Health Care in your country

[betahat]

A historic victory yesterday for health care reform in the US. Moving in the right direction - the richest country in the world will have a less shameful number of citizens without basic medical coverage due to poverty or pre-existing conditions.
The main changes coming are (a)no discrimination based on pre-existing conditions, no dropping sick patients, and no lifetime caps on coverage benefits, (b)subsidies on a sliding scale for people with incomes less than 88,000 all to be paid for by (c)cost-control measures for the public system (medicare,medicaid) and (d)taxes on high income individuals and "cadillac" health insurance plans (over 27K per year for an individual).
Interestingly they were also going to tax plastic cosmetic surgery, but instead decided to put a 10% tax on tanning salons.

What do you think about healthcare in your country? How much are doctors paid? Do you think there are ways to improve it without hurting someone else, or is healthcare all about distribution and not efficiency?

My family has only had positive experiences with the Canadian (single-payer, private doctors but highly regulated with little private competition) healthcare system, but I know some people have had issues. My wife likes the US care she has but she has/had really good insurance in one of the richest parts of the country, certainly not a reflection of the quality of care of most Americans.

[Ganbare!]

Passionating topic.

I've had a good experience with the Canadian healthcare system as a kid but it's seriously starting to deteriorate because of the lack of medical personnel, months-long wait to get an appointment with specialists, overcrowded emergency rooms (at least in large cities), all these trends are gradually becoming common. National health professionals selfish monopoly, unprecedented levels of demographic growth and an aging Caucasian population are all behind these problems. Many skilled foreign doctors could work in our hospitals but no wait, they are required to start their curricula from scratch like Canadian health studies were vastly superior to other countries' . The US clearly benefits from that failed policy by attracting these physicians. Canadian labour laws and 'compulsory local experience' HR recruitment practices targeting foreign workers are so damaging.

As for the French one, generally considered as the World's best, very selective and longest medical training in the OCDE, state-funded universal protection/drugs, little competition from the private sector, geographically concentrated in the capital region and the riviera, so if you happen to live in these areas, you can book an appointment and actually see the physician in a few hours/days time. Obviously, wages are good from $100k to up to 500k+. Rural areas sadly lack doctors and infrastructures. Sadly, this system is far from being financially effective given it's the main factor responsible for the country's massive public debt, another challenge it's facing is the decreasing numbers of medical practicioners however this socialized medecine system also heavily contributed to the country's high life expectancy ranking (2nd) so I suppose it could be worse.

I have so many things to say about the topic but I'm getting late... Anyways, Barack is Black Jesus and American pharmaceutical shareholders must have celebrated the night drinking $10000 bottles of champaign.

[palavore]

Beta, here's a link to an American documentary on health care in other countries: FRONTLINE: Sick Around the World

When I was in Hong Kong with my aunt, she complained about their "socialized medicine" or public hospitals. She works behind a desk for a pharmaceutical company. I worked in a medical laboratory with doctors and patients. Yet somehow we're on the opposite ends of the political spectrum and on the issue of health care reform in the U.S.

I'm not going get into the details of the recent health care reform attempts in the U.S.--except to say that it is pathetic and corrupted. Following the example of Switzerland should have been the bare minimum for health insurance reform. That doesn't include the problems associated with the U.S. health care system: the bad behavior of the pharmaceutical industry, doctors, and patients.

The stock prices of the U.S. health insurance companies went up. Things really did move in the "right direction" for for-profit health care.

[admin]

I was working in Taiwan and felt very sick. I got there a day before the other folks in the meeting and was on my own. I saw a hospital near the hotel and somehow dragged myself in. They issued me an ID card and I saw a doctor in about 30 minutes who sent me to another group of doctors who examined me, gave me some tests, and stuck around until they got the results. They prescribed a couple of drugs for me, had someone walk me down to the pharmacy. At the pharmacy, I got presented with the entire bill (not just for the drugs). I had to pay for 2 consultations, some tests, and the drugs.

