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Monday, May 16, 2016

Insurance, Coverage, and Access

In a recent discussion, to defend Obamacare, a friend of mine wrote, "About 20 million more people have healthcare now."

That statement is one of those things that is both true and not at the same time. Oh sure, perhaps 20 million more people have insurance and no doubt at least some of them have greater access to the healthcare system than they did before. But there are some other considerations.

There are three terms related to healthcare that are sometimes used interchangeably and do have some overlap but are distinctly different things: insurance, coverage, and access. "Insurance" is a policy to pay for some portion of someone's healthcare costs for which someone pays premiums on behalf of the individual. "Coverage" is a separate mechanism that will pay for some portion of someone's healthcare costs; things like Medical for the poor are the prime examples. "Access" is the ability to actual get a healthcare provider to provide healthcare to you.

To see the distinction, let's say that everybody in the world had healthcare insurance but either there were no healthcare providers or none of the healthcare providers accepted the insurance as payment. Then everybody has insurance but nobody has access.
"I worry about giving 30 million people a card and a false promise." Dr. Atul Grover, Chief Public Policy Officer American Association of Medical Colleges
Since there are almost exactly an identical number of healthcare providers per capita now as there were before Obamacare was enacted, and healthcare providers have always been pretty much fully booked, and the healthcare system at the provider level is not noticeably more efficient (and is perhaps less efficient), for each bit of healthcare that is provided to someone because of Obamacare, a corresponding bit is not, almost by definition, provided to someone else. In other words, with an equal number of booked providers per capita, total services, procedures, etc. remain constant. This one really is close to a zero sum game and is severely stressing the system:
The health care workforce is already facing a critical shortfall of health professionals over the next decade. The ACA breaks the promises of access and quality of care for all Americans by escalating the shortage and increasing the burden and stress on the already fragile system. The ACA’s attempts to address the shortage are unproven and limited in scope, and the significant financial investment will not produce results for years due to the training pipeline. With the ACA’s estimated 190 million hours of paperwork annually imposed on businesses and the health care industry, combined with shortages of workers, patients will be facing increasing wait times, limited access to providers, shortened time with caregivers, and decreased satisfaction. The health care workforce is facing increased stress and instability...
Obamacare is about playing god, literally deciding who lives and dies, since for each person access is provided, it's taken away from someone else.

85 comments:

Clovis e Adri said...

Bret,

---
The ACA’s attempts to address the shortage are unproven and limited in scope, and the significant financial investment will not produce results for years due to the training pipeline.
---

That's the relevant part.

As I understand it, you are injecting more money (and demand) into a market, and though it may take some time (the "training pipeline") it ought to react by providing a greater supply to meet that demand.

Why is it this time it would be different?

erp said...

Here's how it works. Prior, some people didn't have health insurance, but had access to health care. ER's had to see everybody. That's one of the reasons healthcare costs were high -- to cover those who didn't pay. There were also free clinics ... Was the care as easy access and comprehensive as those of us who had expensive private insurance or expensive medicare gap plans? No, but then life ain't fair and it sure ain't fair once the feds get in on it.

Now, people have health insurance, but have no or very limited access to care and ER's actually send people away. Pace Harry. This happens in the real world where we know people on the both sides -- health providers and those looking for them.

The local free clinic is now part of the system. Prior -- they saw everybody who walked in -- now not so much.

Bret said...

Clovis,

Markets more-or-less approximate "providing a greater supply to meet that demand." Governments, not so much. The point of the article that I linked to is precisely that the government is creating this extra demand but really didn't address the supply side at all and that it will be decades, at best, before the supply has even a chance at catching up with the demand.

In the meantime (for decades), anybody gloating about new access for some is also, by definition, gloating about someone else losing access.

erp said...

... must disagree Bret. We're headed for single payer. Can't see any way to avoid it.

Harry Eagar said...

'healthcare providers have always been pretty much fully booked'

A strange statement in view of the closure of hundreds of hospitals.

