Quote: Original post by Zahlman

Quote: Original post by LessBread
One more thing, with regard to the car insurance model. Private insurance failed to cover every car here in California, so the state had to step in and offer a basic liability package for motorists too poor to afford private coverage. It's not free, but it's cheaper. And it's not available to everyone, only to those who qualify.

IMO, if you can't afford to insure your car, you shouldn't have bought the car in the first place. OTOH, IMO, hardly anyone should own a car anyway. :)

I generally agree, however, I have to ask if you've ever visited California because if you haven't, it's damn difficult to live here if you don't have a car. Public transportation is weak, it's super hot in the summer in the valley (too hot to ride a bicycle) and very hilly on the coasts (and not everyone is fit enough to manage the hills on a bike).

I should also add that I'm not absolutely certain of the claim I made. I might have mistaken a "trial balloon" for the real thing.



This last Saturday, Paul Krugman blogged about using the free market to provide health care: Why markets can’t cure healthcare. He recaps an analysis of the topic done by Kenneth Arrow back in 1963, "Uncertainty and the welfare economics of health care" (with a link to the pdf). Both the blog post and the paper are worth the read.

Quote:
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This tells you right away that health care can’t be sold like bread. It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up making decisions about what to buy. Consumer choice is nonsense when it comes to health care. And you can’t just trust insurance companies either — they’re not in business for their health, or yours.

This problem is made worse by the fact that actually paying for your health care is a loss from an insurers’ point of view — they actually refer to it as “medical costs.” This means both that insurers try to deny as many claims as possible, and that they try to avoid covering people who are actually likely to need care. Both of these strategies use a lot of resources, which is why private insurance has much higher administrative costs than single-payer systems. And since there’s a widespread sense that our fellow citizens should get the care we need — not everyone agrees, but most do — this means that private insurance basically spends a lot of money on socially destructive activities.
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Quote: Original post by laeuchli
A fine philosophy, but not really practical, at least in Southern California. Maybe if you live near San Fran. the public transport is a little better, and things are closer together, but I cant speak to that personally.

Manhattan is the best it gets in the US in terms of public transportation: you can live in Manhattan without owning a car and be quite comfortable. Brooklyn and Queens? Not so much.

Washington D.C. is the next step down. It has about five lines and they do a great job as a commuter resource to bring people in from the suburbs, but unless you live right in the heart of D.C. you'll find it tough going.

San Francisco comes next. Note that both the BART system around San Francisco and the WMATA system around Washington D.C. do not run 24 hours a day. New York's MTA is probably alone in that regard. While the BART system is clean and efficient, it has a limited number of lines. Also, within San Francisco, it is severely limited, as the system is more of a regional commuter line than a metropolitan area transit solution. Ditto WMATA, basically.

Honorable mention, I guess, goes to Chicago for the El, but it's the system I know the least about, having never actually ridden it.

Basically, in the US, you need a car. Period. I recall my first semester (of three) in Greensboro, NC, when I went to the school's information desk and asked for a map for the bus system. I was coming from Ithaca, where the TCAT system was pretty decent, as long as you wanted to basically commute between Downtown, Cornell and the mall (maybe with an occasional excursion to Cortland), and do so during the day. The lady at the information desk looked at me and said, "Honey, don't take the bus." I would later learn that the bus was notoriously unreliable and the drivers were poorly trained, sometimes causing near-misses or even actual accidents.

Just thought I'd share. [smile]

Quote: Original post by Oluseyi

Quote: Original post by Eelco
<stuff>

I will no longer be responding to you. You have no interest in a discussion of improving the system. Congratulations. "You win at the internets."

Congratulations. You have ejected from the discussion over an inability to admit a simple mistake.

Quote: Original post by Eelco
Like i said, i think the case for nationalizing emergency care is strong.

It is my understanding that this is already the case though; that US hospitals are not allowed to refuse emergency care. Which is a rather fucked solution, as it leaves the questions as for whom to foot the bill completely open.

An insurance company making deals for non-emergency care is fine with me, but i wouldnt take a contract that skips on emergency care.

Only nationalizing emergency care would be quite foolish. Setting aside the issues of ownership of the emergency rooms, emergency care is very expensive. The US has excellent trauma care (it's a positive by-product of the military industrial complex - we know how to deal with bullet wounds and car accidents). But emergency rooms are not well suited for dealing with everyday maladies or for treating manageable conditions that should be dealt with by family physicians long before they become emergencies. People shouldn't have to wait until a cold becomes bronchitis becomes pneumonia before rushing to the ER to see a doctor. Nationalizing emergency care without nationalizing family care would be a recipe for financial disaster.

At any rate, here's my story about using the ER. Some time ago I had no health care and no dental care. I had a cavity that began to ache. I dealt with it for six months by taking aspirin and gargling with salt water and antiseptic mouthwash. I have a pretty high tolerance for pain, so the discomfort was manageable. Unfortunately, the cavity was close to the gum line and it got infected and within the space of two hours caused my cheek to swell up to a noticeable size. This was on a Tuesday evening. I took some aspirin and went to bed. I figured I would see if a good night's rest would make a difference before going to the ER. It didn't.