Total cost, $14.

Yeah, something is wrong with the U.S. health care system and my spidey sense tells me Mr. Obama didn't do anything to fix it.

[Ganbare!]

People always find a way to complain, we're talking about people that would leave hospitals with knife wounds because they couldn't pay the bill, thinking too much in terms of money is inhumane, it's not perfect but it still going the right direction.

Importing the Swiss system to the US is nigh impossible, the two countries have nothing in common. For starters it's much smaller, has one of the highest gdp and lower income disparities. The population is very civic, respect laws, it has one of the lowest crime rate in the West. You are mad to think the US could pull it off. I'd pay more taxes for social peace ANYTIME considering how many people the excessive cost of healthcare has pushed over the edge.

[betahat]

My understanding is that the US spends about 1 trillion more per year than a comparable country for healthcare, with about 400 billion going to higher salaries for healthcare providers, 300 billion going to "unnecessary, inappropriate, ineffective, and positively harmful care prescribed by doctors who fear malpractice liability, have sweetheart deals with those entities with which they subcontract, or simply do not know what treatment protocols are worth doing" and 300 billion on administration by insurance companies screening and denying coverage.

My understanding of this bill is that it will have no effect on salaries, it will cut out some of the inefficiencies in parts two and three by implementing some cost controls in the public system, promoting competition among private providers and somewhat limiting their ability to (and hence willingness to invest resources in) screening and coverage denial. On the other hand it adds about 33 million new people to the system, which is why the CBO puts it at budget neutral or a slight positive over a 10 year horizon.

I'm mostly excited about the increased coverage - it might be a crappy, bloated, inefficient system (or the best in the world with the highest paid doctors and best technology, depending on how you look at it), but increasing the profits of a few corporations or raising taxes on some rich people seems like a fair trade-off to me to get 33 million coverage and reduce the number of people who die every year due to lack of insurance from its current estimate of about 40,000 a year.

[palavore]

Mar 23, 2010 15:56:11 GMT -5 betahat said:

On the other hand it adds about 33 million new people to the system, which is why the CBO puts it at budget neutral or a slight positive over a 10 year horizon.

I'm mostly excited about the increased coverage - it might be a crappy, bloated, inefficient system (or the best in the world with the highest paid doctors and best technology, depending on how you look at it), but increasing the profits of a few corporations or raising taxes on some rich people seems like a fair trade-off to me to get 33 million coverage and reduce the number of people who die every year due to lack of insurance from its current estimate of about 40,000 a year.

Nobody is getting anything for free in this reform bill. In order to be budget neutral, most of the insurance subsidies will come from cuts in Medicare. We've got an inefficient health care system, yet the response has been to put more public money into that system. <-- Stupid.

Nobody is getting anything free because they're being mandated to buy insurance. This won't have any affect on those who are already covered by their employer. The cost of health care will continue to go up. This is like tolerating chronically high unemployment. The sooner the government acts, the better off our economy.

Regarding profits. The health insurance industry in the U.S. behaves like a cartel. Now they've got a captive market and government subsidies. This is like giving free lunches to the bullies who stole your lunch money.

Regarding taxes. When did taxing union health plans become taxing the rich? I expected this form of regressive taxation from Republicans--not Democrats.

Not everyone will be covered. The poison pill: Insurance companies might not be able to drop you or deny you based on pre-existing conditions, but if you can't afford the premiums you drop yourself. "We don't have to discriminate, because our prices already do."

Under-insured is still insured. Without addressing cost, we're still going to accumulate an unsustainable amount to debt (public and private) in the U.S. health care system. Moving it around the system won't hide it.

Summary: The recent health care reform bills treat the symptoms--not the disease. The U.S. health care system is still moving towards inevitable. What the U.S. Congress just passed was a placebo. Without taking lessons and following examples from around the world, the U.S. continues to remain in denial.

I wrote too much, but I hope you understand my position Beta.

