People like me, college educated and working in software, an industry where talent is in demand (but still not immune to various degrees of off-shoring), are in the only situation where there can be any notion of choice. Even so, I’ve worked at start-ups where there was no health insurance for obvious reasons, sp there are no gurantees.

Studies show that a very high percentage of the population is happy with their existing health insurance, but many are afraid they may lose it since they have no control – it is up to employers (they’d have even less control if it was up to government).

As I have said, the current system is not right. I have pre-existing conditions, requiring me to stay working for mid to large sized companies until I’m old enough for Medicare, so I am well aware of the issues. I also worked in the health insurance industry for a few years.

On the other hand, the government system already screwed me through “democratic” processes. I’m a Vietnam Vet, but am not eligible for VA care because at some date, they changed it from its original contract with those who served to a means tested entitlement program. If I had signed up before a totally arbitrary date, I’d be eligible all my life. I didn’t know about it in time, didn’t sign up, and hence lost a benefit guaranteed to me by the government in return for my service. Gotta love that government run stuff. OTOH, VA care is so spotty, rationed, and freqently of poor quality so I only wanted it as a last ditch backup.

My argument is to fix the system, not replace it.

See below

But if you’re the kind of person who can only get a job driving a taxi, or working as a waiter, for whatever reason, much of the time you’re just out of luck. That’s not competition–it’s the shaft.

See below

The faith that the true believers put in the ability of the market to cure all ills is so adorable. It’s like putting a tooth under your pillow when you’re 40 and hoping for a quarter.

I have no belief at all that the market can “cure all its ills.” None. So your sneer is off target.

The single payor systems throughout the world do not employ price controls (and BO’s plan did not propose them either). The rest of the world allows their govt to bargain for better prices for their citizens.

I suggest you look up the word “monopsony.” It should give you a clue.

Your idea of everyone buying plans individually would work if the health insurance market was a ‘free market’. As the market is currently constituted, it is definitely not a free market. Whenever products in a market are so uniformly configured and priced, there is something controlling that market – and it is not competition.

See below for what I really propose. As for the products in the market today, they are not nearly as uniformly configured and priced as a single payor system. A lot of the uniformity is either a result of regulation (“must cover” rules) or (duh) customer demand! If you really think insurance execs get together and conspire to produce product with no differences, then you need to go back to business 101! Furthermore, there is actually quite a disparity in coverage in individual plans.

John, the average primary care MD makes north of 300K per year, the average specialist well over 500K. Our economy can’t support that. That’s part of the problem. If government insurance cuts into their standard of living, they can ask everyone else in America what to expect.

Hey, Michelle Obama was making $350K/year as some VP for External Affairs at a not-for-profit hospital – partly for a program that steered the poor away from that hospital to other facilities. Did Michelle contribute more than a primary care MD?Oh, and the median primary care doctor makes $160K, not $300K.

And you are whining about what doctors make? An MD has to spend half his life in training, after being selected from the top of a very competitive group. On top of that, they work very long hours, are often on call, and have enormous responsibility. Paying them less that hundreds of thousands per year would be stupid – it would be a great way to create mediocrity in the doctor ranks – not to mention rationing, as we run out of doctors. I know a number of MD’s who are thinking of leaving the profession, in spite of the pay.

Furthermore, how much will you save? Knock of $100K per year from each and you get about $50 billion, less than the annual amount of Medicare fraud.

It would be better if doctors were paid for their time rather than fee-per-service, however. But it was the government that introduced the fee-per-service into the market, and since the gov controls about half the market, the insurance companies went along.

And that claim that the uninsured are being subsidized by the insured is a crock too. MDs and hospitals charge uninsured patients much *more* than they charge insurance companie

– pa
No, the uninsured are being subsidized by the insured. Not because the uninsured pay less (I have posted elsewhere on the enormous disparity – how the uninsured price for a procedure I had was $5000 while the insured price was $480), but because most of the uninsured simply do not pay. The people who get most deeply screwed by the system are those who are uninsured, responsible and not broke, because they eventually will end up broke (and then, on Medicaid).

———-

Here’s the “see below”

Universal coverage is not only a desirable goal, it is a necessity to get the system under control (and I disagree with many on the right on this). Here’s how to do it with minimal disruption and without handing your coverage decisions to a panel of government bureaucrats ( see NHC’s “NICE” commission which tried to stop access to Herceptin for breast cancer patients, among many other things). Those decisions are INTENTIONALLY handed off to a commission, removing them from the Democratic process, because the legislators do not want to be caught between the unhappy public and the rationing decisions. In Obama’s plan, the commission can only be overriden by a joint resolution of Congress.

