towards profitable enterprises and away from non profitable enterprises. Nursing homes cost a lot of money to run properly. Unfortunately, most seniors don't have a lot of money, so it is difficult for them to pay for care
                    (defined as treatment as human beings) The American solution is to pay caregivers as little as possible and to hire as few of them as possible. My thought was that in a single payer system, nursing home care should be included, and caregivers should be paid commesureate with what they do, which is take care of your dying grandmother.

                    •  If we (0+ / 0-)

                      distribute health care dollars according to the costs per demographic, care for the elderly should receive a great deal.  And we're definitely going to have to hire more caregivers, considering the size of the population we'll have retiring.  

                      We really need to end the war and put that money to better use - right now.

                      Politics is like driving. To go backward, put it in R. To go forward, put it in D.

                      by gkn on Fri Dec 01, 2006 at 01:34:30 PM PST

                      [ Parent ]

                  •  I don't think that la motocycliste (1+ / 0-)
                    Recommended by:
                    gkn

                    was necessarily suggesting that these workers be paid equal to doctors.  Just pointing out that there are underpaid workers in healthcare.  Here I think that nursing home workers make about the same per hour as the better paid workers in retail; $8 - $10 per hour.

                    Teachers and childcare workers could use a raise too, at least here in TX.

                    •  That's terrible, (0+ / 0-)

                      and part of the reason our nursing homes are in such appalling conditions.  You would not believe some of the stories I've heard from some of our hospice patients about their previous experiences in nursing homes...yes, especially considering our rapidly aging population, end-of-life care needs to be prominently addressed.  Funding more hospices, in particular, would do a lot to increase seniors' quality of life.

                      Politics is like driving. To go backward, put it in R. To go forward, put it in D.

                      by gkn on Fri Dec 01, 2006 at 01:32:04 PM PST

                      [ Parent ]

              •  expand your vision of what's wrong!!!! (0+ / 0-)

                Those residents also aren't in 260K of debt from med school, let alone undergrad.  

                You are stuck in perceiving the current training paradigm as the way it must be.  That's wrong and shortsighted.  Train more providers and types of providers in programs that are more socially responsive but also more human and kind to applicants in terms of lifestyles and costs, and you will get more happy students in less debt.  You will also get more provders with less guarantees of great wealth, but that is the way it must be for healthcare to meet a mission of better health for all.  Do you think such a mission has ever been set in this country??

                Political censorship is the root of all evil! It is the antithesis to a functional democracy!!

                by truthbetold on Fri Dec 01, 2006 at 06:57:56 AM PST

                [ Parent ]

                •  I agree with much of what you are saying. (0+ / 0-)

                  For the love of god, I'm not claiming that there's nothing wrong with our medical system!  And I'm not claiming that doctors need to make 500K per year!  Most make nowhere near that, anyway.  But 25-50K is beyond ridiculous, which many people don't seem to see.

                  I don't really see what you think we're arguing about, here.  Your point with the programs is absolutely correct.  But the students still won't be happy to make a final salary equivalent to the stipend of a graduate student.  It's absurd.  You seem to be ignoring most of what I said.

                  And, yes, many specialties have completely overhauled themselves to "meet a mission of better health for all" of their patients.  Anesthesia, for instance.  Anesthesia deaths have plummeted ever since.

                  Politics is like driving. To go backward, put it in R. To go forward, put it in D.

                  by gkn on Fri Dec 01, 2006 at 01:52:02 PM PST

                  [ Parent ]

              •  We'd be better off (3+ / 0-)
                Recommended by:
                April Follies, gkn, ilex

                With scholarships for medical school.

                I also think that a single payer plan would significantly reduce malpractice risk. Most awards now go towards paying for care of the injured party. If that is already paid by the system, there's far less need to sue for damages unless the case is egregious.

                Of course, not that malpractice insurance is related to the cost of malpractice claims. It's more closely correlated with stock market performance.

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

                by elfling on Fri Dec 01, 2006 at 09:05:31 AM PST

                [ Parent ]

            •  And, incidentally, (0+ / 0-)

              I'm going to stay in academia so I can teach.  The main reason I'm doing an MD is to improve the otherwise-dismal odds of becoming a PI these days, and to have something to do if I didn't get funded.  

              Academia also offers more flexible work schedules, the opportunity for sabbatical, few/no classes to teach in the summer, free grad school if you are in the sciences, etc.  That said, I still think it's appalling that we pay professors (indeed, all teachers) so little.  

              And, a lot of the time, medicine is nowhere near as fulfilling as people imagine it to be when they start out.  That's why we have so many depressed physicians.

              Politics is like driving. To go backward, put it in R. To go forward, put it in D.

              by gkn on Thu Nov 30, 2006 at 10:07:58 PM PST

              [ Parent ]

              •  Those are the reasons why (2+ / 0-)
                Recommended by:
                April Follies, terran

                my daughter's friend, who is a lawyer, went to Ivy-League schools, etc., is now teaching at the local community college.

                She has a little girl. Her husband has a good job.

                Could she make more money staying in law? Sure. Would she see much of her child? No.

                What's more important? The law will still be there in 5-10 yrs, and she's teaching paralegals, so she'll stay connected. But she will have MUCH more control over her schedule, many hours will be outside the classroom (all teachers have lots of non-classroom time) and most of all, SHE gets to raise her child.

                I'm sure she's making less, but money isn't the only thing in the world.

                •  No, money's not the only thing in the world, (0+ / 0-)

                  and I never claimed it was my motivation for doing medicine.  

                  That said, I'm not going to have children, so I suppose I should spend as much of my time as possible working.  Spouses having good jobs also features prominently in these scenarios.

                  Politics is like driving. To go backward, put it in R. To go forward, put it in D.

                  by gkn on Fri Dec 01, 2006 at 01:36:27 PM PST

                  [ Parent ]

          •  Must we work residents for (3+ / 0-)
            Recommended by:
            April Follies, elfling, Hens Teeth

            90 hour weeks?

            It would seem that you certainly need doctors on site for long periods of time in certain specialities (surgery) so that they will have the opportunity to get trauma cases ... but ...

            Why not assign the intern a young, minimum wage orderly who is interested in medicine to act as a runner?

            •  Must we have doctors who can perform? (1+ / 0-)
              Recommended by:
              gkn

              I mean, why not let any Joe operate on you?  As it is now, if you want to be a cardio-thorassic surgeon you do 4 years of med school, 3 years of residency and 3 years of specialty training residency stuff all the while working insane hours and getting paid dirt.  

              If you cut the hours in half the surgeons may be 60% as good because they don't have as much experience.  

              I want a well-trained surgeon operating on me, thank you.

              -Fred

              Democrats *do* have a plan for Social Security - it's called Social Security. -- Ed Schultz

              by FredFred on Fri Dec 01, 2006 at 10:25:37 AM PST

              [ Parent ]

              •  The experts disagree: cutting hours is good (2+ / 0-)
                Recommended by:
                ilex, Hens Teeth

                A lot of studies have looked at resident hours, and the effect on patient care and training.  The overall consensus is that overworking residents is BAD for patient care and BAD for resident training.

                That is why as of 2003, residents no longer work the type of hours this thread is talking about.  24-hour shifts and 80-hr workweeks are now the maximum -- a maximum set after exhaustive study and discussion by the Accreditation Council for General Medical Education:  http://www.acgme.org/...

                I have personally seen residents trying to care for patients after 36 hours on shift.  It's dangerous to the patients, and the residents aren't learning anything.  

                •  I think you would (0+ / 0-)

                  have to increase training time, though.  If I go into neurosurgery, I want to be damn confident of my abilities before I'm going it alone.

                  But, I completely agree with you - I see learning drop off in people who've been working ridiculous hours.

                  And those hour requirements do not get followed in many large institutions.  No one wants to complain about it, either, because then you look like a slacker compared to the inevitable gunners who want to work forever.  

                  And note that there is no regulation of the time medical students spend on the wards.

                  Politics is like driving. To go backward, put it in R. To go forward, put it in D.

                  by gkn on Fri Dec 01, 2006 at 01:40:44 PM PST

                  [ Parent ]

            •  Actually, it seems we don't (0+ / 0-)

              The max is 80 hours/wk and 24 hour shifts: http://www.acgme.org/...

              I don't think 80 hours is too much at all.  24 hour shifts seems excessive, but it is justified because studies show that it helps patient care: you get the same doctor for 24 hours at a time in the hospital, which helps "continuity of care" and reduced the amount of lag time while new doctors come up to speed.

              Of course, nurses have much shorter shifts, and they're a lot more important to hospital care, so maybe the 24-hour shift thing isn't so justified after all.

              •  Ha! (1+ / 0-)
                Recommended by:
                Hens Teeth

                If you think people follow those requirements, particularly in busy surgical fields, you are sorely mistaken.  People will even tell you that before you go in.  Hospitals don't exceed the maximum too egregiously anymore (90 hrs is about right), but see my comment above - residents are loath to complain when they have to work beyond the maximum.

                Politics is like driving. To go backward, put it in R. To go forward, put it in D.

                by gkn on Fri Dec 01, 2006 at 01:45:22 PM PST

                [ Parent ]

                •  Maybe a few lawsuits would straighten this out (0+ / 0-)

                  Having seen residents botch medication calculations and mess up painful and dangerous procedures while barely standing from exhaustion, I think that such silence by residents and acceptance by hospitals is an abrogation of duties to patient safety.

                  Now that there are clear standards for this, exceeding maximum work hours would be per se malpractice.  It's surprising it hasn't resulted in lawsuits.

          •  No (0+ / 0-)

            Compensation for anything, however, should be directly related to the time/money/difficulty a person invests in order to enter that field.

            I frankly only care about the inherent difficulties, not the imposed difficulties.

            One of my former neighbors is an anesthesiologist.

            He moved here from New Mexico so his wife could be near her family. He and his wife moved back to New Mexico after he couldn't pass our state exam.

            •  What? (0+ / 0-)

              Really?  If you're in six figures of debt, you shouldn't be compensated so as to be able to pay it off?  You shouldn't be paid more for working longer hours?  

              I think most people would disagree with you.

              Politics is like driving. To go backward, put it in R. To go forward, put it in D.

              by gkn on Fri Dec 01, 2006 at 01:46:45 PM PST

              [ Parent ]

          •  Truly? (1+ / 0-)
            Recommended by:
            April Follies

            I know plenty of grad students who work 90 hour weeks for a wage that barely pays their subsidized housing. And then when they've got the coveted Ph.D., they too can earn a whopping $50K - oh, after all those years as a post-doc.

            Honest, medicine is not the only field of rigorous training, it's just the best paid field with rigorous training.

            That said, I don't begrudge doctors a comfortable living at all.

            Can I say that I sure don't want a resident working a 90-hour week supervising my medical care, particularly at the end of a shift? Doctors, of all people, should know better.

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

            by elfling on Fri Dec 01, 2006 at 09:01:50 AM PST

            [ Parent ]

            •  And I know a lot of graduate students (0+ / 0-)

              who don't spend nearly that much time in the lab, but get done in 5-6 years, which is about average.  Sure, they don't graduate with 20 papers, but it's also a matter of efficiency.

              I'm doing a PhD as well.  For me, at least, the medical side of things is much more exhausting and difficult.  But, then, I do prefer the research.

              Politics is like driving. To go backward, put it in R. To go forward, put it in D.

              by gkn on Fri Dec 01, 2006 at 01:42:53 PM PST

              [ Parent ]

            •  Seriously (1+ / 0-)
              Recommended by:
              elfling

              I'd rather we paid them decent, but not incredible salaries, and then treated them like human beings rather than machines -- honestly, sometimes I think my friends doing residencies are basically going through a kind of hazing. There's no reason for it that I can see.

              We'd also probably stop weeding out the many, many people who would make terrific doctors, but who want to have a little time for having well-balanced lives.

      •  Time For Govt. Mandated "Tuition Control"? (1+ / 0-)
        Recommended by:
        April Follies

        Admittedly it's a revolutionary idea, which will be rejected vocally and vehemently by the universities, but it would seem in the interest of all the people of this country to find ways to make the cost of educating physicians more affordable.  I know--every other profession will feel a justification for lowering tuition costs and their arguments will have merits.  Yet, we are in a healthcare crisis in this country, and people are dying unnecessarily because of the whole mess.  I would think,howerver, if the government does get involved in mandating a single payer system, they should also get involved in researching ways to cut the costs providing medical care, including the cost of educating physicians.

    •  Take (0+ / 0-)

      a look at the training of doctors in wartime:

      here.

  •  "Civilized Medicine" not "Socialized Medicine" (15+ / 0-)

    Let's change the name, just like Republicans changed the name of the "Estate" tax to the "Death" tax.

    "There ought to be limits to freedom." -- G W Bush, 1999

    by Jimdotz on Thu Nov 30, 2006 at 07:43:18 PM PST

  •  Why not just make people be able to buy Medicare (2+ / 0-)
    Recommended by:
    Bob Love, Tailspinterry

    Sell Medicare to people below 65  priced  depending on income.  This could control  prices of  premiums.

  •  Shameless diary plug (2+ / 0-)
    Recommended by:
    rickeagle, Tailspinterry

    "Power always has to be kept in check; power exercised in secret, especially under the cloak of national security, is doubly dangerous."William Proxmire

    by Rothbardian on Thu Nov 30, 2006 at 07:52:23 PM PST

  •  You have just debunked (6+ / 0-)

    so many myths that I have heard Repugs use to argue against universal healthcare. Thank you for giving us the ammo to make others more enlightened about this, and hopefully help to someday make this a reality.

