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We are utterly unable as a nation to have an adult discussion about Medicare. The latest example is from Eric Bolling, who says "Obamacare may literally kill you", but let's be honest: nobody in their right mind wants to touch that third rail.

With the exception of Paul Ryan. Setting policy aside - because, let's be frank, that's not what figured in to his stance - the political calculus he made is very close to that of the Obama administration.  His plan is a massive giveaway to the insurance industry, taking a gamble that the campaign money that can be pulled in from these deep pockets will more than make up for the political fallout from the "don't touch Medicare!!!" crowd.

The PPACA ("Obamacare") legislation was pretty much crafted on the same lines, in the end. No public option, certainly no move towards single-payer or away from tying health insurance to your job. It became a massive giveaway to insurance companies. Yes, there are key differences on the policy side: insurance companies gave up some things in the bargain, most importantly coverage for pre-existing conditions.  But the political calculus? Pretty much the same.

Both dance around the 800 lb gorilla in the room: growth in costs. From 2000 to 2007, health care costs in the US climbed 14%.   And health care already consumes 16% of GDP.  The rate of Medicare growth per-patient is somewhat lower, at 3.1% per year, but that still means it doubles every 23 years.

The PPACA established the Independent Payment Advisory Board, due to make reccomendations in 2014 for containing costs. Its specifically prohibited from rationing care. But still, the right used it to create a tremendous furor over "death panels".  No doubt that meme will be revived again when it issues a report.  Even the most mild attempts at reining in costs are political suicide.

The unavoidable truth is that, in some way, care will have to be rationed. With some drug treatments hitting as much as $400,000 and numerous treatments for cancer running well in to six figures, the boank check can't continue. At some point, the adults in the room - on both sides - need to acknowledge this.

You can ration care in one of three ways: bureaucrats, insurance companies, or block grants.

With the first option, government makes the decisions. Their incentives are to control costs and minimize political uproar. Not a perfect solution, but perhaps the least bad of the bunch. But any Democrats who seriously propose this will be tarred and feathered.  We mustn't deny a comatose 86 year old with multiple organs failing that expensive treatment that might extend life a few weeks or months, no matter what the cost. Because: killing grandma!

So most likely we'll paper it over.  That's the Ryan plan: hand it over to insurance companies, and let them ration care.  Since their only incentive is profit, don't expect medical efficacy to play much of a role in making decisions.

Or we can go with the Republican answer for Medicaid - block grants.  That's the worst con job of all: let's declare goals, then pick an arbitrary number of dollars that won't remotely be enough to meet those goals, and hand the money to the states.  The states make the tough choices, and can blame Congress.  Congress can shrug and say, it was your choice. The buck stops where people end up dying frmo easily preventable or treatable illnesses.

And that's where we end up. In a rational world, we'd study outcomes for treatments for particular patient profiles - Medicare already gives us a wealth of data with which to do this - and draw a line on the chart.  Below this level of effectiveness, Medicare doesn't pay.

And that means some people would die, who could otherwise have had their lives extended.  That's the reality. We're in a nation that thinks an 80 year old's health is a sacred thing that must be protected at all costs, but a 20 year old woman, unless she's so very poor as to qualify for Medicaid (an income under $5,000 a year in many states), is on her own. And even the minimal health services she might receive from Planned Parenthood are under threat of defunding.

Nope, not an adult in sight. Our media model doesn't allow for a serious discussion: getting leaders from both sides in a room, and spending an hour or two asking them pointed questions about the hard choices. The public won't demand such a discussion, so we're not going to get one.

That, folks, either the Ryan plan (privatization) or block grants will be adopted. Probably the latter.  As policy, they suck.  But the political calculation is pure gold.

Originally posted to Things That Fell From My Brain on Thu Aug 16, 2012 at 02:25 PM PDT.

Also republished by Community Spotlight.

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Comment Preferences

  •  If we are forced into a voucher system (4+ / 0-)

     I hope it would pay for healthcare overseas.  Older Americans would live in other countries if their medicare would cover them in what is more than likely a cheaper venue to receive healthcare and pay for it.  I'd love to think that's an option in retirement planning.  Old age is too expensive in the USA.

    Shine like the humblest star.

    by ljm on Thu Aug 16, 2012 at 02:44:38 PM PDT

    •  If the moved to another country (5+ / 0-)

      And paid taxes in that country they won't need Medicare. Their new resident country will probably have single payer.

      Republican Family Values: Using the daughters from your first wife to convince everybody that your second wife is lying about your third wife.

      by jsfox on Thu Aug 16, 2012 at 02:56:28 PM PDT

      [ Parent ]

    •  Give me the choice to use the Canadian system (1+ / 0-)
      Recommended by:

      Watch how fast I would choose socialized medicine if that option were available.  For example, cut a deal with a couple of Canadian provinces to let seniors live there, and get the Medicare and Medicaid coverage through the Canadian system, at their far lower costs, and Canada will have a housing boom for all the US geezers that will move there.  I would gladly pay Canadian taxes in return for Canadian services.  If North Dakota wants the boom instead, let them offer socialized medicine too.  We'll fill the place.

      •  And just think . . . (1+ / 0-)
        Recommended by:

        it'll be nice and toasty for the Coumadin generation - what with global warming and all.

        Yes, I'm feeling particularly snarky today.

        When the power of love overcomes the love of power, the world will know peace. -- Jimi Hendrix

        by gnutpnut on Fri Aug 17, 2012 at 08:14:26 AM PDT

        [ Parent ]

  •  Unconstrained exponential forecasts are fraudulent (32+ / 0-)

    It's a sure sign that an economic model is is garbage, unrealistic, and wrong. Always. In most cases, assuming unlimited exponential growth in any economic or financial projection is a way to scare the crap out of people and to create a false urgency or an edge-of-the-cliff scenario.

    This is how the right wing projects the inevitable end of Medicare and Social Security. It's the whole premise of Willard's "save Medicare" bullshit.

    Surprise. Medicare is not doomed. Social Security is not doomed.