The next day I went to the ER. I arrived at 9 am. The waiting room was already packed. I was able to see a nurse for triage within 30 minutes. So far so good I thought. The nurse took my temperature, asked me some questions and then sent me back out to the waiting room. They called my name an hour later, not to see a doctor but to see the woman who dealt with people's insurance. I told her I had none. She told me about a medical indigency program that the county offered. She didn't sign me up for it, she didn't even give me a brochure about it or tell me where to go or who to talk about the program. The hospital was a public-private hospital. She sent me back to the waiting room. I waited for a very long time.

While I waited I watched the other people in the waiting room. There were at least 100, probably 200 through the course of the day. From what I could tell, most of the other people had various kinds of colds. No one had broken bones. One man came in with a badly cut hand, the kind of trauma ordinarily associated with an ER. I waited all day.

I didn't see a doctor until 9:30 pm. He gave me painkiller and an antibiotic and a prescription for more and said he would refer me to the county dentist for an appointment for the next day. I got home at 11 pm.

The next day I woke up early and went to see the dentist the doctor had referred me too. I thought I would be on the list of appointments. I was wrong. It was first come first serve. Fortunately, I got there early enough to get an appointment. I later learned that they only provide service to the public on Thursday. I was lucky because it was Thursday. I had to wait again (and by now the pain killers had worn off).

While I was waiting I went to deal with the medical indigency paperwork. Luckily the office was in the same complex so I didn't have to walk very far. And even more luckily for me, they let dental patients cut in line, so I didn't have to wait for the 25 people ahead of me to talk to a social worker. I finally saw a dentist at 2 pm. He lanced the abcess and told me I needed to have the tooth pulled, but that couldn't be done until after the swelling went down. At least with that taken care of I could get to the pharmacy and use the medical indigency to pay for the pills. Again, I was lucky and got to cut in line. I finally got home a little after 5 pm.

I went back a week later and had the tooth pulled. For that procedure they actually set up an appointment. The care I received was fine. It was just as good as the care I received when I had insurance. But I had to wait two entire days that first week. Since I wasn't working at the time, I had the time to wait. If I had been working at a job that didn't provide health care, I probably would have been fired for missing two days straight in the middle of the week. All of that could have been avoided by a two hour visit to the dentist two months earlier, but since I didn't have insurance, I didn't do that. I coped with the problem as best I could until I no longer could and then I went to the ER. The bill for the ER was $2000. The medical indigency program covered it, so I didn't have to pay. I don't know how much the pills cost or the two visits to the dentist. Another $1000 at least. They didn't send me a bill for that. The bottom line is that the ER is no substitute for a solid health care plan. What could have been fixed for $500, ended up costing six times as much.

By emergency care, i was more thinking of people no longer able to walk to a hospital themselves.

But i agree, making emergency care free does introduce a slippery slope.

Quote: Original post by Eelco
Congratulations. You have ejected from the discussion over an inability to admit a simple mistake.

You're still not discussing improving the system...

The US is facing an actual crisis in healthcare, especially when you consider that the boomer generation will be retiring soon and further overloading an already overloaded system, but we can't even have an honest conversation about the easy stuff right now because opponents of nationalized healthcare reduce everything to flippant soundbites - "socialism!", "taxes!". In that grand tradition, you're ignoring the steak and potatoes of the discussion to focus on the garnishing snippet of parsley that is the supposed confusion over "savings plans."

Who. Gives. A. Fuck?

Is a savings plan a viable strategy for dealing with healthcare? How does it cover the costs of catastrophic incidents like cancer? If it doesn't, what is your proposed alternative to cover such incidents?

I "eject" because I feel frustrated that all you want to do is distract from a real discussion of the core problems, and I feel - without any factual basis, just an unjustified perspective - that it's because you have nothing to contribute on the core issues other than an occasional admission that something being proposed "makes sense."

I don't care about arguments the way I used to. I don't want to "win," I really don't even want to engage. I want to get to the point and either learn something or share something, and if neither of those is happening then I want to move on. (For the record, because I suspect you misunderstand me, one meaning of "equity" is fairness - this is the root of the phrase "equitable distribution".)

You feel I made a mistake? Fine. I apologize. Can we move on now?

Here's my take on the whole healthcare issue.


It's pretty clear that insurance is the key point to focus on with regards to improving the whole situation. Unfortunately, insurance has its own intrinsic faults, which make the market prone to catastrophic failure without intervention of some sort.

The bottom line problem that I see with healthcare is that company incentives are nowhere close to being aligned with the goals of consumers (or broader society).