    Those who can make you believe absurdities can make you commit atrocities. -- Voltaire

    by jetskreemr on Thu Nov 30, 2006 at 07:55:59 PM PST

  •  My favorite part: (11+ / 0-)

    Wake up. We already have rationing.

    People seem to conveniently forget (ok - perhaps they never knew) that the whole point of markets is to allocate limited resources: a.k.a. "Rationing."

    And private markets can't/don't/won't efficiently allocate the resources for public goods/services as efficiently as can the government: a.k.a. "Econ 101"

  •  My-T Fine Work! (4+ / 0-)
    I don't know how many parts you plan, in all, but it would be great to have a single source for the entire compendium, when you're finally done.  That way we could point to an elegant essay about the whole set of issues.  This is such great stuff that you should consider submitting the compendium for publication in a relevant magazine.

    My sister, a registered nurse, has expressed doubts about a single-payer system, but could not rebut that large US manufacturers should be all in favor of it--GM spends more on health care than on steel.  Tipping the big manufacturers in favor could bring along the unions, and a coalition is rolling.  When small businesses and their employees get it, it's a done deal!

  •  England (4+ / 0-)
    Recommended by:
    SarahLee, elfling, annetteboardman, ilex

    It might be useful to see how and how much General Practioners are paid in England (in US terms these are Primary Care Physicians but they also act as "gatekeepers" for specialist referals within the NHS)

    Very recent figures put their average income at around $200,000. This is a considerable increase which is partly explained in a Q&A on the BBC site

    One significant change over the past few years has been a move towards payments for targets. These include things like having a certain percentage of women in their client base having cancer tests. Others might be a demonstrable reduction in the numbers with high blood pressure. Basically this is payment on outcomes (ie better health) than on input (number of procedures, visits by patients etc). From the link:

    Dr Hamish Meldrum, head of the BMA's GPs committee, said the new contract was leading to improvements in care.

    "In the area of raised blood pressure alone (hypertension) GP care under the new contract means that over a five year period, 8,700 patients in England will avoid having a heart attack, stroke, angina or heart failure."

    •  Is any of this attributable (0+ / 0-)

      to the rise of the private market in health care in the UK.

      I work a great deal with the UK - and many tell me they frequently don't use the National Health Service.

      I am always surprised when I hear this - but never really have time to understand better why.

      •  Private health insurance. (4+ / 0-)
        Recommended by:
        fladem, elfling, mmacdDE, terran

        There are a few reasons for the private insurance system carrying on.

        The first is that some things are not entirely covered like the cost of dental and ordinary eyesight problems for those of working age where what you would recognise as co-pays come into effect. The most widespread insurance schemes are to cover these co-pays or to provide money for people while in hospital to cover additional costs such as travel for relatives etc.

        The second is to get access to what you might call better hotel facilities. Private facilities tend to have single occupancy rooms rather than the typical ward systems common in many of the older hospitals. Even these are being replaced by "bay" systems where four or six beds are in small wards clustered round a central nurse/facilities station.

        The big selling point though is access to treatments to fit in with lifestyle. There are still waiting lists for non-urgent procedures so the private systems cater for those who want to be able to make their own arrangements of when they will have the treatments rather than being allocated the slot in turn.

        A more recent cause for taking private insurance is to cover treatments not undertaken by the NHS. There is now a body called the National Institure for Health and Clinical Excellence which assesses treatments on the basis of their cost effectiveness. There have been recent cases where treatments are not deemed to be worthwhile in that they are new drugs which offer very little additional benefit at huge cost. Some new cancer drugs for example merely extend life expectancy by a couple of months in most cases while costing vast sums.

        Ironically the one case where probably the most is spent on private health insurance is the least realised and well known. The NHS has the right to (and increasingly does) bill the insurance companies of drivers responsible for injuries for the cost of treating those they injured. Since all drivers are required to have at least third party insurance, these costs are also spread over large numbers so are little realised.

        One other thing Blair has done is to use private facilities to bring down waiting lists. As a patient you should now be offered a choice of NHS hospitals to have an operation in but if say you are unable to get a joint replacement operation in a reasonable time in them you might be offered a place in a private hospital (or even one in another EU country, probably France) where your local NHS region has a contract.

        One thing that no one uses the private system for is emergency treatment. If you are taken ill with say a heart attack or are seriously injured you will be taken by NHS ambulance to the nearest emergency department with no question of money being asked for or evidence of insurance. Of course you can then elect to get follow up treatment in private facilities once you are stable. Incidentally while obviously pre-existing and minor conditions are excluded, serious emergencies or injuries are also treated free for visitors.

        One thing you might like to note is that the Conservative Leader of the Opposition has a child with cerebal palsy and the Chancellor Gordon Brown's baby son has been diagnosed with cystic fibrosis. Both are being treated by the NHS.

        •  Thank you for the answer (0+ / 0-)

          BTW - most of the people I work with still like the NHS - but they can afford not to use it.

          Of course, one of the people I work with will go on and on about the greatness of the current mayor of London....

      •  Private health insurance. (0+ / 0-)

        There are a few reasons for the private insurance system carrying on.

        The first is that some things are not entirely covered like the cost of dental and ordinary eyesight problems for those of working age where what you would recognise as co-pays come into effect. The most widespread insurance schemes are to cover these co-pays or to provide money for people while in hospital to cover additional costs such as travel for relatives etc.

        The second is to get access to what you might call better hotel facilities. Private facilities tend to have single occupancy rooms rather than the typical ward systems common in many of the older hospitals. Even these are being replaced by "bay" systems where four or six beds are in small wards clustered round a central nurse/facilities station.

        The big selling point though is access to treatments to fit in with lifestyle. There are still waiting lists for non-urgent procedures so the private systems cater for those who want to be able to make their own arrangements of when they will have the treatments rather than being allocated the slot in turn.

        A more recent cause for taking private insurance is to cover treatments not undertaken by the NHS. There is now a body called the National Institure for Health and Clinical Excellence which assesses treatments on the basis of their cost effectiveness. There have been recent cases where treatments are not deemed to be worthwhile in that they are new drugs which offer very little additional benefit at huge cost. Some new cancer drugs for example merely extend life expectancy by a couple of months in most cases while costing vast sums.

        Ironically the one case where probably the most is spent on private health insurance is the least realised and well known. The NHS has the right to (and increasingly does) bill the insurance companies of drivers responsible for injuries for the cost of treating those they injured. Since all drivers are required to have at least third party insurance, these costs are also spread over large numbers so are little realised.

        One other thing Blair has done is to use private facilities to bring down waiting lists. As a patient you should now be offered a choice of NHS hospitals to have an operation in but if say you are unable to get a joint replacement operation in a reasonable time in them you might be offered a place in a private hospital (or even one in another EU country, probably France) where your local NHS region has a contract.

        One thing that no one uses the private system for is emergency treatment. If you are taken ill with say a heart attack or are seriously injured you will be taken by NHS ambulance to the nearest emergency department with no question of money being asked for or evidence of insurance. Of course you can then elect to get follow up treatment in private facilities once you are stable. Incidentally while obviously pre-existing and minor conditions are excluded, serious emergencies or injuries are also treated free for visitors.

        One thing you might like to note is that the Conservative Leader of the Opposition has a child with cerebal palsy and the Chancellor Gordon Brown's baby son has been diagnosed with cystic fibrosis. Both are being treated by the NHS.

  •  What do you mean by this? (6+ / 0-)

    Won’t this result in rationing like in Canada?

    I was wondering if you could explain to me how my health care is rationed because last time I used the system -- like last week -- nothing was "rationed". I don;t ever recall when it was, and I've been around for awhile.

    •  are you in canada? (0+ / 0-)

      not sure i understand the question.  in the US we have our care rationed constantly, through having coverage of various procedures denied without cause by our insurers.

      l'audace! l'audace! toujours l'audace!

      by zeke L on Thu Nov 30, 2006 at 08:47:14 PM PST

      [ Parent ]

      •  Yes, I am in Canada. (3+ / 0-)
        Recommended by:
        April Follies, Lesser Dane, ilex

        Procedures aren't denied without cause like I have seen described here that I know of. I have lived in four provinces and one of the northern territories so have used a number of different systems.

        I've seen the term rationing here to describe our system before, and I don't understand it, or where it's coming from.  To me it means our access is limited in some structural way. As in you can only have one hip replacement a year, or I can only get 1/2 of my insulin supplies paid for. Or I have to use certain pharmacies or doctors. That's utter nonsense.    

        The only rationing I know of is coincidental because of some kind of access problems. Canada is a big country, where services are varied due to the wealth or poverty of the province which is administering the health care, and because it's kind of hard to put hospitals and specialists in the middle of nowehere. Our health care is centralized in population centres not spread out on the tundra.

        I'm sure you can find Canadians who will tell you about wait times and provide horror stories about access to specialists. But that isn't rationing.

        I just want to add that care systems in Canada did not just happen -- it/they have developed over 50 odd years, beginning with basic hospital coverage for everyone to the more comprehensive programmes we  have now.

  •  Excelent, thanks. How are regional disparities (0+ / 0-)

    in provider distribution resolved? Physicians in high-paying specialties cluster in metro areas while rurals struggle to recruit Family Practicioners. I see a greatly expanded and money-saving role for Advanced Practice nurses, especially in ambulatory care. Also, if income differences are smoothed out, more med school grads might choose primary care over the highly lucrative sub-specialties.
       But these are minor details in the larger picture. You have refuted every major opposition. I highly recommended that policy journalists and Congress members read your diaries.
       See FDR in my sig. Single Payer is the logical next step to honor his legacy.

    ....the only thing we have to fear is fear itself. FDR 1933

    by Tailspinterry on Thu Nov 30, 2006 at 08:24:56 PM PST

    •  A few med schools (4+ / 0-)

      will pay a significant portion of your debt in return for your practicing in rural areas for a set amount of time - kind of like the legal aid program.  I'd work on expanding that.

      You can't totally smooth out the compensation differences between the specialties because of differences in training time.  If I spend 8 years becoming a neurosurgeon, I expect to be paid more than I would if I spend 3 years becoming a family practitioner.

      I think you'll have to figure out other inducements for more med students to choose family practice, though.  For many people, including me, it just isn't interesting.  For instance, after doing her (rural) family practice rotation, my mom said that if she had to do that for a living, she'd quit medicine.  (It apparently consisted of repeatedly telling people "you need to watch your cholesterol, take your blood pressure meds, exercise, eat less McDonald's, and stop smoking.  Here are some suggestions for doing so."  Then, they'd come back six months later having done none of the above.)

      Politics is like driving. To go backward, put it in R. To go forward, put it in D.

      by gkn on Thu Nov 30, 2006 at 08:49:55 PM PST

      [ Parent ]

  •  holy crap this is amazing (10+ / 0-)

    Wow, thank you for writing all of this!

    BTW, my favorite complaint about universal healthcare is "we'll have waiting lists" - to which I answer "How's that worse than now, where you aren't on a waiting list to begin with because you can't get the care you need period?"

    As for waiting lists, we've already got 'em. If it weren't for a nice nurse sneaking me into my headache doctor's stroke clinic, I STILL wouldn't have seen him. I called for an appt in August and they offered me January. Thanks to the nurse who helped me, I've been able to see him 3 times in the last 6 weeks instead.

    Recipe For America - A people-powered movement to take back our food system

    by OrangeClouds115 on Thu Nov 30, 2006 at 08:29:43 PM PST

  •  Did you put this together by yourself (0+ / 0-)

    or are you representing a group?

    Life is what you focus on. Let's focus on ending the war. After that the rest will be easy.

    by relentless on Thu Nov 30, 2006 at 08:31:26 PM PST

  •  fabulous job!! (4+ / 0-)

    I'm a board member of the California Nurses Assn.  As you likely know, single payer is the heart and soul of our agenda.  We look forward to working with FNHP in the furture!!

  •  Great diary but far too long. n/t (0+ / 0-)

    Much better, thanks. And you?

    by Bob Love on Thu Nov 30, 2006 at 08:38:30 PM PST

  •  Something needs to be done (8+ / 0-)

    My son and I are w/o health insurance for the first time in more than 7 years, and even though I make a decent income, I have been avoiding certain medical tests and procedures. Not to mention my son and I are both on migraine and other meds that cost over $100/month EACH in cash payments (minimum monthly family prescription costs are currently over $350).

    Then there's the fact that my brother is currently serving with his National Guard unit in Kuwait. He re-enlisted in the National Guard several years ago for the health insurance benefits for his family.

    Then there's the story of the Frist family's HCA firing half (or more) of the nurses in their HCA-owned hospitals to cut costs, leaving the nursing staff there with quadruple the number of patients, and the patients in greater danger as the already overworked nurses try to keep on top of things and provide quality care without the luxury of bathroom or lunch breaks.

    Thanks for all the info.

    •  I'm in a similar situation (4+ / 0-)
      Recommended by:
      April Follies, terran, ilex, Hens Teeth

      I agree with this statement:
      "We know that the uninsured delay or avoid seeking care because they are afraid of health care bills."

      I have been having joint pain for the past few months, but I have been waiting to see a doctor, because you don't start your deductible in September or October, right?  And now, I may be unemployed starting in January, so I may not be seeing a doctor about this for a year or more.  Too damn bad for me if it is something progressive, huh?  My own damn fault for having bad genes (or whatever).