    Each of these programs will need some adjustments, but letting the Republicans get their hands on the $2.6 trillion currently in the Social Security Trust Fund so they can force you buy into private investments, is their wet dream. This ends Social Security.

    We can extend the payroll tax to higher income levels. Right now, it amount to a regressive tax. It really ought to be a progressive tax, but that sould be an uphill battle. The reason it's regressive is that the wealthy don't need as much Medicare coverage. so the old conservative excuse is that the wealthy shouldn't have to pay more for something less. It's the same crap of not paying for schools because you don't have kids in school. So a progressive schedule for Medicare is probably not going to happen. But an increased income tax would work, too.

    Other countries have implemented strict price and profit controls for procedures and medications, etc. Removing the health insurance businesses from the loop would be miraculous, but we've blown that option. Nationalized insurance providers might be a direction to consider. Universal health care will be necessary eventually. We should move away from the concept of employer-provided health coverage. Those who retire or are unable to continue to work can't be punished by losing their health coverage when they are certain to need more coverage. Medicare for all might be a place to start. An option to buy-in before age-eligibility is something that's attractive to me.

    Economic models have limits and constraints that keeps exponential growth under control. So don't buy into any forecast that grows without limit. It's not valid or realistic. Economic models are devilishly complex, so simple models are not going to be useful. Ever.

    If you redo the numbers using a modest 2% increase in GDP, magically, Social Security and Medicare are solvent for much longer.

    The prediction that these programs are doomed is entirely bogus.

    But if Willard buys this election, I'll be living in Canada.  

    "Never wrestle with a pig: you get dirty and the pig enjoys it"

    by GrumpyOldGeek on Thu Aug 16, 2012 at 04:00:36 PM PDT

    •  Repubs do this all the time. Everything is a (4+ / 0-)

      phony crisis.  If they convince you of this, then you are ready to agree to anything, usually a Republican plan that kills the public institution, e.g. public schools, Medicare, Social SEcurity, etc. so they can reduce teh tax burden on people like Mitt Romney with their show pony deductions.  Meanwhile, you are scammed.  

      When will the American public wake up to the fact that their public institutions are functioning very well and with some tweeking of a minor nature, can be guaranteed to function well into the foreseeable future?

  •  Both of your examples are of pharmaceuticals (22+ / 0-)

    The "adult-in-the-room" discussion should, but will not, include and be focused around constraint, by l have in the past taken a medication that, if I had had to pay for it out of pocket at the pharmacy, would cost me $5,000 a month, and this was when said medication was new, several years ago. It is not yet available as a generic and will not be for some time. The cost of developing the medication is one thing; allowing for obscene profit margins is quite another. And the costs of the medications you mention is driven largely, if not entirely, by profits, not by the costs of developing it. It's driven by the fact that people need that medication to stay alive, so the pharmaceutical company is permitted by our system to put a sort of gun to all of our heads and say "your money or your life", in a very literal sense.

    As someone who requires medications that carry a total out-of-pocket cost of well over $20,000 a year to keep my transplant and thus stay alive, I know the feeling all too well. I have a good prescription plan, and those particular medications are currently covered under Medicare Part B (I do not and have not had Part D, as I have better coverage through my partner's employer), and Medicare Part B pays nowhere near $20,000 a year for my transplant drugs. Two of the three are generics and still cost that much, because the companies making them can get away with it due to the fact that people will die without these drugs.

    Any discussion of medical costs must center around pharmaceutical costs, as they are more of a problem and require a much simpler correction than medical treatment and procedure costs.

    Organ donors save lives! A donor's kidney gave me my life back on 02/18/11; he lives on in me. Please talk with your family about your wish to donate.

    Why are war casualty counts "American troops" and "others" but never "human beings"?

    by Kitsap River on Thu Aug 16, 2012 at 04:58:48 PM PDT

    •  One more fact to add to your discussion of obscene (8+ / 0-)

      profit margins. The US government doles out hundreds of millions of dollars every year for the research and development of cures for multiple illnesses and diseases. So even the claims by Pharmaceuticals that the cost of research must be included in the pricing smells to high heaven.

      "I cannot live without books" -- Thomas Jefferson, 1815

      by Susan Grigsby on Thu Aug 16, 2012 at 05:09:13 PM PDT

      [ Parent ]

      •  One example (4+ / 0-)

        I was taking prescription Dexedrine for some time, very heavy doses of it (I'm all but immune to its effects). It was about fifty cents a capsule (in Canada; might be higher in the States). Now, Dexedrine came on the market in the 1930s, based on research that had been done around the turn of the century. Research costs much? It should have been five cents a capsule, not fifty.

        "They smash your face in, and say you were always ugly." (Solzhenitsyn)

        by sagesource on Thu Aug 16, 2012 at 08:23:19 PM PDT

        [ Parent ]

        •  Dexedrine is generic. (1+ / 0-)
          Recommended by:
          Susan from 29

          The only brand-name version of it is a different formulation to allow delayed release (which required additional research)

          Generic pill costs are almost entirely production costs.  Many drugs are simply expensive to manufacture.

          Dexedrine, in particular, is so low profit that most of the generic manufacturers have quit making it.

    •  Sold out to Pharma (7+ / 0-)

      Congress and Obama sold out to Big Pharma, as did AARP.  Much of the Medicare cost problem can be solved by requiring negotiation with drug companies for lowest price, as the VA now does.

      Funding problem can be fixed for both Medicare and Social Security by removing the tax cap and taxing ALL income (like Rmoney's dividend and capital gains income) as well as salaries for both SS and Medicare.

      Finally, we need to replace the current fee-for-service plan with some type of total care & wellness plan for providers.

      And of course Medicare For All would get the insurance company profit bleeding out, and enlarge the pool so that Medicare would not cover just the population most likely to be sick.

      "Everybody wants to go to Heaven but nobody wants to die" --- Albert King

      by HarpboyAK on Thu Aug 16, 2012 at 09:17:54 PM PDT

      [ Parent ]

    •  It makes far more sense to have (0+ / 0-)

      the research & development costs paid directly in some other fashion, and then have patients pay for a cost that covers manufacturing the drug.