[betahat]

^Nobody is getting anything for free in this reform bill.

Nobody said they were.

^ most of the insurance subsidies will come from cuts in Medicare.

True, exactly what I said above. Is that a bad thing? You seem to be in favor of cost controls.

^Nobody is getting anything free because they're being mandated to buy insurance. This won't have any affect on those who are already covered by their employer. The cost of health care will continue to go up.

Well, a big part of the cost of the program is subsidies. Those subsidies are very progressive - medicaid expanded to 33% above the poverty line (about 30K for a family of four) with sliding subsidies up to 88K for a family of four. This cost is a direct transfer from the rich to the poor. Yes, that includes some union members (with health plans worth over 24K) versus people in s***ty paying non-unionized jobs with no health care.
I don't think you can analyze the plan fairly and conclude that it has a progressive impact, even without thinking about potential increases in the top marginal rate that are coming anyway (e.g. repealing the Bush tax cuts on the top 1%).


^This is like tolerating chronically high unemployment. The sooner the government acts, the better off our economy.

I agree here, but you're sounding a bit like a Marxist who wants things to get worse so that we will get the grand single-payer revolution. My reading of US politics these days is that things don't work that way (though maybe I am misreading the lesson of the great depression and subsequent rise of the US welfare state). I wish we had 300 progressive democrats in congress and 70 in the senate and we could pass the Kucinich plan or whatever, but to quote a much overused phrase these days, I don't want to make the perfect the enemy of the good.


^Regarding profits. The health insurance industry in the U.S. behaves like a cartel. Now they've got a captive market and government subsidies. This is like giving free lunches to the bullies who stole your lunch money.

Well, that's what the public option is for. I don't know if the health insurance exchange will do a whole lot to control costs in the private market by increasing competition, but the public option is waiting there in the wings. I'm interested to see what the bill will do as is, since it stipulates that the exchanges must include a not for profit (but private) insurance option.
Of course, there are lots of "profits" (or rents as we economists would call them) throughout the system, and the ones related to doctors and nurses salaries, pharmaceuticals, etc. probably dwarf the actual profits of private insurance companies, and these are not addressed at all.

^Not everyone will be covered. The poison pill: Insurance companies might not be able to drop you or deny you based on pre-existing conditions, but if you can't afford the premiums you drop yourself. "We don't have to discriminate, because our prices already do."

If you look closely, the high-risk/pre-existing people are going into a (heavily) subsidized pool at first, with the idea that they will move to the exchanges as they develop around 2014. Now I don't know how well these exchanges are going to work, but if they maintain the status quo in terms of screwing over these individuals, I have no doubt we will get a public option.


I wrote too much too! Perhaps I should just ask you a few questions instead of trying to argue with you point by point - do you think this bill is worse than having no health care bill for the next decade? I think we both agree that much, much more needs to be done and we would probably agree on a lot of the specifics of what that the ideal system looks like. We both would have liked a different bill. But my point being, would you take this over nothing? You seem to have an alternative worldview where this doesn't get passed, and then sometime in the next few years we get your dream bill. But what about the politics, as opposed to the policy?

Suppose this bill did nothing other than cover 33 million extra people, by paying insurance companies with public money, gained by the progressive income tax system. Can you really object to that?

[palavore]

Mar 24, 2010 18:04:50 GMT -5 betahat said:

wish we had 300 progressive democrats in congress and 70 in the senate and we could pass the Kucinich plan or whatever, but to quote a much overused phrase these days, I don't want to make the perfect the enemy of the good.

What I see is mediocrity making friends with the status quo. Now the U.S. has got a wait-and-see period of several years (as the bill produces its effect) before realizing how little it has changed and how much initiative they've wasted.

But my point being, would you take this over nothing? You seem to have an alternative worldview where this doesn't get passed, and then sometime in the next few years we get your dream bill. But what about the politics, as opposed to the policy?