      Yes, we need "civilized medicine"!

  •  Hi, DrSteveB, (1+ / 0-)
    Recommended by:
    April Follies

    and thanks!

    I am an MD/PhD student who is very interested in this issue, and I have a couple of questions for you:

    1. The only point I take issue with above is that about the higher risk/higher premiums.  I completely agree that cancer, genetic conditions, etc. should not cause patients to pay a higher premium.  But what about "optional" pathologic conditions - say, smoking, refusal to alter diet/exercise to counter obesity/HTN/cholesterol?  From what I've seen, no amount of education can induce many patients to change their behavior.  Without any penalty, they'll have even less of an incentive to do so.  I know that monitoring programs have been shown to help with diabetic care, but I'm skeptical of their ability to help with, say, smoking.
    1. I'm trying to get speakers for my med school's AMSA Health Policy Week.  Is there a way for me to find an active PHNP member at/near my institution?

    Thanks again for this series - keep going!

    Politics is like driving. To go backward, put it in R. To go forward, put it in D.

    by gkn on Thu Nov 30, 2006 at 08:39:12 PM PST

    •  The diet police (4+ / 0-)
      Recommended by:
      SarahLee, Blissing, ilex, Hens Teeth

      Not a good idea. The fat police?  Not a good idea. Are you going to tax people by weight like they are trucks?

      •  Sounds familiar (3+ / 0-)
        Recommended by:
        April Follies, rickeagle, Dar Nirron

        This concept seems to be catching on in insurance plans already.  See this article in the Seattle Times:

        BUS DRIVERS KICK, step, clap and shout in unison during a spirited morning aerobics class at Metro Transit's South Base. Downtown paper-shufflers have their meetings walking down the street. Smokers attend classes to quit. Overweight folks sign up to learn about nutrition. Whole departments bond through group salad days.

        All of them work for King County — and all of them are doing what they do as part of an ambitious "wellness" experiment that ties what they pay for health benefits to the effort they make to be healthy. The approach represents a novel and relatively benevolent ripple in what has become a sea change in how employers are addressing health benefits...

      •  No. (1+ / 0-)
        Recommended by:
        April Follies

        But, these people do have higher premiums now.  They also have massively massively increased incidence of the health problems killing most people in the U.S. right now.  Smoking increases your risk of damn near everything.  Look, if you're not even making an effort to take some responsibility for your own health, you should do something to help offset the huge increase in costs to the system.

        We definitely need to do something, public-health-wise, about reducing the nation's addiction to 1000-calorie cheeseburgers.  I don't know what will work.  I see people at school all the time who are on oxygen but are still smoking; people who are seeing their physician for heart disease but are eating their lunch at the campus McDonald's (which shouldn't be there in the first place.)

        Incidentally, people already have to pay in other ways for their habits - frequently, lung tumors will not be removed until the patient quits smoking.  Maybe we could just make that a bit more public and people might think a bit more.

        Something's gotta give.  These lifestyle habits are one of the main reasons the US is so much less healthy than the rest of the industrialized world.

        Politics is like driving. To go backward, put it in R. To go forward, put it in D.

        by gkn on Thu Nov 30, 2006 at 09:14:04 PM PST

        [ Parent ]

        •  So how would you do it? (5+ / 0-)
          Recommended by:
          April Follies, SarahLee, dvx, Blissing, ilex

          I suggest positive measures rather than punishments.

          •  I have no idea. (3+ / 0-)
            Recommended by:
            April Follies, terran, Chris 47N122W

            Some people have suggested tax credits for achieving various health goals; most think that's ridiculous.  Maybe it would help.

            I'd start by overhauling public education, meals included.  Students would have some amount of physical activity every day and take a very detailed, comprehensive nutrition/health/human biology class, and they wouldn't graduate if they didn't get at least a C.  The way these classes are structured now (if they exist at all), students consider them worthless, pay no attention, and generally blow them off.

            Preventive programs, such as regular meetings with nutritionists, might help.  They seem to help diabetics control their illness.  Once again, though, you have the problem of getting people to keep regular, frequent appointments - and actually do what the nutritionist recommends.  

            Apparently, Big Macs just taste so good to many people that they won't quit eating them.  I wouldn't know; I'm a vegetarian.

            Politics is like driving. To go backward, put it in R. To go forward, put it in D.

            by gkn on Thu Nov 30, 2006 at 09:42:48 PM PST

            [ Parent ]

            •  sorry (1+ / 0-)
              Recommended by:
              ilex

              But I ain't gonna stop indulging in the occaisional quarter pounder with cheese every once in awhile...I dunno if I've been conditioned to like them from eating too much MickeyD's in my youth, though I prefer Burger King or Wendy's anyway :)

              •  Totally fine, (0+ / 0-)

                just don't eat them every day up to and after you have a heart attack...like some patients I see.  :)

                Politics is like driving. To go backward, put it in R. To go forward, put it in D.

                by gkn on Thu Nov 30, 2006 at 11:52:08 PM PST

                [ Parent ]

            •  Maybe the problem is a society ruthlessly based (2+ / 0-)
              Recommended by:
              terran, Hens Teeth

              on maximizing financial gain, which leads to two Americas--the investor class that works in a stimulating, professional environment, hires help to take care of mundane daily living tasks, eats healthy, small meals with lots of fresh vegetables and fruits and lean meats or fish prepared by others (except on weekends when they cook "for fun", exercises daily at an upscale gym; versus the wage-earning class who do not get to set their own hours, may have to work more than one mind-numbing job, are constantly worried about having enough to pay the rent and utilities, are simply too mentally exhausted at the end of the day to think about cooking or exercise. For some people a big Mac is comfort food--it's surely less harmful than an equal amount of whisky, which is what workers used to take comfort in at the end of the day.

              "All governments lie, but disaster lies in wait for countries whose officials smoke the same hashish they give out." --I.F. Stone

              by Alice in Florida on Fri Dec 01, 2006 at 12:42:14 PM PST

              [ Parent ]

        •  a quibble (1+ / 0-)
          Recommended by:
          April Follies

          But, these people do have higher premiums now.  

          Actually, most people have care through Group policies or through medicare/medicaid.  Group policies have to charge everyone the same regardless of health (HIPAA).  Medicaid is more likely to pay if you're sicker, and I assume Medicare doesn't charge more for bad health habits either.

          These lifestyle habits are one of the main reasons the US is so much less healthy than the rest of the industrialized world.

          I'm pretty sure that the US smoking rate is less than in most industrialized countries.  I could be wrong, though.

          I see people at school all the time who are on oxygen but are still smoking; people who are seeing their physician for heart disease but are eating their lunch at the campus McDonald's (which shouldn't be there in the first place.)

          I think you have to separate out smoking from the burger issue:

          • Because it's horribly addictive, a lot of people won't quit smoking even when their life is on the line.  If they won't quit in that case, why should we think that a couple hundred dollars a month will make them quit?  Indeed, they already pay a couple hundred a month in cigarette taxes.  
          • People have not woken up to the burger problem yet.  But it's not just the consumer that's at fault.  Like with tobacco, burger-producers are perpetrating a massive fraud on their consumers by presenting something as safe food when it's really a slow poison.  Maybe we need some burger lawsuits - like the tobacco lawsuits - to start slowing this trend.
    •  Standard payments (6+ / 0-)

      I think for a national system you have to move away from the thinking of the insurance companies where higher risk=higher premiums. If you try to assess somebody's risks you automatically have to have a large bureaucracy in place. This is exactly why insurance company costs are so much higher than the administration in socialized systems.

      What you can do is a benefits analysis before offering more expensive treatments. What good for example would it be to offer a liver transplant to someone who had no intention to stop drinking three bottles of spirits a day?

      You perhaps also point to a societal fault in the USA where the individual takes no responsibility for their own health but relies that one of the many pills they see advertised on TV will fix any problems they bring on themselves.

      •  I think, (0+ / 0-)

        in many respects, it's a total lack of self-control or desire to take responsibility for everything.  It's just like the neocons sending others to fight their war when there's not a chance in hell they'd fight it themselves.

        It really wouldn't have to be a huge bureaucracy.  If you smoke, if you're morbidly obese, if you refuse to take your meds and then wind up in the hospital for a hypertensive crisis, you pay a bit extra.

        As I said above, simply publicizing the fact that you won't get a liver transplant if you still drink like a fish (you already won't) might help solve the problem.  And, for godsake, let's end the direct-to-consumer pharma advertising!  (plus a lot of their egregiously expensive physician advertising)

        Maybe I'm just jaded from seeing so much easily preventable disease eat up resources that could be used to help people with problems completely/largely beyond their control.  I just can't figure out how to motivate people to take care of themselves.

        Politics is like driving. To go backward, put it in R. To go forward, put it in D.

        by gkn on Thu Nov 30, 2006 at 09:22:31 PM PST

        [ Parent ]

        •  The problem with that (3+ / 0-)
          Recommended by:
          April Follies, ilex, Hens Teeth

          is that the more we study genetics, the more we now many of these conditions are in some measure out of the individuals control.

          Take weight for example.  Environment has a lot to do with it.  But I am technically obese - and run about 3 miles a day.

          As my GP tells me - I lost the metabolism lottery.

          •  Very true. (1+ / 0-)
            Recommended by:
            April Follies

            But you're making an effort to take responsibility for your health, which should, I agree, be taken into account under the "conditions you can't help" exception I mentioned above.  Many, many, many people are not making any effort whatsoever.  

            And smoking, aside from perhaps a tendency toward addictive behavior, is not genetic.  It's a difficult habit to kick, but we've developed many effective ways of helping people to quit.

            Politics is like driving. To go backward, put it in R. To go forward, put it in D.

            by gkn on Thu Nov 30, 2006 at 11:56:06 PM PST

            [ Parent ]

            •  Who gets to judge whether or not I am taking (5+ / 0-)
              Recommended by:
              elfling, dvx, DMIer, ilex, Hens Teeth

              responsibility.

              That is a very scary road to go down.  I want no part of it.

              Neither will the country.

              •  Measures (4+ / 0-)
                Recommended by:
                April Follies, elfling, ilex, Hens Teeth

                You also get situations where the measurements used are totally inappropriate. As an example, just using Boy Mass Index as a measure of obesity would mean that a competetive bodybuilder with 5% body fat would count as morbidly obese.

                It also depends what you are going to offer in the way of care for the elderly. Ironically if you are looking at things in strictly financial terms, you ideal population would contribute throughout their working lives and drop dead immediately upon retirement. Most people's medical costs are concentrated in the last couple of years of life.

                •  Fine, get rid of the obesity exception (0+ / 0-)

                  (though we absolutely have to do something about it from a public health standpoint, and there are tons of not-poor people - in my family, for instance - who don't do a goddamn thing to take care of themselves.)

                  There's NO reason not to do it for smoking.   Cigarettes are expensive and becoming more so every day.  They increase your risk of things you probably never knew about - like, for instance, renal cell carcinoma.  It's absolutely ridiculous not to impose some sort of carrot-and-stick technique to get people to quit.

                  Politics is like driving. To go backward, put it in R. To go forward, put it in D.

                  by gkn on Fri Dec 01, 2006 at 01:26:50 PM PST

                  [ Parent ]

            •  You don't just wave a wand and know (1+ / 0-)
              Recommended by:
              ilex

              who is doing what. What you are ignoring is that gathering information--by itself--is a lot of work. You are talking about a system that requires gathering a lot of information, and also one that ends up (on average) charging poor people more than rich people, when all is said and done. (Those in the upper income brackets are most likely to fit your "taking care of oneself" ideal--it's so much easier to do if you're rich--the poor are far more likely to be obese and enjoy big macs rather than $u$hi.

              "All governments lie, but disaster lies in wait for countries whose officials smoke the same hashish they give out." --I.F. Stone

              by Alice in Florida on Fri Dec 01, 2006 at 12:48:26 PM PST

              [ Parent ]

              •  Then (0+ / 0-)

                do more of the farmers-market programs that are on the front page.  

                Whenever I buy chips in the grocery store, it immediately occurs to me that I could've bought a huge amount of fruits and vegetables (probably not organic) with the same amount of money.  Fast food is the only junk food that's cheaper.

                Politics is like driving. To go backward, put it in R. To go forward, put it in D.

                by gkn on Fri Dec 01, 2006 at 01:28:57 PM PST

                [ Parent ]

        •  It would be easier and simpler to tax cigarettes (1+ / 0-)
          Recommended by:
          ilex

          Than to try to do what you describe to health care payments.

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

          by elfling on Fri Dec 01, 2006 at 09:52:06 AM PST

          [ Parent ]

      •  It might be possible to charge taxes (2+ / 0-)
        Recommended by:
        April Follies, ilex

        on cigarettes and other problematic consumer goods and have the money placed in the healthcare trust fund.

        A smoker paying a $5 a pack tax each day will pay about $50,000 by the time he is 50.

    •  You've already dealt with obesity (3+ / 0-)
      Recommended by:
      April Follies, Alice in Florida, ilex

      Smoking is a physical addiction, which makes it a health problem just by itself - even independent of the consequences. IIRC, nicotine is in fact one of the most addictive substances - legal or illegal - used in our society.

      People who manage to quit smoking by themselves are certainly praiseworthy; however, those who don't are not deserving of blame, but rather therapy.