I prefer an approach roughtly like this (you will note these is not your usual Republican talking points, and some of these proposals are in the Dem plan):

1) Require everyone to purchase basic health insurance, Subsidize those who cannot afford to do so.

2) Require insurance companies to forego medical underwriting (pre-existing conditions), a practice they must do today. You need #1 in order for #2 to work.

3) Forbid insurance recision (cancelling your policy) – an abhorrent (fortunately rare) practice of private insurance.

4)Enact strict tort reform on medical malpractice in order to cut down on “defensive medicine.” The Democrats refuse to do this becausee they get huge amounts of money from tort lawyers (i.e. corruption). Note that in a government run system, you cannot sue for malpractice at all, allowing, for example, lousy VA doctors to just keep on cutting off the wrong limbs.

5)Require EVERYONE to make co-pays for everything. This has been shown to significantly cut down on over-usage.

6)Penalize those who really abuse the system. It is not uncommon for medicaid or even the uninsured poor to call for an ambulance for a ride to the ER for routine care. It is not rare for them to use that ride just to get to that part of town.

7)End the AMA monopoly on MD licensing. I believe there are 3 fewer med school slots in the US than there were in 1970, when we had about 1/3 the population!

8)Make pre-paid health care (what most people imagine “health insurance” is) a separate category, and don’t subsidize it except for the poor. Put in insurance terms, this means start with significant deductibles, and then switch to co-pays after the deductibles are met.

9)Equalize tax treatment so individuals can deduct the cost of their health insurance the same way their employers can.

10)Make insurance regulation national, so that risk pools can be formed across multiple states.

11)Implement (through financial coercion if necessary) appropriate IT improvements in health care: electronic patient records; electronic transmission of prescriptions, lab results, path reports, etc; This should also include uniform billing systems (the current government created HIPAA billing exchange message “standard” is a gigantic joke – so I’m not sure the government can do any better next time).

12)Change government payment systems from fee-per-service to free-per-time-by-specialty, or something like that. fee-per-service rewards certain specialties at the cost of others – especialyl primary care docs.

Medical billing in more rife with fraud than the New Jersey construction industry. No argument there. But I’ve never seen any evidence that this problem is worse in Medicare than in private insurance.

If billing fraud is a big problem, there is a very obvious solution; nationalize the whole industry and put everyone who works in the sector on a pure salary. I’m in favor of that, but I doubt you are.

John, the average primary care MD makes north of 300K per year, the average specialist well over 500K. Our economy can’t support that. That’s part of the problem. If government insurance cuts into their standard of living, they can ask everyone else in America what to expect.

Besides, it’s hooey to claim that Medicare and Medicaid are cutting into their profits. Most Medicare and nearly all Medicaid patients would get no health care at all without those programs. That would reduce demand, prices, and MDs’ incomes dramatically. Besides that, providers can choose to accept Medicare or Medicaid. Most of them do accept it, which is not likely if it were unprofitable.

And that claim that the uninsured are being subsidized by the insured is a crock too. MDs and hospitals charge uninsured patients much *more* than they charge insurance companies. Check your next health care EOB. The nominal charge is what you would have paid out of pocket. It’s usually somewhere between 150% and 400% of the agreed price that the insurance company nominally pays (that will also be on the statement.) After that, the insurance company also gets pay to play kickbacks that you don’t see. You might argue that uninsured patients who do pay subsidize those who don’t, but insurance certainly does not.

a) The cost of processing and fighting over claims means that private insurance is not an appropriate way to finance routine costs, like doctor visits. Medicare doesn’t have to worry about this because, as a government funded, single payer system, they don’t have to try to push costs onto other entities the way private health insurance does.

What a joke. It is Medicare and Medicaid that cause the greatest cost shifting (other than care fo the uninsured). Just ask any hospital or doctor. Health insurance pays not just for the care of the insured, but also those on government programs.

As for claims processing – you get your choice: fraud or claims processing overhead. Medicare chose fraud, and has enormous fraud losses.

health care costs are too predictable to be suitable for insurance. People who are sick now will likely get sicker. An insurance company can’t take sick people at the same rates as healthy ones (and, despite what the Dems are saying now, there is no likelihood at all that the final bill will require this.) If they did, sick people would buy insurance and healthy ones wouldn’t, the costs would get so high that the sick ones couldn’t pay, and there would be no market at all. The only way to address this is to include everyone in a single risk pool

This is only partly true. Large risk pools are a necessity if one wants fairness or universality in insurance coverage. Large corporations provide these, as do government employers. Anyone else is subject to discrimination based on health status.