Suppose this bill did nothing other than cover 33 million extra people, by paying insurance companies with public money, gained by the progressive income tax system. Can you really object to that?

That makes this discussion solely about welfare reform not health care reform. It's this masquerade that really injures the reform process and the national dialogue. We're stuffing public welfare through the gaping mouth of the private sector in the hopes that something will fall out the other end for the birds. Shouldn't this be called Vodoo socialism or trickle down corporate welfare?

Redistributing care through taxation, like redistributing wealth, is an artificial method stabilizing societies that might otherwise lead to unrest. The problem is inherent within the system. We shouldn't pretend to fix things that are broken. That leads to a greater crisis.

Regarding what you see as being an inflexible Marxist. Full equality under the law was the goal of the civil rights movement. Had they settled for less at the time, the U.S. would have had a far more painful history.

Wrote too much again.

[betahat]

^ before realizing how little it has changed and how much initiative they've wasted.

So you really do think they could have gotten a better bill if they had just stuck it out or something. Were you envisioning big gains for the Democrats in the mid-term elections. Sure don't look that way.

^Full equality under the law was the goal of the civil rights movement. Had they settled for less at the time, the U.S. would have had a far more painful history.

Fair enough, but ending slavery was a first step towards that - however imperfect and cruel the fate of southern blacks during and after reconstruction. As imperfect as that was.

^Redistributing care through taxation, like redistributing wealth, is an artificial method stabilizing societies that might otherwise lead to unrest

Yes, social democracy and the welfare state is the enemy of a Marxist revolution, because it is aimed at preserving capitalism. Maybe we do have a fundmental disagreement - while I'm not in favor of market-based healthcare, I do believe in capitalism fundamentally, albeit with lots of redistribution, regulation, and government involvement.

I guess we just see the politics of this differently - I think achieving close to full coverage is really a precursor to more serious reform. It fixes one of the fundmental problems of the American system while leaving the other one unchanged. Maybe having all of the health care costs out in the open - including the cost of subsidies paid to insurance companies - will actually spark debate about serious reforms? Perhaps I'm just optimistic. I know that reforming any health care system is really hard, including in places that face rising costs but have single-payer universal coverage like Canada. There is lots of inertia and resistance by stakeholders. So I take your point that this reform could make future reforms harder, but my sense is that those other reforms - like cutting doctors and nurses salaries in half, ending disparities in drug prices, and completely crushing the private insurance and medical litigation industries - are going to be damned hard and would have been damned hard (and unlikely) even if this bill went down in flames or had never been proposed. I don't know how the US will ever get to a place politically where they will tackle the long-term health care cost issue - they'll need a lot more than black jesus.

[palavore]

Mar 25, 2010 14:22:49 GMT -5 betahat said:

Yes, social democracy and the welfare state is the enemy of a Marxist revolution, because it is aimed at preserving capitalism. Maybe we do have a fundmental disagreement - while I'm not in favor of market-based healthcare, I do believe in capitalism fundamentally, albeit with lots of redistribution, regulation, and government involvement.

I guess we just see the politics of this differently - I think achieving close to full coverage is really a precursor to more serious reform.

I think you're trying to marginalize my views through comparison to some Marxist revolution. It's quite a sensible position. It's not a matter of political ideology, but competence. Other countries have achieved better patient outcomes at a better cost within markets or without markets. It can be done, it has been done, without a Marxist revolution, if the labor is done under competent government.

Indeed, I would have been happy had the U.S. adopted Swiss style health insurance reform not because it was a Marxist revolution--the Swiss still have private insurance--but because it was competent and solely within the public interest.

I'll give you today's glaring contradiction/hypocrisy. The U.S. administration wants to eliminate the middleman (the markets) from the student loan program which the government subsidizes and guarantees. The House has already passed a bill. It's more cost effective for the government to lend directly than to share profits with the banks. The recent health care bill was a stunning reversal of this logic. Medicare and Medicaid are responsible for over half of the U.S. health care expenditures. They have lower administrative costs. They are the lower cost vehicle for delivering health services. Yet the U.S. government has chosen to subsidize and guarantee (through mandates) the health insurance policies of the private sector.