      And for the record, I'm one of those hardcore no-smoking-in-my-vicinity assholes.

    •  Fantastic novel expands on this idea (2+ / 0-)
      Recommended by:
      terran, Hens Teeth

      "Holy Fire" by Bruce Sterling is a SciFi book set in the near future, that envisions a world largely based on the ability to get health care.  Healthcare is free -- but you're only allowed to have it if you can prove you take care of yourself.  People who eat meat or smoke basically die young.  Those who have never eaten anything wrong, or ever taken a physical risk, are able to live incredibly long life spans.  The implications are a lot to think about.

    •  If it was about financial incentives (4+ / 0-)
      Recommended by:
      terran, d7000, ilex, Hens Teeth

      Why would anyone smoke at all? Cigarettes already cost money.

      Let's talk about other behaviors that increase risk.

      Cycling - my friend the long distance cyclist had an accident that resulted in a $50k knee injury.

      Driving more than average - Auto accidents are a huge risk and cost on the health care system.

      Pregnancy - women who have babies cost a lot more than women who don't.

      Fundamentally, despite a certain holier-than-thou attitude among people who want to say that they're better than the rest of us, every one of us engages in some sort of "risky" activity that could increase health costs. America would not be the better for telling people that they couldn't do anything that might increase their chance of an accident.

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

      by elfling on Fri Dec 01, 2006 at 09:23:23 AM PST

      [ Parent ]

    •  I'm okay with creating disincentives (0+ / 0-)

      for some negative behavior, but I don't think it should be directly tied to the availability of health care.  Plus there should be widely available mental healthcare just as a matter of course to help people deal with addictive or damaging behaviours.

      1. Continue to make tobacco products more expensive.  They are already rather socially unacceptable.
      1. Penalize restrauteurs that serve high fat/high sugar/low nutrient items over X percent of total sales.  They will pass on the cost, but I'm okay with that.
      1. For grocery items, tax high fat/high sugar/low nutrient foods and subsidize the cost of fresh produce.  I saw a study (wish I could find it) that showed the biggest coorelation between environment and childhood obesity was the availablity of inexpensive produce.  If you are poor you tend to buy what costs less.  If apples cost less than snack cakes there is a better chance that you will have apples in the house.

      The effect of these actions should be to reduce/limit smoking and consumption of "junk food".  People will still smoke, and people will still eat less healthy foods, but they might eat them less often if they cost more than good food.

  •  excellent series so far! (4+ / 0-)

    I am a healthcare provider (optometrist) who deals with the frustrations of dealing with insurance companies.  In my opinion there are two important distinctions you make here.

    First

    For the insurance company the main incentive is to not provide care; it is their fiduciary responsibility to maximize their profit, and this means denial of care.  Their profit is your no care.

    This is the most important, imho, and easily seen in doctors who complain about declining reimbursements and patients and employers who complain about rising premiums?  Where does the money go?  Just ask William McGuire...

    Second

    This would also more complete the separation of health care coverage from employment, jobs and business.

    I think this is a second failing of the so called "free market" model of health insurance.  Who really has choice when it comes to deciding health insurance?  If you choose the benefits offered by your employer maybe you have two companies to choose and then there is a choice of two or three plans within that (though the plans are tailored to "the single person," "the young couple" or "the family", so again your choice is made.)  Most probably aren't afforded that luxury.  So you are stuck paying for the plan that your employer chose.  If access is open and care is covered then you are going to have a real choice to get the best care, and conversely, it makes the providers compete to provide care and therefore attract patients, i.e. they are not "guaranteed" a pa ient base by subscribing to be a provider on one plan versus another.

    Overall these two diaries have been excellent and really created a useful framework to engage this community on the benefits of single payer health care.  I believe that this is a change that must happen and is a close second only to global warming as the most important priorities we face as a nation.

    Bravo!  (does PNHP welcome OD's too?)

  •  patient (3+ / 0-)
    Recommended by:
    terran, Tailspinterry, Chris 47N122W

    Dear Dr. Steve,

    Do you accept GHI health insurance in your practice?  If so, can I have an appointment?  If you're a proctologist, ignore this request.

    Seriously, thanks for being on the side of good.  The problem with your plan is the rich can already afford healthcare and they would fight any attempt to level the playing field. To get what you propose passed, we would need the large corporations that already pay 8.5+% to lead the campaign for healthy Americans.  

    I still feel there should be a small copay--not so large as to dissuade patients, but not so small as to make it too easy to go get superfluous care and meds.  I saw how crowded ERs became in the inner city--making for huge waiting times.  I know that Canada's system is better than ours, but I also know that it can take a long time to get an appointment in certain specialties.  No system is perfect, but ours happens to be the worst.

    •  At some point (3+ / 0-)

      I will write about the experience in Vermont in the mid-90's.

      Vermont made a serious effort to enact a form of universal care.  There was very real political momentum behind it, and Dean had made it his issue.

      The failure had many causes in Vermont, but what became clear I think was the closer you got to enacting an actual law, the more people turned away from it.  The bottom line is many people are happy with THEIR Health care.  They have a ton of worries about the system, and I think those worries are worse now, but this is a serious barrier to getting helath care reform enacting.

  •  Just had a procedure... (10+ / 0-)

    I just had lithotripsy to disrupt some kidney stones, and the billing process has been a nightmare.  I am a male in my 30s, so this was my first real experience with medical bills.  I am shocked at just how fucking complicated it is.  I have a STACK of filed claims from a three-hour period in the hospital.  There are multiple groups submitting claims (hospital, doctors, pharmacists, anesthesiologists, radiologists, urologists, etc)...and I had to point out to the insurance company that some groups were double billing (which they eventually cleared up).  I am lucky though...my insurance does cover 80% of all the costs with a cap of $2500/year on all expenses.  I do still spend over $4000/year for that coverage (6.4% of my salary, so a 2% tax instead would be a financial boon for me).  I would gladly pay the entire annual premium amount for some form of universal coverage.

    I consider myself "smarter than the average bear," so I cannot imagine the problems that the elderly or others might have in navigating the process.  Even just switching to a system in which there is ONE set of forms and ONE biller, it would be tremendously more efficient.

    I just don't understand why the big manufacturers in the States (that would be those guys in Detroit) aren't hounding the US government about this.  They would be so much more competitive if they could somehow restructure their health care obligations for the work force.

    The only war Bush is winning is on Science.

    by Mote Dai on Thu Nov 30, 2006 at 09:13:28 PM PST

    •  It is a nightmare (2+ / 0-)
      Recommended by:
      April Follies, SarahLee

      I dread it when anyone in our family goes to the hospital or even the doctor.

      With Medicare and the new policies all of them are different. Imagine figuring out those.  The info isn't laid out clearly.  

      Life is what you focus on. Let's focus on ending the war. After that the rest will be easy.

      by relentless on Thu Nov 30, 2006 at 09:28:45 PM PST

      [ Parent ]

      •  Ugh..don't get me started on Medicare/Medicaid (4+ / 0-)
        Recommended by:
        April Follies, SarahLee, terran, ilex

        An elderly friend of my mother, over 80, recently required surgery.  She had to be in the hospital for 3 days before the program would pay for the hospital time, but she didn't have money for that, so the hospital released her 24 hours after the procedure.  They wouldn't let her remain the other 48 hours before the benefits started.  Talk about a major gap in coverage.  To make it worse, she was evicted from her apartment that week as well (medical bills took priority over rent), so she really had nowhere to go after getting kicked out of the hospital.  My mom and aunt assisted her during her recovery time.  They had to drive her to another friend's house an hour away.

        The only war Bush is winning is on Science.

        by Mote Dai on Thu Nov 30, 2006 at 09:54:24 PM PST

        [ Parent ]

        •  Rent Has to Take Priority (0+ / 0-)

          Go ahead and let the bill collectors call....

          •  More (3+ / 0-)
            Recommended by:
            Mote Dai, terran, ilex

            And just to make sure I say it...I am sorry about what happened and hope she has somewhere to live now.. I've made similar choices before, and unfortunately the car payment was a higher priority than rent (I was looking for work at the time, and a friend kindly pointed out that you can live in your car, but you can't drive your house...and with the War on Public Transportation and the movement of employers to the suburbs, well, you are apt to need that car to get a job)

    •  I've been through a pile of tests at various labs (5+ / 0-)

      Now I have bills from hosptials, clinics, and doctors I never heard of to sort through.  The bills rarely match the insurance statements. And I get caught in the middle while insurance company and medical provider fight about whether or not they are on "the list".  It's a challenge to figure out what I owe, let alone pay it.

      Single payer can't come fast enough for me.

      "Davis-Bacon prevailing wage, I'm not sure what that is" Sen. Jeff Sessions

      by Hens Teeth on Thu Nov 30, 2006 at 11:17:02 PM PST

      [ Parent ]

    •  Imagine if you are really sick! (4+ / 0-)
      Recommended by:
      April Follies, terran, ilex, Hens Teeth

      Not that you weren't sick, but just imagine trying to handle all these bills while trying to recover from radiation and chemo, for example!

      I just got my letter from Blue Shield, and my insurance is going up to $500/month!

  •  Couple comments: (1+ / 0-)
    Recommended by:
    Chris 47N122W
    •  Perhaps carve this into more digestible sections -- revisit parts of this with more detailed discussion (even accounting for comments within the threads).

    I have not fully read through -- a bit wiped out -- but will print out.  Within that ignorance / partial awareness:

    • One effect of universal coverage and (immensely) simplified forms/administration will be that amount of care will be skyrocketed -- medical care providers will spend a fraction of the time they currently do worrying about insurance forms, reimbursements, etc ...
    • I am not a believer in no direct fiscal responsibility from the patient. Zero fees / copayments does encourage overuse.  In France, I pay about 22 euros for a doctor's call when I'm there. Free, would I go more often -- probably not, but there are those who would. In France, over-the-counter drugs are reimbursed by supplemental insurance if there is a doctor's prescription for them A good friend who is a doctor have people come at the tail end of their colds asking for prescriptions so that the supplemental insurance would pick up the 8 Euros they had paid -- and the supplemental insurance pays the 22 euros for the doctor's visit.  By the way, in the specific cases we laughed (argued) about over a bottle of wine, the patients were rather well off financially (but penny pinching).

    In any event, thank you for great work ...

    The Energy Conversation: Learn - Connect - Share - Participate: For a new dialogue on Energy issues.

    by A Siegel on Thu Nov 30, 2006 at 09:15:46 PM PST

  •  You have put a lot of thought into this diary. (0+ / 0-)

    Lawsuits could be less, because the medical care of those who have been damaged would be taken care of, but a lawsuit is justice for the injury, ruination or death of a loved one. The burden to the rest of the family needs compensation. The lawsuit should not be totally eliminated.

    There is nothing wrong with the government using the money in Social Security Trust Fund. It is set up that we can only loan that money, in the form of bonds, to the government, because those bonds are the safest place in the world to invest money.  Social Security earns interest every year on those bonds. What is wrong is the government is using th bonds to pay expenses.  They say it is going to be a burden to pay them back.  It would be better if they would use the money they borrow to finance college loans or something useful like that, that pays the interest, then there would be no pay back problem.

    Social Security needs to be kept separate, because the longer you work and the more you pay in, the more you get back, so the records need to be kept. There is also a larger percentage of benefit given to those who make the least so they will have a livable income when they retire. The payroll tax we pay keeps us aware that this is our retirement. FDR said he set it up that way so no SOBs could beat people out of their Social Security retirement. (that may not be the exact words, but close.) There are protections for Social Security written in the income tax law.  The republicans plot to get rid of that law.  Democrats shouldn’t let them do it.  Maybe it would work if the business was taxed for it with income tax and the worker with a payroll tax.  As long as the money from the employer matched the contribution of the worker and was deposited in the Trust Fund, it shouldn’t matter whether it came from income or payroll tax unless it would allow them to change the laws already there for Social Security.  The same would work for the employer paying unemployment tax on income instead of on payroll. But then, all of us would be paying for his expenses.

    Military  and national security spending should be taxed on income tax. (or better yet, charge user fees, let those who love war, finance it.)

    That percentage is more than we pay for Social Security, but if it actually covered nursing home and all the other things you say, it would be worth it.

    There is a trust issue that would have to be addressed and strict rules and regulations would have to be iorn tight, so certain people could not ruin the whole thing by jacking up the price.  We could end up paying more for less.

    Life is what you focus on. Let's focus on ending the war. After that the rest will be easy.

    by relentless on Thu Nov 30, 2006 at 09:19:06 PM PST

  •  Single Prayer Health care (0+ / 0-)

    is what the cons want.

    Assassin: Its worse than you know. Malcolm: It usually is. 宁静

    by TalkieToaster on Thu Nov 30, 2006 at 09:32:38 PM PST

  •  One FAQ needs fixing (0+ / 0-)

    Why shouldn’t we let people buy better health care if they can afford it?

    We will.  People with money can go to doctors and pay out of their own pockets, in cash, for treatments not covered by the national health system.  (As if we could stop that!)

    -5.63, -8.10 | Libertarian Liberal

    by neroden on Thu Nov 30, 2006 at 09:38:25 PM PST

  •  Good for business (5+ / 0-)

    A RELATIVE BARGAIN: George Mercieca, a worker at a GM assembly plant in Oshawa, Ontario, shows off his Canadian health care card. GM spends an average of $1,385 a year on medical bills for hourly workers in Canada. An American autoworker costs the company about $5,000, but studies show Americans are no healthier than their foreign counterparts.