      The other issue is that costs are sloshed around because you're paying not just for the cost of the winner drug that you're taking, but the cost of all the drugs they tried to develop and failed with.

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

      by elfling on Fri Aug 17, 2012 at 01:05:38 PM PDT

      [ Parent ]

  •  Um, hello? (16+ / 0-)

    What are you talking about?

    Obamacare took our existing patchwork of private health care insurance for people younger than 65 and made some improvements to it.

    That's not the same as taking the single payer system that we now have called Medicare and converting it into a voucher system. Not by a long shot.

    •  Well, enough Repub propaganda just might lead (0+ / 0-)

      the Am public to think that we have to adopt the voucher system.  It's already well underway:  Medicare is doomed if we don't do something!  There's a crisis!  (Like Chicken Little - the sky is falling).  The only plan that gets any sustained attention in the media is the Ryan Plan.  And indeed, it's the only plan anyone can probably name!  What is Obama's plan?  He does have one but does anyone know what it is?  I know I've heard about it, but even I don't remember.  Funny how that works.  Where in the media do you see any sustained, informed, accurate effort to portray a variety of alternative solutions?  Nowhere did you say?

      The media goes along selling the whole package of propagandistic lies - oh yes, there's a crisis and here's the man with the plan, Paul Ryan, a voucher system.  What else can we do? We must act!  That must be the answer.

      •  The Ryan plan is no solution (1+ / 0-)
        Recommended by:

        to the problem of increasing health care costs for the elderly. It just makes the elderly bear the burden of those increasing costs.

        You try shopping for a private health insurance policy at 65 with a crappy voucher. For starters, without the ACA you'll be looking at having all of your pre existing conditions excluded and a lifetime maximum benefit to worry about. You'll need to buy an individual policy, because you'll probably be retired and not eligible anymore for an employer sponsored group plan. With an individual policy, your rates go up ever year because...surprise surprise...the insurance company has you over a barrel and health care costs are going up!

        And your voucher is fixed.

    •  In fact (1+ / 0-)
      Recommended by:

      The affordable care act actually strengthened and expanded Medicare, and is currently saving seniors money. That is the opposite direction of a voucher system.

      Republicans are far more socialist than Democrats. Just because they want to redistribute the wealth upwards does not make it any better.

      by MrAnon on Fri Aug 17, 2012 at 09:47:39 AM PDT

      [ Parent ]

  •  Real political fallout argues against the scenario (9+ / 0-)

    Your hypothesis satisfies the minimum cynicism requirement, but actual political reaction to Paul Ryan's voucher system is a strong, and real-world, indicator to teh contrary. There is no political appetite for this voucher system. There is no reason to date to think a voucher system will become popular.

    Every system rations health care, BTW. No resource is infinite. This is not unique to health care.

    Every industry in the US has been forced to undergo tremendous cost-saving from overseas competition. The American health care industry has continued to go on up its exponential growth curve.

    There is tremendous overcharge in the American system that can be squeezed out without reducing services. What it will reduce, is specialist salaries from the high six-figures and above. American voters will see that happen before they give up their own health care.

    •  Glad you, elmo, CupaJoe and zinman replied. (1+ / 0-)
      Recommended by:

      I didn't have the time or need the headache.

      Now I'm just trying to figure out what a Rescue Ranger was thinking (or smoking?).

      Stig. There are some really excellent writers here who know their strong subjects and write very well in those areas. Search the tags related to health care, insurance, Medicare, etc. and read the ones with big #s of recs.

      "People, even more than things, have to be restored, renewed, revived, reclaimed and redeemed; never throw out anyone. " Audrey Hepburn "A Beautiful Woman"

      by Ginny in CO on Thu Aug 16, 2012 at 10:14:51 PM PDT

      [ Parent ]

      •  Good advice (1+ / 0-)
        Recommended by:
        Ginny in CO

        And I will read some of the people who, I am sure, know the issues around health care far better than I.

        What I was speaking to was the politics. The fear, the reactionary seniors who are easily stampeded, the power of the simplistic, "They're killing grandma!"  

        Nobody dares say, well, yeah, maybe there are situations where we don't spend the money and let grandma die.  

        That's an adult discussion. That's what we can't have.

        I know its frustrating that this ignores facts, economics, policy, lessons learned from other systems, etc. But that's the nature of a democracy. If you can stampede the heard, you can get them to run off of a cliff.

        •  The discussions about grandma or hubby, etc. (0+ / 0-)

          not being aggressively treated go on at least tens of thousands of times per day in America. With doctors, nurses, social workers. This was the beauty for us of allowing people to have those talks in advance with their physicians who would get paid for the time it takes to explain prognosis, treatment options, etc. So the whole complex issue does not hit them in a crisis situation when they are unprepared.

          Hospice and palliative care are everywhere. The media and RW are doing to this discussion what you talk about and what the whole field of messaging and winning words is about. How to take the discussions back by replacing the misleading words with accurate ones.

          Especially to understand how key words are associated with values in the mind - where the hindbrain first processes incoming information and flags negative value words sent to the cortexes while triggering the fight stress response - or ignore.

          The Winning Words Project was started by a Kossack. I am switching ISP, browser, etc and haven't transferred that yet - easy to find on search. Lot of good reading suggestions there on the communications concepts. Way past Lakoff.  Understanding how/why some people can't seem to deal with facts and act against their own self interests has been a psych research issue for decades. John Dean used a lot of Bob Altemeyer's The Authoritarians (Free PDF download) in his Conservatives Without Conscience.

          I have a separate bucket for my books to read list ;)

          "People, even more than things, have to be restored, renewed, revived, reclaimed and redeemed; never throw out anyone. " Audrey Hepburn "A Beautiful Woman"

          by Ginny in CO on Sat Aug 18, 2012 at 10:07:43 AM PDT

          [ Parent ]

    •  I think you're being overly optimistic (0+ / 0-)
      Every industry in the US has been forced to undergo tremendous cost-saving from overseas competition. The American health care industry has continued to go on up its exponential growth curve.
      Sure, costs have gone out of a control.  A lot of that is making up profit margins due to foreign price controls, though.  We're bearing someone else's costs.
      There is tremendous overcharge in the American system that can be squeezed out without reducing services
      This is pure pie in the sky.  We already have a doctor shortage that's only going to get worse.  We're certainly not going to make that any better by cramming down salaries.