However, one need not throw out the whole system to cure this defect. Requiring mandatory coverage (with adequate disincentives to not having insurrance, unlike the plan in Mass) and requiring large pool rating by insurance companies can solve the universality problem (you also need a way to provide funds to those who cannot afford to buy insurance).

“As Wolin predicted in his book Democracy Incorporated: Managed Democracy and the Specter of Inverted Totalitarianism (Princeton, NJ: Princeton University Press, 2008): “Should Democrats somehow be elected, corporate sponsors [will] make it politically impossible for the new officeholders to alter significantly the direction of society. By offering palliatives, a Democratic administration contributes to plausible denial about the true nature of the system.” (from Paul Street, znet.org).

there are at least two severe problems with this. First, most people can’t afford around $15,000 a year for family coverage, and the government is not going to subsidize it to the extent that would be necessary-that would be far more expensive than single payer with its attendant cost reductions.

Secondly, the only way to get everyone into the same pool, at the same rates, with private insurance is to regulate it so tightly that it would lose whatever advantages competition might provide. If there is any variation at all between plans, sick people will buy the most complete plans and healthy ones will buy the cheapest. The sicko plans will quickly become too expensive for anyone to buy. I’ll note that there are other forms of insurance that are legally mandated-everyone who owns a car has to buy car insurance, employers have to buy workers’ comp-and none of them are available to everyone at the same rates either, for the same reason.

>high-risk members of the pool are
>routinely excluded by several
>ethically-challenged, deplorable tactics
>which occasionally come to light

You’re missing the really important point. It’s not that health insurance companies sometimes do dirtbag things like rescinding individual policies. It’s not even that they routinely, consistently do cynical stuff like making sick people fight with them over claims.

The real political point is that, in health care, private insurance can’t do the job no matter how ethical their business practices might be.
Everyone knows this, which is why Medicare is not really controversial. Medicare takes the part of the population that uses most actual health care services and pays for its care out of tax dollars, because private insurance can’t do it and doesn’t want to.

Private insurance can be an efficient way to finance high cost, low probability risks, like house fires or premature death. That doesn’t describe health costs.

a) The cost of processing and fighting over claims means that private insurance is not an appropriate way to finance routine costs, like doctor visits. Medicare doesn’t have to worry about this because, as a government funded, single payer system, they don’t have to try to push costs onto other entities the way private health insurance does.

b) health care costs are too predictable to be suitable for insurance. People who are sick now will likely get sicker. An insurance company can’t take sick people at the same rates as healthy ones (and, despite what the Dems are saying now, there is no likelihood at all that the final bill will require this.) If they did, sick people would buy insurance and healthy ones wouldn’t, the costs would get so high that the sick ones couldn’t pay, and there would be no market at all. The only way to address this is to include everyone in a single risk pool.

Moore, at least in a govt run system there is the possibility of influencing decision making through democratic means. Go tell your health insurer that you don’t think it’s fair that people should be charged 20% co-pays on bills over $100k because people who are convalescing from major surgery or illness should not also incur major debt. See how responsive they are to reasonable requests.

“…because the US system doesn’t price control everything (pharmceuticals, for example), US citizens subsidize the R&D that provides medical innovations to the whole world.”

The single payor systems throughout the world do not employ price controls (and BO’s plan did not propose them either). The rest of the world allows their govt to bargain for better prices for their citizens. Bargaining for a better price is a tactic that is central to the concept of free markets. Why don’t you call up Pfizer and tell them you want a 35% discount on your blood pressure medicine – let us know how successful you are with them one-on-one.

Your idea of everyone buying plans individually would work if the health insurance market was a ‘free market’. As the market is currently constituted, it is definitely not a free market. Whenever products in a market are so uniformly configured and priced, there is something controlling that market – and it is not competition.

Also, it’s a fact that huge amounts of public investment in drug research are picked up at the back end by drug companies. Moore’s “analysis” of pharma is full of holes and his “reform” proposal (everybody buy their own policy and the market will take care of all problems) is ridiculous. And the notion that the US taxpayer and consumer have to subsidize a “free ride” for everyone else, to the degree there’s any truth in that notion, is crazy. That in itself is cause for reform. And if there is a shred of evidence that investment in research is falling off because drug companies profits are squeezed, increase public investment. It can and will happen in that event. That’s the rational solution, not letting companies that have an absolutely terrible track record in how they choose to “innovate” and how they market drugs to run free.