    The General and the Beast

    In U.S., it's pay more, get less

    GM's health care costs are far lower in Canada, other countries

    Ron French / The Detroit News

  •  My husband's employer just informed us that (5+ / 0-)

    "our" portion of the insurance premium will go up again on Jan. 1 - for the 2nd time in 6 mos.  We will be paying double what we were in May.  The cost will be $6,000/yr for just 2 of us.  Instead they are pushing those health savings accounts.  What a disgrace that our healthcare system is in such a state and that this country has millions of uninsured citizens.  If this keeps up we could become one of them.  Great diary, thank you.

  •  the amount of care (0+ / 0-)

    Your discussion of rationing left me curious. There seems to be some discussion of the reasons why there aren't enough doctors and nurses. But even leaving aside the question of prohibiting luxury care (as you seem to do), isn't this basically just a redistribution scheme? In other words, does this plan do anything besides redistribute a fixed amount of total care "produced"?

    I realize that the plan counts heavily on savings to be had by excluding the insurance companies from the process, and also counts on "universal Medicare" to be as energy-efficient as it is supposed to be in its current role. And I imagine you expect eventual savings in the present uninsured group from preventive care.

    But under this plan, those who don't have insurance now will be given the same rights to draw from the fixed pool of resources as those who are currently on Medicare, AND those who are currently covered by employer-paid plans of all kinds. Medicare bureaucrats, lean and far between in your portrayal, will be confronted with even more wrenching choices than insurance company bean counters are now.

    Is there any specific program for increasing the amount of health care, so that we can go from deficiency to sufficiency?

    I have one other question - what are the specific differences between this plan and the one offered by Clinton in 1993, and Kerry in 2004?

    -10.00,-10.00. Beat that, motherfuckers.

    by frenchman on Thu Nov 30, 2006 at 09:53:37 PM PST

    •  The Clinton Plan in '93 (3+ / 0-)

      was a multi-payer system, which was largely to have been run by the States. I can't speak about the Kerry plan.

      Here is how the Clinton Plan would have worked:

      1.  The Federal Government would have set guidelines for what was covered.  
      1. The States would have been required to implement those guidelines.  Within each State insurance companies would have to show that their plan met the state and federal guidelines.  Alernatively, the State could chose to implement a single payer plan.
      1.  People would then have chosen from the plan or plans in thier state.

      I do not remember the funding mechanism for the Health Care plan.

      The main criticism of the Clinton plan was that it was too complicated.  

  •  You're way too left for my blood on this (0+ / 0-)

    You're over on the communist side. Not only are you wanting to destroy numerous companies (100,000's by my estimate) you actually want to ban the taking of profit for the provision of superior care, the number one most effective source of motivation for improvement in all of human history.

    Yes, the health care issue has to be solved. But FUCK NO we don't try communism redux in trying to do it.

    You can still be on the team, even if you're not in the choir.

    by peeder on Thu Nov 30, 2006 at 10:00:06 PM PST

    •  Well he is with about 83% of Americans (7+ / 0-)

      like me, who want Universal Single Payer Health Care.

      I personally prefer the Conyers Medicare for All bill, HR 676.

      It isn't communism.  It is providing for the general welfare of our citizens.

      Do you consider your fire department "communist?"  Once upon a time, fire departments were private companies and served only their customers.

      •  83% of Americans (0+ / 0-)

        answered that unlinked poll (if it was that), with an opinion that they wanted all those businesses banned and competition for profit from superior service quality forbidden.

        I think not.

        If there's one thing making excess money would be worth fighting for, better health is it. Period.

        You can still be on the team, even if you're not in the choir.

        by peeder on Thu Nov 30, 2006 at 11:25:04 PM PST

        [ Parent ]

        •  You don't eliminate competition for profit. (0+ / 0-)

          At least, not completely.  You're ignoring part of the equation of competion. Profit is not solely determined by the price set for services, but also by the volume of services provided.

          There have been two primary care docs on our same street, who though they were accepting the same insurances for the same pay scales as us, went out of business.

          Why? Because we're efficient in how we handle our time and appointments. Because we give good care.  Because we're nice. Because we kept getting tons of patients as a result, and their patients kept leaving. Thus, we did more patient volume, while they did less.

          None of that would change under a single payer system. Doctors would still compete for patients, and the ones who give superior care would still win.

          Democrats - We refuse to caucus in the missionary position.

          by SaneSoutherner on Fri Dec 01, 2006 at 03:03:11 PM PST

          [ Parent ]

      •  Btw the health equivalent of the fire dept (0+ / 0-)

        is the CDC, which is and should be a public institution. That handles diseases that can spread like fires. That's actually the exception in medicine (for things beyond common colds and flus).

        You can still be on the team, even if you're not in the choir.

        by peeder on Thu Nov 30, 2006 at 11:29:41 PM PST

        [ Parent ]

        •  No (0+ / 0-)

          The CDC is a research group. They don't actually treat or cure any patients.

          If we have an epidemic, or even a terrorist attack that injures large numbers of people, hospitals are going to be left with a lot of unpaid bills.

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

          by elfling on Fri Dec 01, 2006 at 10:01:42 AM PST

          [ Parent ]

      •  Watch what happens (1+ / 0-)
        Recommended by:
        peeder

        to those poll numbers when you tell them that single payer means that they cannot pay for thier own health care.

        Single Payer is a label that I don't think people fully understand.  It is one of many ways to get to universal coverage.

        •  What the hell are you talking about? (0+ / 0-)

          If people wanted to pay for their own care, they should be happy as clams now. Very few people can afford this. Anyway, people in countries with single payer can still pay cash for their own care if they want (or, if they're that rich, go overseas)--they just can't get private insurance.

          "All governments lie, but disaster lies in wait for countries whose officials smoke the same hashish they give out." --I.F. Stone

          by Alice in Florida on Fri Dec 01, 2006 at 12:55:29 PM PST

          [ Parent ]

          •  No they can't!! (0+ / 0-)

            In Canada it is illegal to pay someone for a core medical service, like an x-ray within the country.

            There is tremendous confusion here about Universal Health Care and Single Payer.  Some countries have UHC (England, Germany) without having a single payer system.

            •  There's more than one type of system (0+ / 0-)

              Maybe the confusion is what is meant by single-payer. If taken to the logical extreme, that no one else can pay, I guess that would be right. But what we all mean is getting rid of private health insurance. Maybe we should call it single-payer health insurance, because that's what we're talking about (even though it would be funded by taxes rather than premiums, there would still have to be actuarial assumptions for determining how much was needed to fund the system, expected demand, etc.) The point is to cover needed care for everyone, so that no one is unexpectedly bankrupted.

              Personally, I don't see a problem with charging a copay for services that is within reach of the average working person, say, $10-20 per visit (with an exemption for those below the poverty line). That would keep things accessible while discouraging overuse of medical services (people who bring their kid to the doctor every time he gets a cold).

              "All governments lie, but disaster lies in wait for countries whose officials smoke the same hashish they give out." --I.F. Stone

              by Alice in Florida on Fri Dec 01, 2006 at 06:01:51 PM PST

              [ Parent ]

            •  And one more thing (0+ / 0-)

              I sure wouldn't mind not having to--or even not being allowed to--pay for an x-ray.

              "All governments lie, but disaster lies in wait for countries whose officials smoke the same hashish they give out." --I.F. Stone

              by Alice in Florida on Fri Dec 01, 2006 at 06:07:59 PM PST

              [ Parent ]

    •  huh? (5+ / 0-)
      Recommended by:
      April Follies, d7000, DMIer, dmh44, ilex

      red baiting aside what 100,000 companines are hurt?

      other than insurance companies and drug companies, every other company in the country benefits.

      Also, once again, there would be competition on the delivery side (hospitals, clinics, group practices, offices). For profit is a funny word. for all the employees still make money, and have incentive to keep business open, and competitive.

      Just not organized as publicly (or privately) traded for-profit stock company, with perverse incentives (short term stock valuation).

    •  One company that won't be destroyed (6+ / 0-)

      Mine.

      I own a small business, and I am hit very hard by insurance premiums. We have a very minimal package we provide for our employees. We want to be able to give them more (like lower deducibles), not just for them, but so we can stay with our competition, who can offer their employees more.

      Any relief I can get here will be like oxygen.

      And for what it's worth, screeching "communist" at the diarist isn't really a very effective counterargument.  

    •  I think you misunderstand (2+ / 0-)
      Recommended by:
      dmh44, ilex

      The PNHP proposal would not "ban the taking of profit for the provision of superior care"

      That's a total myth that must be stamped out.

      Single-payer will ban profit-taking for basic health INSURANCE. Insurance has nothing to do with provision of superior care.

      Doctors and hospitals will still be able to compete on quality, thus making "profit for the provision of superior care."  While it is true that providers may not be able to compete on price under single-payer, it's important to note that doctor's don't compete on price today.  Instead, insurers set the price that a doctor receives for a service based on a strict fee schedule.  

      So under single payer:

      • ability to compete on quality is unchanged
      • ability to compete on price is unchanged.
      •  Not according to what's written here (0+ / 0-)

        Doctors today can charge more for their services. I go to a dentist that charges vastly in excess of insurance coverage. I go to doctors that do the same. I pay out of pocket for my choice.

        The best doctors will get more demand. The text says they'll just compete on quality, not price. This reflects a complete lack of comprehension of how economics works. The best in a market will not be able to meet demand. That means they filter demand by increasing the price. The ability to filter demand by raising price leads to profit. The profits so generated are the primary motivation for excellence in this system. Otherwise you are only motivated to generate demand equal to the clearing price for your supply.

        You can still be on the team, even if you're not in the choir.

        by peeder on Fri Dec 01, 2006 at 12:01:20 PM PST

        [ Parent ]

        •  Wow. What doctors are those? (2+ / 0-)
          Recommended by:
          dmh44, Hens Teeth

          I go to a dentist that charges vastly in excess of insurance coverage. I go to doctors that do the same. I pay out of pocket for my choice.

          That's pretty impressive.  I wonder how they convinced you to do that??

          My family is a very high-volume consumer of healthcare.  We see tons of specialists.  We never pay anything more than what the insurance pays.  We ALWAYS go to the doctors that are the highest rated in their specialties, in medical centers that are world-renowned for excellence in that specialty.

          ... so it sounds like you're gettin' ripped off, dude.

        •  That is very dependent on your insurance. (0+ / 0-)

          My plan only has in-network coverage, meaning that if I want to see someone that charges more/isn't in plan then I have to pay 100% of the cost myself.

          Doctors that are "in network" have to agree to a set fee for services negotiated by the insurance company.

          The only customers of a highly priced provider are likely to be folks who are well paid themselves and/or have superior insurance coverage.  

          By allowing different providers to charge different prices for the same procedure you effectively ration "superior" care, though I think there could be some argument over what makes a higher priced provider superior.

          I do like the idea posted above? about a program in Britain that pays physicians more for hitting "targets", such as improving cholesterol numbers in their practice, or getting a certain number of patients to be screened to prevent disease.  It sounds like there is a "base" salary and then the provider has the opportunity to make more.  I think providing a bonus for continuing education might be good too.

        •  You may want to check your.. (1+ / 0-)
          Recommended by:
          Hens Teeth

          docs insurance contracts.  If your doc is contracted with your insurance plan, it is not legal for him/her to charge you out of pocket over and above the contracted rate.

          Seriously, check on it.  You may be getting ripped off.

          Democrats - We refuse to caucus in the missionary position.

          by SaneSoutherner on Fri Dec 01, 2006 at 02:39:25 PM PST

          [ Parent ]

  •  My Two Cents (2+ / 0-)
    Recommended by:
    April Follies, SarahLee

    I love your Diaries and cannot wait for more they are like Chocolate  you just cant get enough  and want more, and do request that you re-post this one again due to earlier tonight I tried to log in and could not due to some sort of update on the server.

    As for the AMA I am disabled and see several doctors on a regular basis and have spoken to each of them and was advised that they refused to join the AMA and would advise any new doctors not to join due to restrictions that are placed on them by the AMA.

    I do have a problem with your diaries, and that is that they are posted here and not all over the USA were it needs to be,
    For years I have been reading about the concept of UHC but it has always been on a blog on the computer not everyone has access to this information we need to find a way to put this out so we can get more people on board  

    Just an Idea once you finish this series all here on Daily Kos and put together a professional package spelled out just the way you have here and all of use here at Daily Kos chip in and send a copy to every Congress Person and Senator, and once this has been completed we start an e-mail campaign to these same Congress Persons and the same for Senators  asking why if we can figure this out why not our elected officials’ and demand answers.

    Investigate, Impeach and Imprison the corrupt criminal enterprise known as The Republican Party.

    by unit24 on Thu Nov 30, 2006 at 10:08:54 PM PST

  •  Much of what we think we know (3+ / 0-)
    Recommended by:
    April Follies, SarahLee, Hens Teeth

    about healthcare is a result of a massive, long-term propaganda campaign. Like many other corporatist causes, the battle to maintain the healthcare system as a repressive mechanism for separating the middle class from its wealth has think tanks, big donors, and media shills overt and covert.  

    The debunking here is valuable.  Some of the lies:

    Rationing - clearly a scare tactic and inaccurate, a favorite talking point nonetheless.