      At the end of the day, almost all cost savings are going to come from restricting services, one way or another.

      •  so, foreign price controls are to blame for (0+ / 0-)

        our healthcare problems -- ????

        typical rw talking points bullshit!

        the rw wants the rest of the world to bend to the will of the us's for-profit healthcare industry instead of the other way aroound.

        at the end of the day, going to universal single-payer healthcare will create more services for everyone involved & eliminating the dinosaur pay-for-fee system for doctors will put an end to the phony "doctor shortage" the rw is always blathering about.

        your comment is pure rw trolling

  •  I think we skipped over some important parts (8+ / 0-)

    Before you start claiming that medical care has to be rationed because of high costs, you first need to examine why costs are high. For example:

    (1) What fraction of U.S. health care spending goes toward administrative functions related to billing and insurance coverage? I.e., how large is the sum total of insurance companies' net revenue, plus the amount spent on other administrators and staff who's job it is to assign responsibility for paying costs?

    (2) Why is a price of $400,000 assigned to a drug or treatment? Does it truly cost that much to manufacture the drug? (No.) Would that price be justified if the drug had been discovered through government-funded research? (No.) Do drug companies enjoy a favorable regulatory environment that grants monopoly status? (Yes.)

    *** All our work toward economic and social justice won't be worth a damn unless we start reversing global warming right now. ***

    by CupaJoe on Thu Aug 16, 2012 at 08:39:40 PM PDT

    •  There's so much more to it than that? HOw many (0+ / 0-)

      drugs are approved and prescribed to the tune of billions in profit and then years later, oh my, turn out to be harmful and not helpful.  Vioxx, e.g.  and so many others.  We could use a functioning FDA.  My doctors are still harping on vitamin D after I've read in the NY Times that the whole vit D thing is bogus.  But I submit to the tests at god knows what expense like a good little sheep. Recently I got tested and low and behold, my vit D levels are A-OK. Did I take expensive supplements like doc wanted?  No!  I've been spending a lot of time outdoors in the sun and yes I use sunscreen and wear a hat!

      •  Vioxx is another case of our dysfunctional system (0+ / 0-)

        Vioxx is a perfectly useful drug for some people, and an appropriate choice, better than the existing drugs. BUT, only a small number of people.

        The problem wasn't that the drug was useless or all bad. The problem was, that to get their investment back, the companies marketed it for anyone and everyone and worked hard to get people to take it who were better served by existing drugs.

        Then, when those people had problems, the drug was pulled for everyone, including people for whom it was a good/best option.

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

        by elfling on Fri Aug 17, 2012 at 01:08:32 PM PDT

        [ Parent ]

  •  So every country with national healthcare (4+ / 0-)
    Recommended by:
    congenitalefty, Zinman, notrouble, elfling

    deals with some version of this.  But its a different conversation when nearly everyone is part of the game, I think.  Not as a hopeful sorta thing, but because that's how it seems to work Europe and Canada.    There will be a constant tension about this stuff, like every other mandated and shared cost.  Why have the conversation now while half the country is hell bent on making sure ever fewer people have access?

    ...j'ai découvert que tout le malheur des hommes vient d'une seule chose, qui est de ne savoir pas demeurer en repos dans une chambre.

    by jessical on Thu Aug 16, 2012 at 08:49:17 PM PDT

  •  Not the Ryan plan, not block grants, no way (4+ / 0-)
    Recommended by:
    ybruti, Ginny in CO, geordie, SoCalSal

    Neither the Ryan/Romney plan, nor block grants, can be enacted because they have no popular public support, no institutional Democratic support, and no rational way to acquire any of the above.

    It's more likely that we will adopt a single payer Medicare for All system than any of the Ryan/Romney non-starters.

    Eradicate magical thinking

    by Zinman on Thu Aug 16, 2012 at 09:05:57 PM PDT

  •  Here in Japan, (13+ / 0-)

    there's no rationing of healthcare because the national insurance system simply pays two-thirds of the bill for whatever treatment you seek, excepting purely cosmetic or voluntary procedures like cosmetic plastic surgery.  There are no lists of doctors or hospitals; you simply walk into any medical facility, from the tiniest village clinic to the biggest hospital in Tokyo, and it's all handled exactly the same.  The clinic or hospital does all of the paperwork.   Everyone pays a monthly tax based on household income (My wife and I make about $38K a year, and we pay about $180 a month).  Medical and drug costs are controlled by the government, so a typical doctor visit for a cold will cost about $12 out of pocket, plus another $5 for medicine.  My wife recently had an endoscopy and treatment for gastritis, which set us back $90 total.  A couple of years ago, she had a biopsy to check on a thyroid nodule, which cost us $120.  We had the exact same procedure done in the U.S. two years before that, and it cost us $3200.  

    The Japanese system faces crisis because of the declining population (fewer young people paying into the system which is supporting more older residents).  Adjustments have been made; the system used to cover 70-90% of the cost of treatment, now down to 66.7%, which is still manageable.  The bigger problem is with a large segment of younger people who simply don't pay their insurance bill.  There's no system of enforcement- the national health insurance bills arrive at the house each month, and can thus be ignored.  You can instruct your employer to just deduct the cost from your paycheck, but there's no mandate to do so.  Some of the younger generation, especially, frightened by tales of how the system is underfunded, or simply wanting an extra hundred-something bucks in their pockets each month, don't pay.  The problem arises when you do need the coverage, in which case you can get it re-instated by back-paying everything you owe in one lump sum.  There are people like my father-in-law, who hasn't paid his premiums in thirty years.  He's now faced with glaucoma and cataracts and is refusing to go to the doctor out of fear of the bill and shame at his non-payment.   I look at this situation and shake my head... the people doing this stuff have the golden goose and don't even realize it.  