I can guarantee you there are a dozen ways to incentivize and fully fund great medical research that will result in major innovation without just giving a free hand to Big Pharma (which I wouldn’t even allow to advertise prescription drugs to the public – that’s one of the most perverse phenomena in our “market” system of health care.)

This is increasingly untrue, however, as more and more companies don’t offer health care to their employees, or play games with their hours, keeping them just below the threshold where they would have to provide more benefits.

Globalization, the exodus of American jobs that can sustain these sorts of benefits, and their replacement by low-paying service jobs makes the notion of “choice” here laughable.

People like me, college educated and working in software, an industry where talent is in demand (but still not immune to various degrees of off-shoring), are in the only situation where there can be any notion of choice. Even so, I’ve worked at start-ups where there was no health insurance for obvious reasons, sp there are no gurantees.

But if you’re the kind of person who can only get a job driving a taxi, or working as a waiter, for whatever reason, much of the time you’re just out of luck. That’s not competition–it’s the shaft.

but still perverse compared to the individuals buying their own policies. The latter would increase the competition oriented towards what the citizens really want

The faith that the true believers put in the ability of the market to cure all ills is so adorable. It’s like putting a tooth under your pillow when you’re 40 and hoping for a quarter.

The unique aspect of the US system is that the funds are first funneled through private, profit-making entities who also control disbursement of the funds via internal decision-making which is completely out of the control of the participants whose funds finance the system.

You mean unlike centrally controlled systems, where the decision making really is out of control of the participants.

In the US, flawed as the system is, there *is* competition, either directly for private customers, or indirectly through employers. Employers have to compete for employees, and part of the competition is for benefits. If that competition didn’t exist, no employer would offer any health benefits.

Furthermore, because the US system doesn’t price control everything (pharmceuticals, for example), US citizens subsidize the R&D that provides medical innovations to the whole world.

In other words, the whole world is a free ride ron the American health consumer. If we end the private system in the US, there will be nobody left to free-ride off of, and medical innovation will fall off a cliff.

All that being said, the US system as it exists is perverse. Employers providing health insurance is better than the government doing it, but still perverse compared to the individuals buying their own policies. The latter would increase the competition oriented towards what the citizens really want – and no other system will do that. However, that won’t work unless everyone is able to buy that insurance and everyone is required to buy it.

So we need reform – just not Obamacare.

The US system of ‘private’ health insurance and the single payor systems both socialize the costs of health care. The main differences being that the single payor systems include all of their citizens while the US system is limited to those who have access to, and are accepted by, private businesses through which the health care funding is routed. The private businesses – accountable only to themselves (aside from meager, weak govt safeguards) siphon off up to a third of the health care funds provided by the consumers (to profits, extravagant and misleading advertising campaigns etc) before placing the funds into the risk pool. The US system’s risk pool is decidedly different from its European and Canadian counterpart: high-risk members of the pool are routinely excluded by several ethically-challenged, deplorable tactics which occasionally come to light (though curiously forgotten by the mainstream media during the past few months).

Both systems spread, or socialize, the risk among the participants. The unique aspect of the US system is that the funds are first funneled through private, profit-making entities who also control disbursement of the funds via internal decision-making which is completely out of the control of the participants whose funds finance the system.

Occasional challenges to the US system elicit huge advertising campaigns by the health insurance industry in favor of an unpopular status quo. The funding of these multimillion dollar campaigns coming from the one-third of the participant’s healthcare dollars that the insurance companies skim off the top.

It would be hard to imagine a more undemocratic system of health care funding – and impossible to find one that is simultaneously more expensive and has worse outcomes. Whatever the arguments are, for or against the meager reforms offered by the centrist Obama administration, it’s clear corporate america has no problem with socializing costs so long as they get their take of the consumers money and can control how the money is spent.

John, do you work in the private sector? It’s full of rent seekers, side deals, people stealing from their employers and stockholders, and all kinds of corruption. Oops, maybe I shouldn’t talk about the private sector at all-it ought to be clear now to everyone that “privatte investors” are ultimately playing with the taxpers’money.

Yes, I do. And parts of the private sectory – primarily in the finance area – are indeed out of control. It’s an agency problem that’s been growing with quite a while. However, saying they are playing with “taxpayer’s money” is a bizarre way of putting it. If that’s true, then we should cut down the size of government, which will mean there’s less taxpayer money going into that sector – right?

The biggest hit those folks made was closely tired to government action – namely the government pushing for more and more housing, reducing lending standards, and outright financing big chunks of it (Fannie/Freddie).