You would have been on firmer ground if you had said that health care services are very unevenly distributed and Obamacare does nothing immediately to even them out -- although Obamacare or, better yet, universal insurance would over time tend to even it out

Bret said...

Harry wrote: "A strange statement in view of the closure of hundreds of hospitals."

Why's that?

With better post-op care and other factors, a lot of in-patient was moved to outpatient. It still requires as many providers.

Harry Eagar said...

They're closing in places that had only one.

Clovis e Adri said...

Bret,

---
government is creating this extra demand but really didn't address the supply side at all and that it will be decades, at best, before the supply has even a chance at catching up with the demand.
---

And their arguments are not much convincing, IMHO.

The way to "address the supply", as in any market, is to direct more money to it. ACA does that through indirect ways (a higher numbers of insurances), but it does. The burden is on that article (or you) to show why the market will fail to respond accordingly.


Bret said...

Harry,

Yeah, so? That still has nothing to do with how booked providers are.

Bret said...

Clovis wrote: "The burden is on that article..."

Ok, if the article didn't convince you, I probably won't be able to either.

It was convincing to me because I live it and doctors seem to me to be very demotivated. Note that the number of both general and specialty physicians per capita was lower in 2012 than in 2009 during the initial Obamacare debate and enactment. We can hope that was just increased retirement as existing older physicians became fed up and that it will grow again rapidly.

erp said...

Clovis, ... to show why the market will fail to respond accordingly.

There is no open market, so it can't respond. Health care is conpletely controlled by the feds and the supply of doctors has fallen because many, almost all in our acquaintanceship, have either retired earlier than they wanted to or are preparing to retire. These are people well under retirement age. I don't know if admissions to medical schools has fallen, but certainly the best and the brightest won't be clammoring for admission as they did in the past.

When hospitalists, employees of the hospital, took over in-patient care to the exclusion of patients' personal physicians, the death toll started and Obama finished it off.

Clovis e Adri said...

Bret,

As far as I can see it, you can increase the number of doctors from day to night by just allowing easier paths for foreigner doctors to be hired, to take one single example.

It would be beautiful to watch president Trump enacting some new laws opening up your medical market to Mexican and Cuban doctors.


Clovis e Adri said...

Erp,

Were those doctors getting worse paid? Because from their point of view, either the money or conditions for working need to be getting progressively worse for them to give up the profession. Do you believe both of those boxes check?


As many other professions, I think doctors will experience the consequences of Bret's robots sooner than later. That's another instance of market/supply response to demand that Bret's post does not consider.

erp said...

Clovis, re: foreign doctors

In the past several years, my husband has had lengthy hospital stays eight or ten times at three or four different hospitals in Florida and Connecticut and every single one of the hospitalists were encountered were foreigners mostly from south of our border (including the islands), but some from Asia, especially the Philippines and Africa, mostly Nigeria.

Quite a few were not proficient English speakers and some were difficult even impossible to understand. Remember these doctors aren't assigned to a patient. They come and go at various times and have very little knowledge of the patients other than a quick scan of the vitals and comments on the computer screen.

Often diagnoses and medications are changed without anyone being told the reason ... I was at the hospital a lot and rarely saw the same one twice. A very bad system.

If it weren't for the nurses, I don't know how patients would survive.

erp said...

Clovis, re: Early retiring doctors.

Over the years regulations have become so burdensome and expensive to navigate and more staff needed to be hired and as bureaucratic costs for Medicare and Medicaid have increased exponentially, payments to physicians have been cut until it's almost impossible to make ends meet. Dealing with health insurers (a friend ran a surgical office with 5 surgeons needed 9 clerks just to deal with patient insurance) had always been challenging, but now it's a Kafkaesque.

Harry Eagar said...

A great argument for single-payer.

The government has been offering bounties for decades to get physicians into underserved areas (Bret is not in one of those places, so his experience matters not).