    •  Although the Japanese system is rather nice... (1+ / 0-)
      Recommended by:
      Hatrax's worth noting the country has gone into ridiculous debt funding it (Well, and plenty of other economically dubious decisions.)  Having 200% of your GDP in government debt is ridiculous.

      The sales tax increase is a step towards righting the fiscal ship, but having a nice health care system via unlimited debt spending makes things seem rosier than they are.

      •  how much leverage do us corporations carry? (1+ / 0-)
        Recommended by:

        do you consider their leverage "ridiculous?"

        •  The U.S. has about 103% of GDP (0+ / 0-)

          in government debt.  The top countries in the world for GDP-debt ratio are:

          1.  Japan  229%
          2.  Greece  161%
          3.  Saint Kitts and Nevis  153%
          4.  Jamaica  139%
          5.  Lebanon  136%
          6.  Eritrea  134%
          7.  Italy  120%
          8.  Barbados  117%
          9.  Portugal  107%
          10.  Ireland  105%
          11.  USA  103%
          12.  Singapore  101%

          Canada is 20th at about 85%,  UK 22nd at 83%.  The lowest "first-world" country is Estonia with only 6%.  Notice by how much Japan "beats" everyone else.  

          Thank you, Wikipedia.

          •  thanx for the info, but my question was to (0+ / 0-)

            mgross, who said in her/his comment to yours about japan's healthcare system, that japan's debt leverage was too high.

            i wanted mgross to tell me what the us corporate debt leverage was.

            of course, i don't really expect a reply from mgross.  s/he never responds to difficult questions until s/he's checked with (ahem) higher authorities for the answer.

      •  I agree, but... (0+ / 0-)

        You're absolutely right about the debt problem.  However:

        1.) My point in lauding the Japanese system is to show that one can have freedom of choice, zero rationing, and affordable care without any of the BS that the conservatives whine about.  Japan is one of the most awful and wasteful bureaucracies on the planet.  Surely, with the USA's streamlined bureaucratic system (the US has the smoothest-functioning bureaucracy I've seen in a lot of world travel), and a desire to cut waste and fraud and red tape, we could have all of the good and little of the bad adopting the same basic goals for a U.S. system.  

        2.)  Most of Japan's debt comes from corporate welfare.  In the U.S., corporate taxes are winnowed to nothing.  In Japan, taxes are higher, but the corporations are given sweet government contracts encased in barrels of pork big enough to choke a sperm whale.  This takes the form of things like useless construction projects (building toll highways through most of Hokkaido, where very few use them, encasing every last riverbank in Japan in concrete, erecting monuments in the middle of nowhere, and doing things like adding a huge park and visitor's center to a local hydroelectric project that's so remote that no one comes to it- I check the guest register and find that on an average day there are four visitors) and propping up failing and dead industries (the three largest Japanese shipbuilders had zero orders for five years, and  of course there's the whaling industry-  millions given to illegally kill whales under the guise of research and then dispose of the mercury-contaminated meat in the nation's school lunches.  In short, the corruption needs to come out of the system, and health care funding problems would disappear.  

  •  To me the elephant in the room is single payer (5+ / 0-)

    not voucher system. Here is the reality-If medical costs are too much, or even insurance premiums or co-pays are too much, people simply will not pay. And we know that as a society we will not allow vast swatches of our population to go untreated. Soooooo....people will have to look to single payer as the only sane alternative to get everyone to pay in. In my estimation, sooner or later, this must happen. Unless some teeth is put into the mandate, which will never happen.

    "The problem with quotes on the internet is you can never be certain they're authentic." - Abraham Lincoln

    by realwischeese on Thu Aug 16, 2012 at 09:45:37 PM PDT

  •  Alternative solution... (4+ / 0-)

    And at one time I hoped we were headed this way.

    1) Single payer healthcare.  Everybody gets the same.  It doesn't cover the ridiculously expensive operations.

    2) Private sector gold-plated insurance policies, for people who want to pay extra to be insured for those $400,000 operations that single-payer can't cover.

    Start out with 1) but make 2) legal.  2) will grow to fill the market niche on its own.  We don't have to create an insurance supplement market.  It will develop on its own no matter what we do.  And, really, we shouldn't stop that.  I'd hate to think that if I'm a total psycho about healthcare and I have the money that I can't insure my kids.  If people want to do it, let them.

    Of course, the big problem with all this is implementing single-payer healthcare, which would require a Democratic president.  I mean, a different Democratic president.  Maybe in 2020.  In the meantime, we better get used to what we can get.

    •  So you would let every transplant patient die (2+ / 0-)
      Recommended by:
      jiffypop, elfling

      along with everyone who needed a coronary bypass, or suffered a  traumatic brain injury.  These are all "ridiculously expensive operations".

      I am in Pulmonary Rehab, which means I spend a couple of days a week with a wonderful group of people who are either waiting for, or have already received, a lung transplant. I don't qualify as a candidate because of a previous bout with cancer. These people can live productive lives for decades, if they have a successful transplant, but the operation costs about $1.5 million. Many are middle-aged, but a significant number are in their twenties and thirties. Do you think it is too expensive to keep my friends alive? I don't!

      And you seem to consider yourself a better Democrat than the President? I don't think so.

      Here's my take on it - the revolution will not be blogged, it has to be slogged. - Deoliver47

      by OIL GUY on Thu Aug 16, 2012 at 10:52:37 PM PDT

      [ Parent ]

      •  The diarist asks a valid question. (0+ / 0-)

        Maybe $400,000 is too low.  But suppose there were a $50,000,000 operation that would cure people from a common disease.  How many operations like that can you really give?  

        The rest of the world has already solved problems like these and they seem to do quite well.

        And yeah, I think I'd be a better president than Obama.  I think a lot of people would be.

        •  I'm happy for you that you think so highly (1+ / 0-)
          Recommended by:

          of yourself. Pardon me if I don't share the sentiment.