    Costs - The main proponents of private insurance are ideologues and those in the employ of private insurance. They take a third of the health care dollar just to deny care and tie up docs. This diary has demonstrated that the costs could actiually come down.

    Incentives against overuse - People don't want to go to the doctor. Making doctor visits free won't flood doctors with healthy patients, this is another divisive slander. Why should only the poor be subject to to this disincentive, since if the costs are low enough to not be a barrier to preventive care, they will be negligible for large numbers of patients, and lonely hypochondriacs will still make the co-pay. Only the lonely hypochondriacs who are poor will be excluded. A commenter even delivers an anecdote about how "some people" would abuse it, in the expert opinion of his wine buddy, but not him of course.

  •  Our experience with mandated employer health care (5+ / 0-)

    We live in Hawaii where we have mandated employer health care for all employees who work over 20 hrs. per week. Sounds like it should be a good deal, right?

    Well, my husband's health care is covered by his employer, but because I am self-employed we have to pay the full difference between his individual coverage and the family coverage. That difference is $9,000 per year just for my 8 year-old son and myself.

    Meanwhile I'm constantly reading propaganda by the local insurance companies (there aren't very many because the stiff regulations discourage new insurers from entering the market) regarding how insurance premiums in Hawaii have always been lower than the rest of the nation.  I don't know anyone anywhere who pays as much as we do for two people on an employer group plan.

    I get no sympathy because it is my choice to remain self-employed.  When I attempted to discuss the issue with a reporter once I was told I should either go get a job, or move to the Midwest if I don't like paying for insurance here.

    Meanwhile small businesses are struggling to stay afloat because the premiums for their employees are so insanely high, and many have resorted to hiring twice as many part-time workers so they don't have to pay for benefits at all.

    The result?  In Hawaii -- which was nicknamed "the Health State" for its attempt to insure more people -- the uninsured rate has gone from 5% in 1980 to 10% in 2001. It's probably even higher now, but you only hear the propaganda and the legislature refuses to do anything about it.

    Something has to be done on a national level. Thank you for the diary, Steve.

    •  Exactly the British experience (2+ / 0-)
      Recommended by:
      April Follies, Me Again

      The earliest British National Insurance scheme only covered workers and not their families. The difficiencies were recognised as early as the mid 1920s but economic conditions meant that a true comprehensive system only came in in 1948 after the system was effectively trialled during WWII as part of the war effort.

  •  Again, refer to CA's single payer legislation (3+ / 0-)

    As in Part 1, despite the fact the CA chapter of your group Physicians for National Health Program strongly supports it, again you made no mention that the single payer wheel has already been invented in fully formed policy legislation that passed the California legislature this Fall only to be vetoed last month by our worthless Gov Schwarzenegger (whose #1 campaign contributors and lobbyists are private health insurance companies).

    Readers of your diary series (and esp CA residents) should know about this bill cooking in real-world terms in the world's 5th largest economy. Single payer (SB 840) will be back again next year and the year after that until it's signed by a future Gov. Debra Bowen or Gov. Jerry Brown or some other smart progressive.

    As I said in my comment to your Part 1 dairy, CA's single payer bill is not pie in the sky. The Lewin Group, a tough-minded economic watchdog, has given single payer in CA a thorough analysis and passed it with flying colors on its financial merits, saving the state $8 billion in the first year. Not only will the plan cover everybody at lower cost with no discrimination against pre-existing conditions but cost-savings for businesses will make them far more competitive, reduce job losses and without losing coverage.

    What a civilized idea! And all it takes is getting rid of profit-hungry insurance company middlemen and generating a large amount of public will which will not be hard if we can get the facts out to the people. But we're getting almost NO news coverage,  which makes it hard to counteract corporate anti-single payer propaganda. Money for our own "Harry & Louise"-style single payer media ad campaigns is hard to come by with grassroots bake sales.

    For new readers of your series, here's a link for overview of CA's single payer plan. Chop to the root of the link (www.HealthCareForAll.org) to prowl around for more info on CA's plan including the Lewin report and comments by the bill's brilliant and well-informed sponsor, state Sen Sheila Kuehl, to give you a real-world practical sense of how such a legislation works.
    ____________________________________

    Restore Our Freedoms! Nix warrantless surveillance in the lame duck session. Then get back our other lost freedoms in the Blue Wave Congress.

  •  two key facts (6+ / 0-)

    Thank you for writing on this important topic for our country.

    I think some of the strongest arguments boil down to two facts:

    Fact 1: only 5% of the population causes 50% of the healthcare expenses in any one year.

    These are people with very serious illnesses so cost cutting solutions like higher copays won't reduce their costs.  

    Fact 2: Over 30% of all U.S. healthcare spending for those under 65 years old goes to administrative expenses, not patient care. This compares to just 2% to 4% for the Veteran's Administration and for Medicare.

    Why? Because all the independent payers in our payment system for healthcare actually have a strong financial incentive to avoid those 5% who cost so much.  Each payer (insurance company) creates its own rules to screen out potentially expensive people and procedures.  We all suffer from these rules and exclusions and unbelievable red tape.  Doctor's offices and hospitals have to hire extra help just to deal with the paperwork and to try to get paid.

    All this bureaucracy and red tape doesn't give society any extra benefit, or lower costs. In fact, its goal is to screen out the very people who need these services the most - the very ill. And one day someone in your own family might well need that coverage. This is a threat that hangs over all of us, especially if we are between jobs or can't find a job with good insurance.

    Several independent studies have shown that if the U.S. went to a single payment system like Medicare has, the savings would cover all of the 45 million Americans who do not have health insurance now, for no extra cost.  In fact we might even get some money back. And this keeps the same medical care as we get today, with the same private providers.  In fact the system would have many other benefits - people wouldn't worry about losing coverage - we'd all be covered, all the time.  Doctors could focus on patient care and wouldn't have to worry about getting paid or which rules cover which patient. The system would be incented to support preventative care which is not only cheaper but saves patients a lot of pain and suffering.

    It's clear to me, as a businessman, that the system of healthcare payments we have now is a fatally flawed design, which has created this Frankenstein of bureaucracy.  It wastes 25% to 30% of every healthcare dollar we spend, for no benefit to society. If we just fix that alone, we could cover everybody with the same private care the rest of us get now.

    We just need to get past the false notion that "free enterprise competition" exists in healthcare. It doesn't and never will.

    Here's some more information from a group I've volunteered with in Washington State:

    Healthcare for All - Washington presentation

    The Lewin Group report for the state of California

  •  Why do we ration the number of doctors in the US? (1+ / 0-)
    Recommended by:
    relentless

    Very informative.

    Even better than Part 1

    You probably missed my comment on Part 1 so I will ask it again

    Why does America literally ration the supply of medical doctors and doesn't this practice in and of itself raise costs and reduce the level of care.

    It's 3:30 AM here on the East Coast and I don't have the reference for this handy right now but it is in the earlier comment and I will provide the web address if anyone would like it.

    No other country controls the supply side of medicine and the only reason I imagine we do is to keep doctor salary's higher than free market forces would dictate.

    If we capitalized medicine better we might not now be faced with having to socialize it.

    When we fix the system, let's fix all of it.

  •  For capitalism to work it has to be (4+ / 0-)

    a competitive market. They say that charges would have to go up if there were more physicians because they would have less patients.

    Those who don't have insurance are charged more than those who do, by physicians and hospitals.  They write off half the charges for the hospitals.

    That makes more people have to take out insurance.  That makes the insurance companies less competitive.

    What we have is communism in reverse in our business structure. They take from the lower classes and give to the rich. They rob with the point of a pen or typed legal paper.

    I call it commutilism or capturism.  Lay that on those who don't want single payer health insurance and say it is socialism.

    Life is what you focus on. Let's focus on ending the war. After that the rest will be easy.

    by relentless on Fri Dec 01, 2006 at 01:52:33 AM PST

    •  If OPEC Pumps More Oil, the Price Goes Down (1+ / 0-)
      Recommended by:
      April Follies

      If the AMA and the Congress allow doctor demand to dictate doctor supply, instead of rationing the supply as is done now, the the cost of medical services will go down, while the quality goes up.

      It's Adam Smith's Invisible Hand.

      This is the referenced article

      http://www.usatoday.com/...

      •  Not really. (1+ / 0-)
        Recommended by:
        terran

        Do you shop for your doctor based on price?

        People pick their doctors in all kinds of arcane ways... but viewing the pricelist ahead of time is not usually one of them.

        Actually visiting a doctor is actually the lowest portion of our (considerable) expenses this year. The majority of the cost was diagnostic procedures like CAT scans and X-rays, medications, and then the fee for simply walking in to the hospital.

        In your area, do doctors advertise with coupons and weekly price specials?

        Healthcare services aren't a free market because there is little to no information about cost or alternatives available to the patient, nor does he have the time or energy to shop if he's sick.

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

        by elfling on Fri Dec 01, 2006 at 10:08:21 AM PST

        [ Parent ]

        •  I was around in '48 (0+ / 0-)

          You are making my point.

          I was around in 1948 when Harry Truman tried to bring National Health Care to the United States.

          The AMA went nuts calling it a communist plot to Socialize Medicine.

          We don't want to Socialize medicine. We want to take it out of its socialized cocoon and capitalize it.

          We want doctor supply to match doctor demand and we want doctors to try and offer better products ( spell that health care outcomes ) to their patients.

          Right now we have the very antithesis of a free market medical system and just as always happens with these kind of systems, it produces a terrible product at a horrific cost.

  •  So what are you going to do for an encore? (2+ / 0-)
    Recommended by:
    April Follies, Mary Mike

    Because this diary will be hard to top!

    Seriously, thanks for this comprehensive and readable summary of how universal health insurance works. Living in a country with a universal health care system (Germany), I can only confirm everything you've written.

  •  Well Crap Dr. Steve (2+ / 0-)
    Recommended by:
    April Follies, Mary Mike

    I feel like I'm reading one of my blog posts over at BlueNC about NC's PNHP chapter, except you do such a better job.

    Keep hammering.  I'm writing one or two health care diaries a week now and we're starting to send out weekly info blasts to NCCDHC members (and hopefully PNHP members soon).  Educate and advocate.

  •  This is a great series on a tough issue. (2+ / 0-)
    Recommended by:
    April Follies, barbwires

    I appreciate the work that has gone into this and you've nailed the theory of risk in the current system.  It's as good an explanation of community rating as is out there.  Well done and recommended.

    Bush 41 to 43: "See, Son, your problem in Iraq is the same one I had with your mother: neither one of us pulled out in time."

    by mattinla on Fri Dec 01, 2006 at 03:08:19 AM PST

  •  Excellent diary (1+ / 0-)
    Recommended by:
    April Follies

    One very minor correction:  In the "won't competition be impeded" section you say "Patients are in position to be full informed and free independent consumers"  I think you mean to say patients are NOT in a position to be fully informed...

    Which of course we aren't-try getting the cost of a major medical procedure in advance.  Or doing without one if you really need it.

    Democrats give you the Bill of Rights; Republicans sell you a bill of goods!

    by barbwires on Fri Dec 01, 2006 at 03:58:36 AM PST

  •  regarding "opt-out" (1+ / 0-)
    Recommended by:
    April Follies

    My view is that one cannot have an opt-out system which would allow the for-profit sector to continue to skim of the healthy and wealthy.  The whole point of insurance is to spread the risk. Therefore, the pool of people paying and covered has to be universal, the whole U.S.  However, this being the U.S., the freedom to purchase some sort of supplemental is probably inevitable.

    IMO, anyone who is rich can pay cash for extra care/services.  They do now anyway.  

    and regarding some small businesses paying more for payroll deduction...
    Many small businesses who are not paying or employees healthcare are still paying for their own, their family and key assistants.  When those costs are lowered I would imagine it might more than make up the difference when they have to start paying 7 percent for employees.

    •  Also the administration time (0+ / 0-)

      A business can easily spend 100 hours of administration time in selecting and managing a health care plan over a year, not counting employee time to fill out forms. That time could be better spent focusing on the core business.

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

      by elfling on Fri Dec 01, 2006 at 10:11:06 AM PST

      [ Parent ]

  •  phooey... yo' moderators (0+ / 0-)

    this only stayed on Rec list overnight.

    not to be too much of diary whore, but I only posted it last night. After this amount of work and strong positive reaction, I was hoping it would stay on Rec list for 24 hours, at least through Friday daytime. Hrrummph.

  •  nevermind... can I delete the above; my apologies (1+ / 0-)
    Recommended by:
    RunawayRose

    not sure what happened.
    i feel like emily latella.

    •  There are no mods (0+ / 0-)

      You just have to choose a good time to post your diary.  If you write it in the PM, and you are able to respond during the daytime, then you should wait until the AM to post it.  

      It's based on recommends and recommends over a certain period of time, or some weird thing like that.

      I don't really get it, but you have to be thoughtful about when you post the diary.  

      Disease is a liberal plot.

      by otto on Fri Dec 01, 2006 at 07:57:36 AM PST

      [ Parent ]

  •  I don't understand (0+ / 0-)

    how this diary thing works. This was interesting and getting a lot of recommends and comments. Now it is off the front page. Most people read the front page only.

    I have learned to comment, as soon as I can, in the Diaries of interest to me, then it is easy to go back to the diary from my page that lists comments.

    It is interesting reading other's ideas and new comments, though.  