The incentives have not nearly equaled the disincentives to being the only GP or only specialist in an area, which means you are on call 166 hours a week.

Also, Medicare payments have been steadily cut, a project of rightwingers primarily, although even leftwingers have played in because everyone (but me) wants lower total health expenditures.

Here's something to think about: If the US went to single payer, it could cover everybody for less than it spends now to cover around 85%. And save at least one-fifth of 17%.

Here's the fascinating part: If you suck one-fifth of 17% out of the economy, over the paat 40 years or so, you put the output into recession nearly every year.

erp said...

Harry, ever heard of the VA?

Clovis e Adri said...

Erp,

Sorry but I am lost in translation here.

I assumed it was the rule everywhere that, in a hospital, you are treated by doctors hired by the hospital (that you call hospitalists), with exception to procedures you can book in advance with an external doctor of your preference.

I guess you mean it was not like that in past - is it? And how so? It must be operationally difficult to do any different.

erp said...

Prior to a few years ago, doctors had various kinds of relationships with one or more hospitals. A doctor might have been "on the staff" which doesn't mean he worked for the hospital, but that he was associated with it, or simply had privileges or part of a group who owned the hospital, but in any case, it was your doctor who admitted and treated you, had access to your records, hospital equipment, etc.

Now that is no longer the case and your private doctor may admit you, but once you're admitted, the hospitalists take over your care. It's a pretty fluid situation because a couple of my husband's private doctors came in to see him, but they were clearly not in charge as they were previously and to our knowledge were not consulted. It's a horrible situation and private doctors don't like it.

There are private hospitals, large and small, public hospitals, teaching hospitals connected with medical schools, hospitals with religious affiliations, hospitals with enormous facilities like the Mayo Clinic and others ...

Now, a good rule of thumb is to stay out of hospitals which are dangerous places where infections are rampant. He got a staph infection in the rehab hospital which he can't get rid of no matter how much anti-biotics have been pumped into him. He was put on the wrong diet and it took me several days of near hysteria to finally get it changed ...

A far cry from our former excellent medical care and we are near the top of the pyramid in this. Our little plastic card opens doors very wide. Unfortunately, what it gets us is subpar in every way.

Clovis e Adri said...

Erp,

---
A far cry from our former excellent medical care and we are near the top of the pyramid in this. Our little plastic card opens doors very wide. Unfortunately, what it gets us is subpar in every way.
---

When you say "our former", how many years back are you talking about?

I suppose that you guys, as aging comes, have been using more and more of the medical system - which means you are also subject to more and more of system failures and medical errors.

But how do we separate, in your experience, what are failures you would find anyway 20 or 30 years ago, from what is consequence of your higher usage?

Let me remind you that medical errors are now being appointed as the third leading cause of death in the USA - and I doubt it wasn't equally dangerous many years back too.

Clovis e Adri said...

Harry,

---
Here's the fascinating part: If you suck one-fifth of 17% out of the economy, over the paat 40 years or so, you put the output into recession nearly every year.
---

It is only fascinating if you believe in an economic black hole, where the money you take from one area suddenly disappears to nowhere-land.

In reality, that same money can well be applied in other places, with even the possibility it would lead to greater economic growth over time in those other areas.

Bret said...

LOL! Poor Clovis is having to explain economic/free market(ish) principles to Harry.

I guess Harry has worn the rest of us radical libertarians/free market advocates down after all of these years and none of us could be bothered to respond. I did think Harry's statement was kinda silly, so thank you Clovis for answering him for the rest of us.

But here's the thing. Even if it were true that those resources went into an economic black hole, it still wouldn't put the country into a recession "nearly every year" since a recession is an economic decline. The economy would only decline the first time you eliminated that "one-fifth of 17% out of the economy" and stuck it in the black hole. The rest of the "paat [sic] 40 years or so" the economy wouldn't decline further, so no additional recessions. And as Clovis points out, those resources might be used elsewhere and perhaps even cause the economy to grow more.

erp said...