          Since there are no $50 million operations, your hypothetical is a bit overwrought. Rationing care is not a good strategy, except insofar as it is important to eliminate procedures which are not proven to benefit the patient. There are many of these, especially in areas like back or foot surgery.

          Here's my take on it - the revolution will not be blogged, it has to be slogged. - Deoliver47

          by OIL GUY on Fri Aug 17, 2012 at 03:35:57 AM PDT

          [ Parent ]

          •  I don't know. I hate to say it, but at the end of (2+ / 0-)
            Recommended by:
            le sequoit, MGross

            life, at what is clearly the end of life, aren't some extreme and expensive measures taken that people could forego if they just accepted the inevitable?  I read about cancer treatments that cost $40,000 and up and they extend life by 6 mos.  I'd like to think that given the choice, I'd forego the treatment.

            But hey, right now, I have to fight my doctor off what with all the tests they want to give and I'm not sick!  and not even 60 years old!  They are padding their accounts shamelessly.

            •  I agree with you on end-of-life care. (0+ / 0-)

              I have made provisions in my living will and medical power of attorney to prevent any extraordinary measures from being used to keep me alive.

              Here's my take on it - the revolution will not be blogged, it has to be slogged. - Deoliver47

              by OIL GUY on Fri Aug 17, 2012 at 02:29:00 PM PDT

              [ Parent ]

    •  Cost-benefit is the right way to look at it (0+ / 0-)

      rather than absolute cost.

      $400k is pretty low for someone with a catastrophic injury or condition. Those cases are pretty uncommon and they're the people who MOST need to be covered.

      $400,000 for someone who is 85 and in frail health is perhaps not the same investment as $400,000 for an infant born with an unusually plumbed heart or $400,000 for a 20 year old previously healthy car accident victim.

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

      by elfling on Fri Aug 17, 2012 at 01:12:23 PM PDT

      [ Parent ]

  •  Stop it (11+ / 0-)

    Stop feeding the zombie lies.

    There is absolutely no reason to imagine that health care needs any sort of rationing, at all, even a little bit, to keep the costs of health care from rising to unsustainable heights.  Yes, you often hear that idea, but you hear it from the same "centrists" and very serious people who are also wrong about everything else.

    Let me start to return the discussion to reason by asking you, and any readers, this question.  If I offer you a free colonoscopy (a roughly $500 value), are you going to take it?  Well, unless you need such a procedure, unless you are convinced that it will give you a greater health benefit than the human cost to you of accepting my offer and submitting to the procedure, you will turn me down, and you will not add to the demand for at least this medical service.

    Now, screening colonoscopies aren't horrifically expensive, and they don't really have that high a human cost.  That relationship, that the monetary costs to the payer and the human costs to the patient vary directly one with the other, holds almost without exception.  We have some pretty horrifically expensive interventions out there -- open heart surgery and liver transplants and bone marrow transplants -- but in all cases, these really expensive interventions are also horrifically expensive in human terms.  You have to have a really bad disease for that disease to manage to be worse than the cure of a liver transplant, and only a tiny percentage of really bad disease also happens to be curable with a liver transplant.  We can give everyone who needs a liver transplant one without breaking the bank because very, very few people need such expensive treatments.  Wake me when we find out that daily doses of diamond dust is the only thing that will control hypertension, and maybe then we would need to talk about the imminent need for rationing.

    So, sure, the amount we spend on medical interventions has been increasing over many decades at a pretty high rate.  There are plenty of low-cost, both money cost and human cost, intervenitons that we have found will benefit large numbers of people.  A century ago, exactly zero interventions fit that description, fifty years ago very few, today a few dozen; but the trend lately is not exploding.  If you had looked at the rate of increase in spending on electricity between 1880 and 1930, I'm sure you would see unsustainably high year-to-year increases.  But while we still find new uses for electricity all the time (i.e., the computer), most of the new uses were already priced in after the first few decades, and those high initial rates of increase in usage of electricity that couldn't have been sustained indefinitely didn't have to be sustained indefinitely.  Electricity dind't break the bank, and medicine won't either.  The demand for electricity was driven by human need, so is the demand for medical intervention.  The latter is not going to rise any faster, no matter how little top-down rationing is applied, than the need for interventions, because, even more so than electricity, medical interventions exact an immediate, highly personal cost on whoever receives them.

    Even insofar as we didn't expect the rise in what we spend on medical interventions to level off as we stop adding universally or even commonly needed interventions to the initial flurry, spending more on medicine would nto be a bad thing purely in economic terms.  People can't earn money unless other people spend money.  If we want our economy to continue to grow, but don't particularly want more things, more goods, we have to rely on people spending more on services, such as medicine, to put money in the hands of health sectro workers who will in turn spend what they earn, thus maintaining growth in demand.  Spending isn't parasitic, it doesn't suck the lifeblood of the economy, it is the lifeblood of the economy.

    This is not to say that we don't have a real crisis in how we pay for medical care, and that that crisis is not both reflective of, and contributory to, a crisis in the quality of care.  But the high medical costs we need to worry about are costs per intervention at 2-3 times what other developed nations pay, not the sum total of what we spend as a nation on all of our health care.  Those high costs, and the resulting distortions in medical decision-making, are the direct result of our tolerating monoplies and cartels in the medical and medical insurance industries.  Of course you're going to get high prices and market distortion if you allow monopolies.  You don't need exotic explanations or exotic solutions -- just stop allowng monopolies.

    A good part of what keeps us from doing the obvious and killing off the monopolies, is a series of zombie lies.  Not the least of these is the idea that, bad as the private insurers are, at least they are more hard-ass on the providers than wimpy old Medicare, which is going to have to get hard-ass and start convening Death Panels, or abolishing the private insurers will just hasten the bank breaking.  This supposed crisis of Medicare in particular, and health care in general, costs rising so fast that we're all going to die is just as spurious as the great Deficit Crisis.  Both species of political terrorism are pushed by the same people.  Don't help them.