    Life is what you focus on. Let's focus on ending the war. After that the rest will be easy.

    by relentless on Fri Dec 01, 2006 at 06:34:42 AM PST

  •  It is still on the front page (0+ / 0-)

    I guess I missed it. Sorry

    Life is what you focus on. Let's focus on ending the war. After that the rest will be easy.

    by relentless on Fri Dec 01, 2006 at 06:38:04 AM PST

  •  I'd just like to put in a vote (1+ / 0-)
    Recommended by:
    terran

    for a federally-managed system, as certain states wouldn't support reproductive care if not required to do so.

    This was a spectacularly informative diary, though.  I hope you keep it up.

  •  hmmm.... just off the top of my head (0+ / 0-)

    1.  Will the private practice of medicine be banned under this approach?

    Yes.

    You can make it sound nice and idealistic, but in effect that is what you have done.

    2.  How excited will my doc be to practice if his income is cut?

    Hard to say.  If he doesn't like it, he can retire.

    Fact is, you can't point to any place on earth with a single payer system where the docs make anywhere near what they make here, despite all the mythical "administrative efficiencies".  But since it's for "the good of society", I guess my doc, in a spirit of socialism, will readily assent to it.  If not, tough.

    3.  How long am I going to have to wait for an MRI, or for a hip replacement or dialysis if I'm over 65?

    For the MRI, since we're targeting Canada as a benchmark, you'll have to wait 6-9 months.  On the hip and dialyzing -- well, some things we just can't afford any more.  We have a budget to hit, after all.  The hip replacement will not prolong your life, and therefore its denial will not affect society's overall mortality rate.  As for the dialysis, reflect on whether you have actually lived a full life, and that it may be time for you to die of uremia.  Works for the Brits.

    If you think people will find this acceptable once they learn of it, you should consider a 72 hour hold.

    4.  What evidence do you have that malpractice premiums will be cut under this plan?

    None.  We just say so.  Essentially we can't do anything about that, since the mere use of the words "tort reform" sends a shitstorm of trial lawyers to Washington, and since they form the backbone of Democratic Party fundraising we have no hope of passing this without kissing their butts.

    5.  What about the tens of billions of dollars of shareholder value represented by the health insurance companies?

    Tough nuggies.  Well, only rich people own stock anyway.  If the price of this grand social experiement is bankrupting several billion dollar companies, well so be it.

    "We got [Lieberman's] ass out of the Democratic party. So we did our job." -Markos Moulitsas, 10/26/06

    by jimsaco on Fri Dec 01, 2006 at 07:26:29 AM PST

    •  You should check some facts. (2+ / 0-)
      Recommended by:
      April Follies, dmh44

      If medicine is so good here and so bad elsewhere, why is it that the US ranks at or near the bottom when compared to other industrialized nations ( all of which have national health care ) for

      1. Life Expectancy at Birth
      1. Infant Mortality Rate
      1. Cardiovascular death rate, which is worse than the average by 170,000 extra deaths per year and worse than the best by 315,000 extra deaths per year.

      A lot of doctors in this country get to become doctors the same way Bush got to be president.

      Because daddy was a doctor.

      They don't have to know medicine and there is no penalty for practicing it with deadly results

      •  response (0+ / 0-)
        1.  You can't compare small countries with homogeneous populations, to a large country with a very heterogeneous population.
        1.  Generally infant mortality is under-reported in much of the world, various standards exist, many live births if the baby does not meet certain criteria are classed as stillbirths and thus don't hit the infant mortality stats.  We are more particular and have better NICU capabilities.
        1.  Explain how socialized medicine will reduce cardio mortality by even one person.  We are the fattest, laziest people on Earth probably.  Middle class, currently-insured people are not treatment compliant with respect to cardio issues -- they don't lose weight, don't exercise, smoke too much, drink too much, etc.  What makes you think that the currently uninsured (lower income, less educated) population will be More treatment compliant?  Hint:  they won't be.  

        "We got [Lieberman's] ass out of the Democratic party. So we did our job." -Markos Moulitsas, 10/26/06

        by jimsaco on Fri Dec 01, 2006 at 01:12:58 PM PST

        [ Parent ]

        •  Re: #3 (0+ / 0-)

          Bullshit.   That's a stereotype to end all stereotypes. Those who are uninsured now are not less likely to be compliant with good care.

          Some of our most conscientious patients are our poorer patients. Some of our worst as far as health management goes drive Mercedes. The very best, most responsible diabetic we ever cared for was a mildly retarded man.  He showed up like clockwork every three months with a detailed bloodsugar list and a diet log.  Perfect control of his diabetes.

          Meanwhile the executives with pricey insurance often don't bother to follow instructions and get pissed at the doctor that there is no "magic pill" that will get their sugar below 250 while they eat what they want.

          High income/intelligence does not = good and conscientious patient, and low income/intelligence  does not = lazy and noncompliant patient.

          That idea is bogus, classist,  and full of crap.

          Democrats - We refuse to caucus in the missionary position.

          by SaneSoutherner on Fri Dec 01, 2006 at 02:50:30 PM PST

          [ Parent ]

        •  Japan is a pretty homogeneous ountry (0+ / 0-)

          Japan is a homogeneous country of a size similar to the US and they smoke like chimneys.

          Yet they have far better health stats and are one of the three best for cardivascular health.

          On a more general note.

          I think we have to have metrics to judge the relative merits of competing alternatives.

          Life expectancy at birth, Infant mortality rate, and cardiovascular death rate seem like great metrics to use to measure the relative merits of competing helath care systems.

          If you would suggest something like the number of BMW's owned by physicians, of course, that would slant the argument the other way.

          Even on a percent of GDP basis rather, than a pure dollar cost basis, we have the most expensive health care by far and it is very poor care at that.

    •  Respectfully (6+ / 0-)

      When I've heard doctors talk about this, they have said that even if their individual payments are reduced in cost to the patient, they will likely earn the same they are making now, because they will get to fire all their bill collection services, and the lawyers and services who work with insurance companies.  

      I can't even imagine how much money is spent a year on medical collection services by doctors.  

      Disease is a liberal plot.

      by otto on Fri Dec 01, 2006 at 08:00:40 AM PST

      [ Parent ]

    •  time for facts (5+ / 0-)
      1. No. Call this number 416-351-3300 (Canadian Doctors for Medicare) and ask some Canadian physicians if they practice private medicine.
      1. See 1., and add this question.
      1. Those numbers are Fraser Institute garbage. Visit PNHP's handout on wait times.
      1. Why don't you bother to look for yourself.
      1. They get returned to the shareholders to invest in useful things.
  •  Dr. Steve (7+ / 0-)

    I purchase health benefits for over 10,000 higher education employees and can tell you for certain that the proposed tax to the employer in your scenario would reduce our monthly per employee cost by approximately 50%, based upon our payroll numbers.  So for 10,000 employees our current cost is $882 per month per employee.  Reduce that cost by a projected 50% to $441 on average (per month per employee) for 10,000 employees.  

    Do the math and the result is 10,000 x $441 x 12 (months) =

                                                      $52,920,000 !!!!

    52 Million!!! This huge number would be an unbelievable boon to taxpayers generally, higher education (in this example) and the employees involved.  America this is a needed reasonable and invaluable solution.

    Great work Dr. Steve and PNHP!

  •  Add in Life Insurance (2+ / 0-)
    Recommended by:
    peaceandprogress, ilex

    ... my crazy idea is to require any entity that offers any sort of health insurance must also include life insurance.  Give the system some direct incentive to keep people healthy!

    Never wear your best trousers when you go out to fight for freedom and truth. -- Henrik Ibsen

    by mik on Fri Dec 01, 2006 at 08:28:53 AM PST

  •  Very informative, thanks!, but one "heartless" (0+ / 0-)

    question.  Or maybe you answered it and I just read the diary too fast.  And I ask because I think other people might be interested too.  And just FTR I am a supporter of single payer.

    If single payer for individuals is to be financed through the payroll taxes, how would this work for dependents?

    If I am a single person with no dependents, shouldn't I pay less into the national healthcare system than a father of five, for example?  If not, why not?  

    The way the current tax system works, people with children and dependents pay less of a percentage of tax than people who don't (somewhat counterintuitive to me because parents with children consume more publically financed services in the first place).  

    So, how could single payer be implemented to insure more fairness at least in this one area for single people with no dependents?

    Help keep America a one party state - vote Republican! (-6.25, -6.92)

    by AndyS In Colorado on Fri Dec 01, 2006 at 08:30:01 AM PST

    •  You aren't paying for kids (1+ / 0-)
      Recommended by:
      ilex

      They cost a fortune. Don't complain.  Someone will have to work to pay for your sScial Security and Medicare when you're old.

      •  Actually, I'm not complaining, just asking a (0+ / 0-)

        question.  

        In my admittedly limited fiduciary sense, it would seem to me a married couple having two kids are merely replacing themselves and in an ideal tax world that would be "neutral" in a generational-tax sense.  It's equivalent to "letting it ride" or leaving one's existing chips on the table in a poker game.

        While a person having more than one child is creating a future taxpayer, they are also adding to the taxes everyone pays in the present.  One is adding "chips" that someone else or many someone elses have to partially pay in a tax sense.  And again, in a strictly fiduciary sense, paying more in the present is worth more than getting your same money back in the future.

        A married couple having only one child or a single person having no children is, in effect, removing chips from the table in a long term tax sense, allowing the government to "cash in".  

        Yet if we pay more taxes percentage wise than a married couple with, say, five children, then factored in over two generations, people who don't choose to reproduce are funding not only their own stuff (like Social Security and Medicare), then it would seem to me they are also funding other people's decision to raise children, everything else being equal.  Again, as I said, I'm not complaining, just asking a question.

        If one accepts the proposition that setting aside common services (I'm not a libertarian) everyone should pay for their own choices then a person deciding to have a child should have to be responsible for their choice.

        Help keep America a one party state - vote Republican! (-6.25, -6.92)

        by AndyS In Colorado on Fri Dec 01, 2006 at 09:14:16 AM PST

        [ Parent ]

    •  We tax income, not people (2+ / 0-)
      Recommended by:
      elfling, ilex

      If your kids work (or receive capital gains or interest), they get taxed, too.

      So your question isn't really about kids, per se - it's about whether we should adjust the tax system to take into account those who receive benefits but don't get any income.
      Old people would be present much bigger present-day deficit than kids in that analysis.  Kids get very little from the federal govt.  A little extra education funding, and the protection of the army, etc.  Even with single-payer, kids healthcare is really, really cheap (for most kids).  Old people are really, really expensive - and they don't pay taxes, either.

      I have a different answer from a philosophical point of view: People should pay taxes on income because income is indicative of the amount of benefit a person is receiving from the government.  

      If I make $200k a year as an attorney or corporate manager, then the roads I drive on, the peace and security I enjoy, and the well-regulated capital market I invest in, are all worth $200k to me, minus whatever I would make without those things.  Without peace and security, good roads, and a well-regulated capital market, maybe I would only make $10k (not much call for attorneys or corporate managers in anarchy).  In that case, government is worth $190k per year to me.

      In contrast, if I make only $20k, it's possible that I am doing a job which would still be worth close to $20k even without good roads, a well-regulated capital market, and peace and security.  For instance, maybe I am a child-care provider or a busboy.  In that case, good roads, a well-regulated capital market, and peace and security are only worth $1k-$2k to me.  

      Thus, paying a graduated percent of income is a good estimate of what government is actually worth to a person.

      Note: because my kids' income is really my income, I'm paying income tax for them too.  If you ask: should I get an extra exemption for having kids?  I have to answer: probably not, under this analysis.  But the exemption probably serves other public policy objectives, like ensuring that kids have enough to eat and stuff.  Maybe then the exemption should only apply to people up to a certain income.

      •  All good, but let's have more clarity on what's (0+ / 0-)

        being done tax wise to us and for us and in our names.  I certainly have no problem with the idea of progressive income tax per se.

        I know it sounds heartless to some people to even ask about tax fairness for singles.  Who wants to be a scrooge and make little children suffer, even if they aren't ours?  That's certainly not what I'm about and I doubt most singles are either.

        While you're absolutely right, we tax income, not people, it should be a fair question to ask whether singles have to fund more of the government's operations over a lifetime (or, really more accurately a family over two generations) relative to the lifetime burden they pose compared to others.

        Or, put perhaps another way, how much should people be asked to pay in taxes for population growth.  There are important environmental concerns even to answer in that regard.

        So, for example, whether old people get more money from the government than they put in wouldn't be at issue for me, it's more about the average amount that person contributed versus how much they "cost" for a lifetime.

        This particular question I ask is not to me about what it costs the government versus what they collect, it's about what people have to pay in relation to the relative burden they pose relative to others.  

        Then, with the question answered, people can decide for themselves if a particular demographic group pays more or less, is it good and right to have them do so.

        If supercomputers can model such complex phenomena as weather then certainly we can develop a tax computer model to answer it.

        In the single payer health arena, I don't consider it a derailing or off-topic question because if it's funded through payroll taxes the question is magnified.

        Help keep America a one party state - vote Republican! (-6.25, -6.92)

        by AndyS In Colorado on Fri Dec 01, 2006 at 10:07:19 AM PST

        [ Parent ]

        •  If it's through payroll taxes (0+ / 0-)

          based on a percentage of income (with no cap), then it's not how much you use but how much money you make. If you make a lot of money, you're benefitting from the system (I mean, the whole thing, not healthcare but the U.S. economy/corporate system). After all, that's how income tax is levied.