Now, I'm not a radical enemy of all markets. I'm the radical enemy of markets that do not work. I saw this move as business sneaking into the government under the guise of social welfare, which also disturbs the market purists on my right.

- Why can't people buy/afford health insurance?

- Why did insurance companies drop their policy holders?

- Why are drugs, medical procedures, and hospital stays so expensive?

- Why do doctors perform and prescribe them so often?

- Why do patients want them?

These questions need to answered not substituted under a different context.

"Her Majesty! Her Majesty! The people have no health care."

"Then let them buy insurance."

[betahat]

^I think you're trying to marginalize my views through comparison to some Marxist revolution.

Not really. I'm trying to convince you that incrementalism can work and that the health care system we both want is MORE likely to happen as a result of the passage of this bill. It's an argument about tactics, not "goals," Marxist or otherwise. I just see a lot of parallels between resistance by Marxists to social democracy and the type of argument you are making, but those are similarities of the form of argument - criticizing a progressive policy because it is imperfect and will satiate the masses' will to reform, postponing or preventing more radical change - and not similarities of substance.

Other than (a)our disagreement about how this bill will affect future reform prospects and (b)your objection to insurance companies making more profits (a price I am willing to pay to the Gods of political expediency to get an extra 30 million people covered and fix some of the problems with screening and denial of coverage) I think we're on the same page.

You never directly answered the question I asked before - was this bill better than nothing? - but I'll assume that we agree to disagree about whether this bill was better than nothing, and that we agree to agree that this bill leaves a lot to be desired.

[jefe]

Have we defined Health Care here? If it is not the same as medicine, as welfare, what is it? Are we referring to the health of the society as a whole (thereby including matters such as public hygiene)? And how do we measure health care? Spending as a % of GNP? Longetivity? Prevalence of certain diseases? Infant Mortality? Some will say that the USA has the best health care in the world; some will argue that it is near the bottom for industrialized countries. Certainly, depending on how you long at it, both are true. Whatever it is, the USA spends more money for it and by *some* measures, seem not to get a lot of bang for their buck - the system existing heretofore did not seem sustainable. By some other measures, the USA does benefit (esp. with the development of new surgical techniques, new technology and new pharmaceuticals). Before we can answer the questions posed above, we might should discuss what health care is and what it is not. I doubt we can agree on that.

THEN, we have to agree what is the appropriate social responsibility of health care. Is it like police and fire protection, the military, education,etc (ie, basic public provision, but individuals can spend more for more service)? Or like transportation? (which is partially subsidized by public funds for everyone) Or is like food, clothing, shelter (which can be subsidized by public money for individuals who need it)? Or is it more like getting haircuts (something everyone needs from time to time, but which are not part of any welfare system or insurance)?

I do have *some* experience in the area.

- Lived for very long periods in the USA and in HK, and short periods in Malaysia, Japan, Taiwan, etc.
- used public and private sector health care services in several different countries
- Worked for the finance department of public hospital in NYC
- worked for a health insurance company in New York
- have 20 years experience in employee benefits and actuarial consulting in DC, NY and HK
- studied (through work and professional exams) about health care delivery systems, including both private insurance and social insurance in multiple countries

[palavore]

^ Yes, having health insurance doesn't mean having health care. Perspective is important here. Some people are in outer space in terms of health care in U.S.--with spectacular, expensive, and experimental treatments--subsidized by public money and insurance.

More people, however, lack access to the basic services because they can't afford it (with or without insurance) and when they have to use it (emergency room), they are charged up to 3 times more than what a patient with insurance would've been charged because they lack the negotiating power of insurance companies.