    We should have destroyed the presidency before Obama took office. Too late now.

    by gtomkins on Thu Aug 16, 2012 at 10:00:03 PM PDT

    •  Nice comment n/t (0+ / 0-)

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

      by elfling on Fri Aug 17, 2012 at 01:13:58 PM PDT

      [ Parent ]

    •  Obviously... (0+ / 0-)

      ...other countries simply ration healthcare out of plain mean-spiritedness, since it's unnecessary.

      Wait-listing you into oblivion is just another way of denying you the treatment.

      •  examples please? of other countries who (0+ / 0-)

        wait-list out of mean-spiritedness?

        btw, the current "halthcare"system in the us rations care vis a vis the ability to pay for insurance premiums.

        how is that different from what you claim is practiced in other countries?

      •  What do you mean by "rationing"? (0+ / 0-)

        There are countries too poor to fund the provision of all medically necessary care.  Yes, these countries have rationing of medical care, in the sense that there is a planned denial of some services so that others can be funded.

        But I'm not aware of any developed nation that has an organized, planned system of health care financing that has, as part of that plan, a system for denying some needed care because it has been deemed too expensive.

        The only denial of care in nations that can afford, easily, the full gamut of such services, occurs not because of some plan, because some Death Panel has decided not to fund services, but because of disorganization and the refusal to plan.  The very worst rationing occurs where there has been refusal to even take the first step of such planning and assume national responsibility.  The US, because it does not recognize any need to plan and organize the provision of medical services, denies incredibly cost-effective services, such as pre-natal care, systematically, to millions of those who need them.  

        When you mention rationing by wait list, I imagine you are talking about Canada.  At least that's the usual case advanced by people who imagine that its particular implementation of a national health insurance somehow refutes the whole idea of such a national system.  Well, wait-lisitng is a dumb idea, but it is hardly a dumb idea that is required by either the concept of national health insurance, nor by economic necessities created by such a system.  Canada went half-way, and for reasons that have everything to do with wrong-headed political ideology, failed to truly nationalize the national responsibility of financing health care.  Thus some provinces opted for the dumb idea of wait-listing, and so some seniors have to wait a year for their knee replacements.  That's not good, but the answer here is not for Canada to abandon planning and organization in favor of the US lack of organization, the answer is to actually fully nationalize their national health insurance.

        Under the US lack of system, not only do plenty of people not get knee replacements in a timely manner, many never get them at all.  Their fault for not having the kind of job that provides insurance, or for needing knee replacements before reaching Medicare age, some would say.  I guess it's the fault of babies born to mothers who can't get pre-natal care that they dind't choose better parents, so that's why they have to live with an easily preventable disability their whole lives.

        You seem to have meant the comment about nations choosing to ration medical care to be sarcastic, to prove that full care for all must be unaffordable to even the richest nations, or there would be no rationing.  But you are quite literally correct.  There is wholesale rationing of medical care in the world.  Only it's not in countries with national health insurance, much less national health systems.  Rationing of medical services in developed nations occurs only where there is an ideology of cruelty that goes against both against both the medical and economic self-interest of the whole nation for no reason other than to inflict cruelty on its poor.

        We should have destroyed the presidency before Obama took office. Too late now.

        by gtomkins on Fri Aug 17, 2012 at 08:33:24 PM PDT

        [ Parent ]

  •  I too was disturbed by this inaccurate diary (8+ / 0-)

    It is based somehow that we have the most efficient system, when we know that 1/3 of all healthcare costs in the US are for profit and to bolster the private hospital and insurance industry. It is clear that we have the most inefficient heath care system in the world. We pay the most and yet rank only moderately in outcomes. People by the tens of millions are too poor for prophylactic care, regular checkups and all the other things needed to keep them, and the system, healthy.
    The insane profit motive has to come out of health care. You can't have a CEO of private hospitals making a few $100 million dollars. Also, I believe that 50%, 60% maybe, of all costs happen in the last 6 weeks of life. See the absolutely insane billing frenzy on a terminally ill loved one. They will be wheeled in for an MRI in a coma to squeeze out the last bit of billing. They will get chemo treatments when they look like Auschwitz survivors, with only weeks to live.

    "You can die for Freedom, you just can't exercise it"

    by shmuelman on Thu Aug 16, 2012 at 10:28:40 PM PDT

    •  Uh, read what you wrote (0+ / 0-)

      "Also, I believe that 50%, 60% maybe, of all costs happen in the last 6 weeks of life."

      Well, gee, then how do we not spend that money?  Wouldn't we need to decide what procedures for what patients have useful outcomes?  Would that not require denying some of those procedures ?

      Is that not rationing care?

      •  I suppose what your definition of "rationing" is. (0+ / 0-)

        Once the profit motive comes out of healthcare, or is at least drastically reduced, then we will see a concomitant reduction in unnecessary procedures. Please see this recent diary:

        "You can die for Freedom, you just can't exercise it"

        by shmuelman on Sat Aug 18, 2012 at 06:24:21 PM PDT

        [ Parent ]

        •  And once I marry a supermodel (0+ / 0-)

          I'll stop hanging out in bars trying to pick up drunk girls.

          In other words, the lobbying power of insurance companies and hospital chains, combined with the lack of blind supermodels, means the status quo will be maintained.

  •  Obamacare might not (0+ / 0-)

    do the deed on that fucking piece of trash Eric Bolling...

    ...but I'd happily volunteer.


    by GOPGO2H3LL on Thu Aug 16, 2012 at 10:28:49 PM PDT

  •  The only way Medicare becomes a voucher (5+ / 0-)

    program is if the current republican party gains the presidency, the Senate and the House. That seems unlikely at this time. Not impossible (therefore we must all do our part to prevent that occurrence), but unlikely.

    The sh*t those people [republicans] say just makes me weep for humanity! - Woody Harrelson

    by SoCalSal on Thu Aug 16, 2012 at 10:29:12 PM PDT

  •  Who would pick this worthless peice of crap (10+ / 0-)

    diary for the "Community Spotlight. The argument that ACA is equivalent to Ryan's voucher plan is totally untrue. ACA will provide near universal healthcare coverage to Americans. We have never come close to this before.