          Consider, also, that the real "jackpot," if you will, of health insurance is the person who turns up with an expensive-to-treat, major illness (something necessitating a series of major surgeries, or an organ transplant): a single person with such a condition can cost more in a year than a whole family without such conditions would incur in 20 years.

          "All governments lie, but disaster lies in wait for countries whose officials smoke the same hashish they give out." --I.F. Stone

          by Alice in Florida on Fri Dec 01, 2006 at 01:23:28 PM PST

          [ Parent ]

        •  Too many variables to be fair. (0+ / 0-)

          I don't know how this could ever be exactly a fair deal.  

          Does our single subject suffer some calamity that causes them to become invalid early in life?  

          Do the parents of the family raise and educate their children to be net contributors to society?

          And what about old age?  How many children on average help out their aging parents and so save the government money that would be spent for care and services?

          I just don't know how you can be completely fair with taxes, e.g. paying in exactly what you get out.

      •  Work is taxed more than Investments (2+ / 0-)
        Recommended by:
        ilex, Hens Teeth

        And the very rich get richer without paying their fair share. It's wrong to tax labor more than sitting on your ass managing your portfolio.

  •  quality assurance... (1+ / 0-)
    Recommended by:
    elfling

    One thing I have noticed in the comments in these diaries, and had not expected, is a great interest in/concern with quality of care related issues. Unfortunately, a lot of misperceptions, among others that malpractice suites, torts, etc have much to do with quality control.  Also that somehow single payer would be bad for quality.  I am a pediatrician but do very little direct clinical work. My direct day to day work is in quality improvement, quality assurance, outcome base performance analysis... so I guess I will have to do a diary on this subject.  The quick answer is to have systems in place that reinforce conducting evidence based medicine, and catch bad practice.  We actually know how to do this, do it more and more, even in current (non)system. Use of clinical practice guidelines and office tools in day to day practice, and after the fact tracking of both service delivered (did diabetes control, HbA1c, get checked 4 time per year... or not) and clinical outcomes (is diabetes in control; HbAc<=7).</p>

    Everybody from for profit HMOs to VA does this sort of thing... at the patient tracking level, at the individual practitioner level, and at the practice level.

  •  These diaries (0+ / 0-)

    should be a must read for the entire US!

    Phinz to the left!

    by eweedin on Fri Dec 01, 2006 at 10:13:28 AM PST

  •  What about Medigap? (1+ / 0-)
    Recommended by:
    ilex

    My understanding is that everyone over 65 gets Medicare, and then you can buy a supplemental policy on top of that to cover what Medicare doesn't cover.

    I have no problem with the supplementals not being allowed to cover what the govt covers.  But if I want one of these gourmet physicals that cost $10k but do all sorts of tests instead of my standard physical then I should be allowed to pay for it.  

    If you say that people of means should never be able to get any better healthcare then the govt system you will never get buy-in because too many people in the middle and upper classes who currently have PPOs because they cover all sorts of "out of network" procedures at a partial rate will not support it.  If I have health insurance and I'm not as left-leaning as I am personally, why do I care if some poor sot somewhere else doesn't?  I'm not going to give up my good healthcare so someone who has none can get mediocre healthcare.

    So from marketing perspective I think you have to allow people to buy policies that add onto what the govt covers (not replace) - this way the "healthy" are still in the govt pool and the "wealthy" may have some extra coverage.

    -Fred

    Democrats *do* have a plan for Social Security - it's called Social Security. -- Ed Schultz

    by FredFred on Fri Dec 01, 2006 at 10:23:51 AM PST

    •  I agree, and don't oppose.. (0+ / 0-)

      the ability of those with more money to get supplemental insurance should they choose.  The thing that would skew the system, in my mind, would be to allow alternative private insurance - i.e. the ability to opt out of the single payer plan altogehter,  in favor of entirely different private coverage.

      In allowing supplementals, the single payer plan would still in all cases be considered the primary insurance, and would be filed (and paid) first.  Any services not covered  could then be filed to the supplemental private insurance, as well as any copays, deductibles, etc.

      It's how Medicare/Medigap works now, and while it does allow a bit of a perk for those with the money to afford it, it doesn't truly skew the system. The lion's share of basic services still fall under Medicare, so even those with more money still have a vested interest in the plan.

      Democrats - We refuse to caucus in the missionary position.

      by SaneSoutherner on Fri Dec 01, 2006 at 10:39:24 AM PST

      [ Parent ]

      •  this phenomenon has been studied (0+ / 0-)

        In Australia by Steven Duckett, and the result is always the same: allowing people to "buy-out" of the system always creates worse waiting times.

        Why?

        Because allowing a private parallel system doesn't create health system capacity, what it does is let rich people buy their way to the front of the line, and gives providers an incentive to leave the public system. Banning duplicate private insurance coverage is 100 percent needed

        •  Okay, I agree. (0+ / 0-)

          Care should be rationed by need, ie the sickest should be seen first and the non-essential stuff should wait.

          But explain to my economist husband why he should not be allowed to pay extra to jump the line if he wants to.... He says his time is worth something. He also argues in favor of co-pays to keep people from clogging up the system unnecessarily.

          I (the original commie mommie) just think that it is an immoral crime to sell health care to the highest bidder. You can imagine we have interesting arguments!

          (-6.63, -6.15) "And as things fell apart, Nobody paid much attention"--Talking Heads

          by terran on Fri Dec 01, 2006 at 01:53:33 PM PST

          [ Parent ]

          •  sure, and remember (0+ / 0-)

            that we're looking at a system that currently spends DOUBLE what the next highest spending country does on care. With the capacity that could buy, your husband should be able to sleep easy knowing that there will be virtually no waits for care.

            And in fact, co-pays have been determined to reduce useful care far more than eliminating them provokes useless "unnecessary" care. If he / you are ever interested, a research team from the University of Manitoba looked at this once, and found that their province's universal access system didn't allocate resources inefficiently at all, as the conventional wisdom might dictate. You can find both studies here.

        •  Agreed. (0+ / 0-)

          That's why I say a supplement for additional non-covered services is fine, but not duplicate primary insurance.

          Democrats - We refuse to caucus in the missionary position.

          by SaneSoutherner on Fri Dec 01, 2006 at 02:01:46 PM PST

          [ Parent ]

  •  This is the definition of what deserves to be (1+ / 0-)
    Recommended by:
    rhubarb

    on the Reco List.  The contrast between this seriousness and importance of this diary and some of the divisve nonsense sharing space on the Reco List is overwhelming.

  •  Question/Concern (1+ / 0-)
    Recommended by:
    OffTheHill

    I'm very concerned about physician compensation under a single payor model. Medical school education, particularly if you decide to specialize on a particular area, costs a lot even if you go to a state school. Virtually everyone who graduates from a medical program assumes the burden of extraordinary debt. It makes sense that fewer people would sign on for the rigors of medical training and whopping debt incurred if their ability to pay off that debt is hampered by capping salaries at a level which makes paying of loans that much more of a burden, and/or removing a potential financial upside.

    Next, why shouldn't smokers and the morbidly obese be penalized in some fashion for their habit or condition, which are well known to contribute directly to any number of medical conditions (from preventable causes), which in turn lead to greater consumption of costly medical services?

    Does anyone have any sense of how, if at all, a single payor/universal health model might impact illegal immigration along southern border states?

    "Imagination is more important than knowledge" - Albert Einstein

    by Citizen Earth on Fri Dec 01, 2006 at 11:46:12 AM PST

    •  on smokers and the obese (2+ / 0-)
      Recommended by:
      Citizen Earth, ilex

      Rather than punishing individuals, many of them poor, why not tax the products that cause health problems?

    •  Good questions (0+ / 0-)

      Education costs should be government subsidized for three reasons: a) increase supply of American medical professionals; b) allow guidance of students into areas of anticipated need, such as nursing and primary care; c) remove the argument that because of high cost and high risk assumed by medical students, they deserve very high salaries, which ultimately cost us much more over the course of a career.

      Penalizing smokers and the obese is a seductive option, but let's not get sucked in. Why penalize the mentally ill, many of whom smoke? Why not go after people who invest and/or work in legal but polluting industries? Or people who use electricity, because it requires mining and burning coal, which has lots of adverse effects?

      Immigration impact is tricky. One way to handle it is to require proof of legal residency for a period of time-- say, two years-- before the full range of services are available. But putting provider organizations in the business of policing eligibility and denying care starts to bring us right back to the bad place where we are right now. It could be more cost effective (in other words, better for us) to simply accept that some ineligible people will get the care they need. This could be considered a "waste" of health care resources, but we could also see it as a cost of foreign, economic, and trade policies that aim to keep the third world in a state of economic colonization.

  •  Question: Malpractice claims (0+ / 0-)

    This is all terrific information, but I'm wondering how malpractice lawsuits/claims would work under such a system.

    Republicans have been claiming tort reform will reduce health care costs when they seem to really be reducing patient rights.

    Thanks.

    •  In Canada (0+ / 0-)

      all physicians are covered under a quasi-public insurer called the Canadian Malpractice Protection Association.

      The biggest things to remember is that single-payer removes the cost of future care from settlements, and that it moves from an adversarial system to a solution-focused one. (i.e. instead of encouraging finger-pointing between doc and patient, it encourages looking at what went wrong in the system to cause the error).

      If you want to see the tremendous effect this has on malpractice premiums, look at CMPA's fee schedule

  •  National Sin tax. (0+ / 0-)

    I think this is some what a way for those with higher risks to pay more of the pot, a national sin tax. Create a national tax on all alcohol and tobacco products.  The less money people have to pay in income tax and pay roll tax the more they will enbrace a universal health care system.  We could tax carbon emisions (kill two birds with one stone), increase tariffs, there are any number of ways to raise funds for this will minimal incresses to income taxes.

  •  OMG!!! (0+ / 0-)

    DrSteve, I can't believe the amount of work that went into this diary.  Thank you for all your efforts to bust these myths.

    I'm a big fan of universal health care and have decided 2007 is the year I will push this issue the hardest.  Out current system is beyond busted, as you explain very well.

    Please keep posting additional diaries if you have more information to share!!

  •  Minor point--Medicare does not just cover the old (1+ / 0-)
    Recommended by:
    SaneSoutherner

    it also covers the disabled--so it covers the two groups with the highest medical costs.

    "All governments lie, but disaster lies in wait for countries whose officials smoke the same hashish they give out." --I.F. Stone

    by Alice in Florida on Fri Dec 01, 2006 at 01:30:19 PM PST

  •  Additional question/comment for the FAQ (0+ / 0-)
    Although the FAQ covered many common questions and comments, there is still one major comment/concern that was omitted (this may simply be because it is not a question).  I suspect that one of the major concerns that people have about single payer health insurance is that they must give up the possibility that if they had enough money, they could get the "best care".  Bare with me, if you can.  

    Even if it is just a possibility, people may prefer the freedom to throw money at their health problems with the hope that if they had enough money, they could solve any of their health problems.  The key here is that it need not be true that money is always proportional to the quality of coverage, or that any particular individual has a realistic chance of exercising this freedom.  For the people that are concerned about this "freedom", their major concern is that they have to give it up.  Their question is, "does this mean I have to give up this freedom," to which the only answer is "yes".  Even if that was the actual question in the FAQ, the FAQ would have at least addressed the issue.

    Now, you can list several reasons why single payer health insurance is superior, yet in doing so you fail to consider that these points do not matter to some people if you are asking them to give up this "freedom".  Consider that giving up this freedom, may very well be a major concern for both the rich and the poor/uninsured.  At the end of the day, the trade off is that in order to have affordable good health care for everyone, you must abandon this "freedom".  In particular, how do you convince the poor and uninsured who recognize that they are poor and uninsured, and yet are hesitant to give up this freedom in return for actually having good health care?

    "I want the freedom to pay for the 'best' health care, even if, in reality, I do not currently get any health care because I cannot afford it."  How do you respond to that?  

    Although the FAQ touched upon many adjacent issues (such as demonstrating that a two-tier system just does not work), it never directly addresses this complaint/concern.  This may not have been your intended audience, but then again, I would not consider the FAQ complete because it skirts around this issue without directly addressing it.

  •  This would be a Godsend (0+ / 0-)

    OK, so maybe the appointments are a little harder to get and maybe the time with the doctor may be shorter, but to me, its worth it.

    My wife had idiopathic pancreatitis five years ago and almost died.  Since then, we can't get decent insurance, and we HATE our doctors.  Its the worst form of HMO.  And since she's been hospitalized for it 4 times, forget about any chance for decent coverage.

    Oh yeah--unless she has her gall bladder removed.  Then she can have better insurance, because the idiotic carriers think this is the only cause of it other than alcoholism.  Problem is, the gall bladder does produce a certain amount of digestive enzymes, and if her pancreas gets worse, she'll need those enzymes.

    My father was from Canada.  Hated US healthcare.  Was non-stop about Canadian "socialized" healthcare.

    We need it, and we need people like you continually educating us so we can speak competently to our Reps in Congress.

    Knowledge is knowing why you're doing something; wisdom is knowing why you're not doing something else. Me

    by Eric Klein on Fri Dec 01, 2006 at 02:10:02 PM PST

  •  State Health Plans (0+ / 0-)

    Do you have any opinion on The Pathway Plan for Wisconsin proposed by ABC for Health, Inc?

    Do you think proposing plans at the state level is a distraction or that it will assist a federal effort?

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