According to Wiki, the hospitalist system started 15 years ago, but we first encountered it when my mother passed away 10 years ago. She was moved from the hospital to rehab without consulting us even though I had every legal document on file at the hospital. I had a fit, but when she was admitted, we signed whatever they put in front of us because after she fell, we had no choice but to admit her to that facility -- there not being any other.

Choices, you see, are things that have been taken away. No competition, no incentive to do well.

My husband got a staph infection at a rehab hospital after a hip replacement -- neither the surgery nor the infection was related to old age.

erp said...

Only the private sector can "grow" the economy. The public sector can only help by getting the h*ll out of the way.

Harry Eagar said...

We cannot usefully employ the capital we have at the margins (well, we could on public infrastructure but rightwingers don't believe in maintaining bridges). The released capital would be used somehow but not necessarily or even probably in any useful way.

As I tried to explain to Skipper at RtO, buying Humvees in Ohio, shipping them to Afghanistan and cutting them up for scrap is not actually real economic activity.

Something like 20% of US health expenditure is spent on administration above the like costs in other modern states, with zero application to providing health care. It is the equivalent of endlessly digging holes and filling them up again.

Eliminating all those pointless "jobs" would also have raised unemployment to politically explosive levels in most of the last 40 years. Nevertheless, we should have done and should do it. The economy will adjust, painfully, but the short-term pain would be similar to what you get by electing Republican presidents and Congresses.

We have recovered from Coolidge prosperity and Bush prosperity. We could likely have recovered from a Romney recession, too.

erp said...

Come on Harry. That's ridiculous even for you. Public sector unions keep raising administrative and every other kind of costs and shoddy union work keeps the bridges and other infrastructure in constant need of maintenance.

Humvees from Ohio to Afghan chop shops???

Harry Eagar said...

Yes. You really should read the newspapers.

And maybe a book about the Erie Canal, a government project had the greatest ROI in history

Peter said...

We cannot usefully employ the capital we have at the margins

Love the royal "we". If it's really "our" capital, Harry, I'm voting for a dividend.

BTW, you are wrong about single-payor some how "evening out" access to medical care. We've had it for fifty years and rural access is a perennial problem. I suspect you are getting in touch with your inner Stalinist and imagine that single payor means the government will just order health care professionals where to live and practice. Once "we've" taken away "our" capital from them, that is.

Bret said...

Peter wrote: "...rural access is a perennial problem."

Why doesn't your single payor just pay more to rural doctors?

Peter said...

Several reasons. Our "single-payor" acts as a monopolistic insurance company, not an employer of doctors or owner/administrator of hospitals. So you'd be talking about paying more for check-ups, stitches, sex-change operations, etc. Secondly, we have ten single-payors because although it's a national scheme, it is administered by the provinces, which determine rates and what is covered. Thirdly, do you appreciate how much of Canada can be defined as rural? There are all kinds of strategies to try and encourage doctors to locate in rural areas, and some communities offer generous housing and other benefits, but I've never heard of different fee structures.

Bret, despite Harry's unreconstucted Marxism, the issue of the fantastic administrative costs of American healthcare--public and private--strikes me as a real one. If your choice was between Obamacare and single payor, what would you take?

Bret said...

Peter,

The beauty of writing hundreds of blog posts is that I've already answered that question in detail here.

I'll excerpt the relevant paragraphs for your convenience:

===========================================================

In the past I've mentioned to you that I don't have a big problem with government (possibly even the federal government) covering at least some classes of catastrophic health expenses. My wife (who works in health care administration) calls this the "doughnut" approach where the government covers some preventative care (the "hole" of the doughnut), each individual is responsible for routine expenses up to some maximum (somewhere between $5k - $20k per year and this is the main part of the doughnut) that can be either paid directly out of pocket or covered by auxiliary private insurance purchased by the individual, and the government covers expenses beyond that (the "outside" of the doughnut). It's as if everybody has one of the high-deductible plans with some preventative care (e.g. vaccinations and the like) thrown in.