    ACA does not do enough to control costs, but it is a start. Once it is fully operational, Democrats will get the political clout to shift the balance of power away from the insurance companies. ACA has already done so, to a considerable extent, by limiting insurance companies' outlays for sales and administrative costs.

    As for controlling costs, the biggest issue is not the very high costs of certain drugs or procedures, it is the thousands and thousands of unnecessary  procedures performed to generate fees for doctors and income for hospitals. This is where government involvement can have a major impact. President Obama has already begun to extract savings from medicare by holding providers and payers to account for what they bill Medicare.

    This doomsday diary does not try to see the changing reality of health care in a post ACA world, but rather crabs about parts of the healthcare system that have not yet been addressed. I am tired of the hackneyed cynicism  that afflicts so many people who want easy solutions to a complex problem that needs to be addressed over time. It is foolish to throw up one's hands in frustration when we are beginning to make some significant progress in tackling this issue.

    Here's my take on it - the revolution will not be blogged, it has to be slogged. - Deoliver47

    by OIL GUY on Thu Aug 16, 2012 at 10:30:45 PM PDT

    •  Policy. Politics. Two different things (0+ / 0-)

      My point was that the politics of the Ryan plan and the politics of the ACA are of a similar calculus, and are both politically viable for similar reasons.

      Of course they are radically different policies. One is a pretty good bargain within a lousy system, and the other is a giant ripoff of both seniors and taxpayers that will merely subsidize those well-off enough to afford to top it off with their own money to buy insurance.

      But that's the problem: we can discuss policy, economics, best practices, and such all day. In the end, what's going to happen depends on the politics.  On what you can stampede low-information voters and selfish boomers to do.

  •  Disagree! But what MUST happen are 5 things: (2+ / 0-)
    Recommended by:
    penguins4peace, NoMoreLies
    1.  Single Payer to eliminate the middle man

    2.  Stop the revolving door between the FDA and corporate junk food and GMO to non-food nonsense

    3.  Return cooking and real food to every school in the U.S.

    4.  Revitalize local parks and athletic facilities for children to enjoy exercise in every neighborhood

    5.  Return JFK's athletic criteria to every school, e.g., every child should be able to run a mile in less than 9 minutes

    Separation of Church and State AND Corporation

    by Einsteinia on Fri Aug 17, 2012 at 12:43:53 AM PDT

  •  Romney wants to overpay private insurance (1+ / 0-)
    Recommended by:

    Romney wants to overpay private insurances private companies at the expense of Medicare.  again it is rich and corporations over middle class

    wall Street Casino is the root of the problem. Don't call them banks.

    by timber on Fri Aug 17, 2012 at 04:20:53 AM PDT

  •  Those 55 and Younger Will Be Thrown Under (0+ / 0-)

    the bus under President Romney and Vice President Ryan this time around.

    Next time around, once those 55 and younger realize they've been thrown under the bus and have only a voucher coupon to use for healthcare, they  will look at those over 55 and say to hell with you, we are voting Republican to throw you under the bus this time.

    So you all who are currently getting Medicare and who think you've been spared wake the hell up.  They are coming for you next time around.

    American voters are idiots.


    The Republican Party is Simply a Coalition of Greed and Hate

    by kerplunk on Fri Aug 17, 2012 at 11:00:27 AM PDT

  •  i call bullshit! (1+ / 0-)
    Recommended by:

    no, the "unavoidable truth" is NOT that healthcare will have to be rationed -- that's rw talking points' crappola.

    first of all, healthcare is rationed NOW under the current taxpayer-subsidized insurance-industry "system."

    and, second, we don't have to reinvent the wheel to solve our healthcare inefficiency paralysis -- all we have to do is look to countries like canada & the uk & france & sweden & every other fucking industrialized country in the world for examples as to how to make it better.

    the diarist ends with her/his typical rw either-or choice: take your poison now, or take it later, but you'll have to take whatever the plutocracy offers eventually.

    •  You're not grasping the point (0+ / 0-)

      Is there a better choice?


      Will we take that choice?

      Socialism!!11!  See how that works?  

      Wake up and smell the politics. I'd love to see a single-payer system: lower cost, better outcomes.  The profit motive screws up health care.

      But see what happens when anybody even tries to make the slightest changes to Medicare.  The right will continue to scare people until the system becomes so expensive it is unsustainable, and then it will get trashed.

  •  Cost lowering idea (0+ / 0-)

    What if it were made a requirement that when people sign up for Medicare they sign off on a living will or a 5 wishes document that specifies exactly what their treatment choices would be if they were in a condition in which they couldn't express them? Soooo much care is provided in situations which it is simply unknown what the patient would want. Out-of-state offspring feeling guilty about not having been around opt to forever extend respirator care and tube feeding, prolonging not life but suffering and death. This document should be easily accessible (read-only) yet amenable in a secure way.

    •  Uh, yeah, we dipped a toe in that water (0+ / 0-)

      And the result was: ZOMG! Death panels!

      We can't have an adult discussion.  So the voters will insist we keep the system with no changes.  Until it is utterly unsustainable, and then they will be conned in to some voucher or block grant bs.

  •  Here's hoping... (0+ / 0-)

    If it's the Ryan plan, then I think we're more or less screwed.

    If it's block grants, and California manages to get a couple more Dems in its legislature, then the state with 1/6 of the population of the US within its borders will, by the time the block grants have come to town, have gone single-payer.

    And if it works in California, and even saves money, other states will follow. Maybe we'll never get all of them, but at least some will have the sense to do what works.

    Don't get me wrong: this is going to suck for a whole lot of people in the US, and I hate that. But there's at least some hope, in some places.

  •  The financial issues with Medicare (0+ / 0-)

    are dwarfed by the financial issues with health care in general.

    Sometime around 2030, given current trends, the cost of the median family health insurance plan will exceed the median family income. To me that's much more alarming than the Medicare funding issues.

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

    by elfling on Fri Aug 17, 2012 at 01:02:44 PM PDT

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