That problem is mostly confined to certain specific areas of the economy: finance, and executive compensation in large publicly held corporations. In general, the system works pretty well outside of that.

I’m not claiming that the private sector is perfect and the government is always wrong. I am claiming that government spending is usually much worse of in areas of efficiency and corruption. The left, ironically, sees this clearly in the military-industrial complex, while missing it in the enormous entitlemenets complex, where it is far more damaging. THe huge amount of government money flowing into research quite often is very corrupting to science – producing lots of work product but, because of funding bureaucracies and other effects, promoting established theories at the expense of breakthrough new ideas. How many billions has the government spent over the last 50 years trying to engineer fusion? All but the tiniest amount of money goes into one problematic approach: Tokomaks. That’s typical of government funded research – it creates constituencies (in this cases, the magnetic confinement folks) who then dominate it.

COmpetition, in the areas where it can work (which certainly includes pharmaceutical development), breaks up that sort of consensus lock, because if the consensus is wrong, someone can make a huge amount of money at it.

Just look at the human genome project… the government was creeping along, but private industry – Ventner – came up with much more innovative approaches and beat them by years. The result of that work, and the private demand for DNA technology, is driving a boom in privately funded research and development that has produced a better-than-Moore’s-law rate of improvement in DNA sequencing and synthesis. DO you think your government did that? Uh uh.

That’s the bullshit line pharma has been using for years. In reality, they finance only the final stage of research, clinical trials. Substantially all the basic science and development are done in universities at taxpayer expense. Pharma is profiteering off our taxes, just like the financial companies.

By your definition, Apple is profiteering off our taxes, too, because it takes advantage of government research. Your internet provider is profiteering off the work of ARPA. Everyone is profiteering off the noble government efforts.

Somehow, the idea that the government does part of the work and business does most of the rest seems to be immoral to you.

What nonsense.

Government does a lot of basic research, but basic research is just that – basic. When it gets to engineering time, private enterprise does a much better job. I don’t know if you’ve ever worked in government-sponsored research, but I have, and my father’s has been doing it for 60 years. The government is riddled with inefficiencies, ideologically driven agendas, and bureaucratic nonsense. Nevertheless, it is neceswsary for many areas, because we need, in science, research that has no obvious payoffs.

When you want medicine, though, you also need a whole lot of direced research focused on payofs. And that’s what pharma does. Have you noticed the tremendous activity in new pharamceutical companies popping up all over the lot? They are incentivized to do that by the profit motive (in the shorter term, by equity investment payoffs), and it is there that you will see lots of benefits. And guess what – when one of them gets successful, it’s likely that “big pharma,” those evil bastards, will buy that company and capitalize on it sexpertise, more quickly moving the results down the pipeline into your bloodstream or mine.

Pharma, btw, does do basic research, in spite of your statements. It does a lot of basic research and a huge amount of drug discovery. The reason is because it cneeds to due to competition and a profit motive focusing the efforts and keeping it from bloat. When my daughter was working on fundamental genetic research into causes of schizophrenia (using NAS money), their biggest competitor for publishing first was a private pharma company. It was doing very advanced basic neurological research.

You’re right, though, any proper definition of socialism has to involve actual socialized production, like the British NHS. Government insurance that just uses tax money to pay for services produced in the private sector, as in Canada, is better described as a welfare-state program, but “welfare” is an even dirtier word in the US than socialism.

Just saying…because this talk about “socialism” when fanning the flames of against reforms aimed at universal insurance is generally absurd. Here, for example, is the notoriously pro-capitalist Business Week on the French system:

http://www.businessweek.com/magazine/content/07_28/b4042070.htm

It means socialism is more efficient than capitalism, at least in the health care sector.

Not sure why you think I’d be surprised that Obama caved to Pharma. The only thing I am surprised about is that, when BHO offered the insurance companies a multi-trillion dollar gift out of our pockets, in the form of a legal mandate to buy their products, they didn’t have the sense to take it.

John, do you work in the private sector? It’s full of rent seekers, side deals, people stealing from their employers and stockholders, and all kinds of corruption. Oops, maybe I shouldn’t talk about the private sector at all-it ought to be clear now to everyone that “privatte investors” are ultimately playing with the taxpers’money.

>BTW, big pharma’s internal rate of
>return on research is now only 7.5%
>– not enough to make the investment >sustainable.

That’s the bullshit line pharma has been using for years. In reality, they finance only the final stage of research, clinical trials. Substantially all the basic science and development are done in universities at taxpayer expense. Pharma is profiteering off our taxes, just like the financial companies.