I'd put people 4 tiers or perspectives:

- First class high health care utilizers (those in outer space)
- Worker bees (those who pay into the system)
- Health care underclass (those indebted to the system)
- The untouchables (healthy, uninsured, can pay out of pocket)

Now, people are always moving in between tiers, but this is basically the class system of U.S. health care.

The growth of high utilizers causes the worker bees to complain about the rise in premiums. The underclass creates instability with hospitals causing some of them to shut down without financial support from the public. Untouchables, despite overpaying for the few services they receive aren't doing anything for anyone else. The health insurance industry is the guardian into the first class--kicking at risk worker bees and some high utilizers into the underclass which creates problems for everyone else.

Mar 28, 2010 19:02:39 GMT -5 betahat said:

You never directly answered the question I asked before - was this bill better than nothing? - but I'll assume that we agree to disagree about whether this bill was better than nothing, and that we agree to agree that this bill leaves a lot to be desired.

Many of supporters of this health care bill subscribed to that idea of false choice. That something was better than nothing, even if it would set them back from their real goals. I do not believe in false choices nor will I present you false choices of my own.

I do think incrementalism can work, if you are moving forward and problem isn't immediate. But even the increments here are bad. Smaller increments could've more easily passed the welfare expansions--but that ought to have been a separate issue altogether. The new series of health care reform in the U.S. should have started with a gradual wearing down of the opposition interests in the health care system beginning with the health insurance industry. What resulted instead was a consummation of political interests. The way I see it now, the insurance companies aren't collecting profits, they're collecting taxes.

You say that our disagreement is solely on process--not substance. But substance of this bill ruins every process that I can think of... It just isn't a competent bill and the pillars that it formed (mandates and subsidies) can't be easily touched by future reform. Cost was the disease causing all the symptoms and they yet haven't even put a band-aid on it.

[betahat]

^Many of supporters of this health care bill subscribed to that idea of false choice.

While asking you how you would vote as a member of the Senate or House is a hypothetical, it is not a false choice. If you can't even answer that simple question - would you have voted to support the bill or would you have voted with the 34 democrats and all of the Republicans who voted against it - then we're not having a discussion about the politics or process at all.
Obviously you would be pushing for a more liberal bill - and maybe you'd be better than Dennis Kucinich or Bernie Sanders at convincing your senate and house democratic colleagues from conservative, republican districts to suppor your bill - but at the end of the day you would be in the same position that they were in - vote yes or no.

Which is precisely where I'm pushing you, even though you clearly don't want to go there. I read a lot of liberal blogs that cover both the policy and the politics of this reform and you might be the most pessimistic person I've encountered in terms of your views about what this bill does and what it means for future reform. So I'm just trying to understand where you're coming from - you seem so confident that they could have gotten a better bill through either now or in the near future. Help me see the light.

I guess we disagree about the substance more than I thought as well. Since the way I see it, the compromise that increased coverage for this bill did require some significant measures to cut costs - how else would the CBO have scored the bill as deficit reducing despite increasing coverage and subsidies massively? - and I do think it will be possible to build on those measures. I do think the door is very much open to a public option, "medicare for all," etc. depending on how the experiment with health care exchanges works out.
I actually think that solving coverage first will make it easier to focus on costs in the future.
But again, now we are getting back into what ifs and the politics of (future) reform, not the design of optimal policy. Getting outside the politics and future reforms (like the Palavore Single-Payer Universal Healthcare Act of 2013) the only reason you have given me for objecting to the substance of this bill - "ruins every process that I can think of... It just isn't a competent bill" - seems largely base on your hatred for insurance companies potentially increasing their profits as a result (the stock market evidence is still ambiguous here). Although it sounds like you don't like mandates either (though I can't see how any progressive person can object to a mandate combined with a generous system of means-tested government subsidies compared to the status quo) and you don't like the cadillac tax since it affects some union health insurance plans in high cost states (even though this is one of the most obvious cost control measures in the plan, and expensive union health plans would either get taxed or get worse under a lot of other pro-efficiency, egalitarian health reforms).