I see the following as the goals which are likely needed:
A) eliminate excessive medical procedures
B) encourage medical procedures which significantly improve quality-of-life
C) promote healthier lifestyles
D) make healthcare affordable
E) determine a baseline cost for coverage
F) deal with end-of-life costs


SUGGESTIONS
===========
If I were modifying the US system, based on the above criteria, I'd probably do something like the following.
1) Create a Medicare-like insurance system which covers only preventative care as recommended by some consensus of doctors. Call it HealthyCare for the purposes of this post ... yeah, I suck at naming stuff.
2) Allow covered HealthyCare services to be subsidized 100% by taxpayer funding. Patients should have no premiums, copays, co-insurance, etc.
3) Extend coverage of HealthyCare to all US citizens.
4) Create a government program to facilitate the grouping of insurance beneficiaries into blocks ... much like what happens with the way employees are grouped together into blocks which their company gets coverage for. Subsidize the administrative costs.
5) Endorse "Patient Block Rating Systems," which pay underwriters to give their estimate of the healthcare costs for both individuals and also blocks of people over the next ... say, 8 years. This is a weak point of my proposal since it'd be a complex beast, and it also extends the privacy problems of the insurance system. Also, this service might need to be run by government(s), since private ratings agencies have been notorious to falling victim to conflict-of-interest issues.
6) Limit insurance underwriting to only the allowable information released through the Patient Ratings Services. This could include, for example, only: Patient rating [low risk, med risk, high risk, very high risk], patient zip code, patient gender, patient prostheses, mobility level, and a few other details I probably hadn't thought of.
7) Create a Medicare-like insurance plan which is available to citizens under 65 years of age, to compete with private insurers. The plan should be forced to pay all administrative costs through beneficiary premiums and government benefits which are readily available to all private insurance companies; in other words, it should be competing on a fairly level basis. We'll call this plan AmeriCare here.
8) I'd suggest modifying the payment structure of AmeriCare significantly from the strictly "fee-for-service" basis that regular Medicare uses; I suggest a novel variation from the dreaded capitation system used by HMOs. Specifically, this variation would seek partial refunds from the healthcare provider when they accept money for a patient that later dies within some number of years .. say, 4 years (unless the healthcare provider shows the death was not from illness). This would have the likely effect of needing to increase the average payouts to doctors (in order to compensate from some of the future refunds they'll need to consider). The amount of the refund would be dependent on the patient's rating from the aforementioned Patient Rating system. Riskier patients would prompt smaller refund percentages.
9) As the AmeriCare payment structure is novel, there may need to be incentives in order for people to try it out. It'd likely be a good idea to offer tax incentives to doctors who register as AmeriCare providers, and agree not to refuse any AmeriCare patients.
10) Establish a government program to subsidize interest charges, and to facilitate healthcare lending. People with copays or who incur medical expenses beyond their means during a period that they are insured should be eligible to receive low-interest 30-year loans. Perhaps, require that at least one person accepting responsibility for the loan be under the age of 50.
11) Make contributing to Health Savings Accounts mandatory by taxing earnings and placing that amount into the individual's account with the insurer of their choice.
12) Maintain the requirement for insurance companies to service only beneficiaries which claim residence in their state.


RATIONALE
==========
#1, #2, #3 ... the rationale for "HealthyCare" is simple. Subsidize basic preventative care. That's the cheapest form of care, and the investments here could do much to curtail more expensive medical problems later. At the very least, this eliminates the excuse that people can't afford the care.

#4, #5, #6 Helps maintain the integrity of the insurance system, while keeping cost increases small. Overall, these measures would reduce adverse selection, and should make private insurance significantly more accessible.

#7 ... a plan with open and public accountability should help establish a baseline

#8 ... a payment structure of this sort should simultaneously encourage both minimal unnecessary spending, while still encouraging the necessary medical procedures.

#9 ... the new payment structure comes with risks to the healthcare provider, so it may need a way to get itself established

#10 ... provides a safety net to make healthcare affordable for those who do suffer catastrophe.

#11 ... this would help people prepare for their own end-of-life care needs

#12 ... prevents the Federal gov't from encouraging a nearly needless "race to the bottom."


Admittedly, the above leaves unaddressed a few very large questions ... the possible need for a coverage mandate, malpractice insurance and guarantees of coverage for those without the financial means (although State Medicaid programs are available).

Anyways, let the flames begin :oP

[Edited by - HostileExpanse on July 29, 2009 9:26:32 PM]

Quote: Original post by Eelco
By emergency care, i was more thinking of people no longer able to walk to a hospital themselves.

But i agree, making emergency care free does introduce a slippery slope.

Yes, well, I suppose I can't fault you for not being familiar with the situation here in the United States. If I had not been able to walk and had to call the ambulance, that would have added another $2000 to the cost (for a four mile trip to the hospital). I don't have a problem with making emergency care free. That's not he slippery slope. The slippery slope is that primary care isn't free. So instead of thinking of people no longer able to walk, think about people no longer able to pay for primary care and waiting until easily treatable problems become life threatening emergencies. Emergency rooms are no substitute for primary care, yet that is the situation here in the United States for tens of millions of people. I didn't survey everyone else in the waiting room (I sat there in misery waiting all day), but from what I could see, the vast majority of people waiting there with me would have been better served with free primary care. It would have been much less expensive for everyone than using the ER instead.



From what I read in the newspaper today, Sen. Baucus is crowing about a bi-partisan deal that excludes the public option. He's excited about selling out the American public for Republican votes that he's not going to get anyway!

Is it feasible for everyone (who currently has insurance) right now to pay $50 - $100 a month [maximum] and still have good health insurance? And I mean without employers chipping in.