I would do this for an overwhelming practical reason. As my wife also points out regularly, some people have health insurance, others have sufficient assets to pay, and others have "coverage" such as medicaid. Whether or not you have insurance, assets, or coverage, if you show up at an emergency room with a life threatening condition, they will treat you, regardless of ability to pay. Why? Because in the seconds or minutes that action needs to be taken to save you, there isn't the minutes, hours, or days to determine ability to pay so they have no choice but to go for it. This is a strictly practical consideration and really has nothing to do with compassion.

If, during the treatment, you end up in the ICU for 6 months, nobody will pull a life support plug, even if you can't pay. Not me, not Ron Paul, not the crowd, and certainly not the medical staff. As a society, we have a hell of time pulling the plug on someone who's in a brain-dead coma for ten years, much less someone conscious with terror in his eyes as you go for the plug. Not going to happen.

Because it's not going to happen, and absolutely everybody has this access regardless of ability to pay, the money ought to come from a public source. Currently, it comes from the hospital increasing fees on everybody else. This means that a relatively poor person who plays it safe and buys health insurance (or who is paid less to fund health insurance out of their compensation package) is subsidizing the relatively high earning 30-year-old man in the example. Whether or not the poor should carry their own weight, I certainly don't think that they should be subsidizing higher-income people, so funding catastrophic health care (i.e. very high deductible health care) from the progressive tax system makes sense and is the only solution that I see that makes sense. That may make me a bad libertarian, but I don't much care.

=============================================================================

So in a nutshell, I believe we should have a single payor system that focuses only on covering catastrophic and some preventative care, everything else should be completely free market with almost no regulation.

Harry Eagar said...

'BTW, you are wrong about single-payor some how "evening out" access to medical care. We've had it for fifty years and rural access is a perennial problem.'

You are conflating different stuff. If rural people can pay for some care, as opposed to not, they will get some.

They will not likely get much because of all sorts of economic and non-economic disincentives. I already mentioned one.

Consolidation and closing of hospitals means many people cannot even go to an ER. For example. I have plenty of experience in Florida hospitals (not nearly as bad as what erp would have you believe).

North Florida Regional Medical Center serves 5 counties. That means people in 4 counties have a loooong drive (should they have transportation at all) to see a physician.

These difficulties have not been caused by gummint interference. Despite erp's continued assertions, things did not use to be better. Rural people had edven less access to medical care.

Des Moines is a useful textbook study. It has Iowa Methodist, Mercy, Iowa Lutheran Iowa Jewish hospitals, all set up long ago to serve the entire confessional population of the tsate. So now Des Moines has way too many beds and the rest of the state too few. But back then, the rest of the state didn't have any.

erp said...

Harry, in your experience with Florida hospitals have you encountered a hospitalist who is U.S. born and bred? Has your own physician been allowed to treat you while you were in the hospital? Was a hospitalist assigned to you or did you have a constantly changing parade of different people making decisions about you from a quick look at your "chart."

It seems odd that, according to Wiki, Hawaii has had socialized medicine for 40 years, you come to red-neck country for medical care?

Rural doctors made rounds and kept office hours. The quality of the care probably varied according the doctors' abilities and energy. Today, technology makes it easier to consult with specialists and helicopters provide quick trips for emergencies. Even our little county has a couple of helicopters that are kept pretty busy.

I'm not sure what level of rural care you think would suffice.

Des Moines hospital beds, like everything in the country, would benefit by the feds keeping their hands off and letting the people decide what their needs are.

Bret, what you describe is what used to be called Catastrophic or Major Medical Insurance. It was relatively cheap because it only kicked in when you reached a fairly high level of medical expenses. We had only that for about twelve years when we retired at age 53 until we were forced to get Medicare at which time the costs of gap insurance and the Medicare premiums were considerably higher and add that to the Part D drug insurance and our free stuff costs are staggering.

Because of all these machinations, costs are fungible. Part D providers can pick and choose which drugs they put into which level of their formularies, so instead of buying a drug at a fixed cost, the cost can go from $0.00 to hundreds of dollars per drug per month. Add the cost of administrating all these diverse plans ... and you start looking at costs that approach astronomical.

Stop it all and let the marketplace set prices for health care as well as everything else. It may not be perfect, but to paraphrase Churchill, 'Free markets is the worst economic system, except for all the others.'

Clovis e Adri said...

Bret,

---
So in a nutshell, I believe we should have a single payor system that focuses only on covering catastrophic and some preventative care, everything else should be completely free market with almost no regulation.
---

Wuold you please define "catastrophic" here?

Bret said...

Clovis,

Catastrophic is everything beyond the "donut" which isn't set in stone but my wife imagines it to be between $5,000 and $20,000 (which, again, can be covered by private auxiliary insurance which will be quite inexpensive since the private insurance doesn't have to worry about the really big expenditures). Could be less, could be more.

Clovis e Adri said...

Bret,

OK, so let us suppose that from now on Obamacare, Medicare, all-other-care are all turned off and every one is for themslves up to $10,000 in health expenditures, but above that the government pays the bill.

Is that what you mean as a good policy?

If so, do you know of any calculation of costs and budget projections?

My guess is it would be little different from a single payer in Canada or UK style.
So little different it wouldn't matter if the govt paid the first 10k either.


Bret said...

Clovis wrote: "So little different it wouldn't matter if the govt paid the first 10k either."

We disagree on this one. In my wife's opinion (and she convinced me), if you expose some part of it to the free market, then you drive innovation and competition, both in the auxiliary insurance market and more importantly for the services that end up being paid out-of-pocket routinely. Then, because those things are less expensive, it pulls other stuff from being beyond the catastrophic threshold (outside the donut) into the donut, further driving innovation.

Admittedly, the data so far doesn't support that very well (high-deductible plans are sort of like the donut thing) and it may be that medical stuff is just too complicated for price competition to work, but I'm not yet convinced.



Clovis e Adri said...

Bret,

Your wife sure has a point.

But mine is related to the expenditure distribution. Where is its mean located and how does it spread?

If, say, less than 20% is below 10k, I guess it is not enough to make the free market magic to happen. Most of the market will be running for the big bucks, and actually most hospitals would have huge incentives to inflate your bills above 10k.

Bret said...

Clovis,

Annual U.S. Healthcare expenditures are $3 trillion. 20% of that is $600 billion which is a really big market!

But again, the data is admittedly more on your side. High-deductible plans have not (yet) had the expected impact.

But we can turn that around as well. I'm not sure there's a big advantage to having the government cover the last $10,000 either.

Clovis e Adri said...

Bret,

I am not advocating it would be good if govt covered it all.

Just pointing out that, in terms of budgets, your plan could end up being almost as expensive as any other single payer out there.

I understand single payer would be quite more expensive to your national budget than present programs. At least this is what I get from projections based on Sanders proposals.

So your option could end up being more expensive than the present system too. Do you think anyone could really sell that to America these days?

Peter said...

Bret, with respect to you and your wife, I think you have to be more careful about leaning uncritically on free market principles in the area of healthcare. It seems to me the issues are costs and access, but what "innovation" are you talking about and what drives it? Hospitals don't compete for market share (although admittedly pharmaceutical companies do), otherwise there would be Black Friday sales on hip replacements. There is plenty of medical innovation going on in Canada, Europe and even Cuba--the U.S. doesn't lead the world across the board. Basically we are talking about public/private/no insurance, not nationalization of hospitals and medical research outfits. And in what sense can it be said that advances in medical research are driven by consumer demand?

The same problem exists with erp's resounding declarations that the people should decide what their medical needs are. I have only a vague idea of what my current medical needs are and I'm basically clueless as to what they will be in five years. If my new granddaughter suffers a rare condition requiring intensive care, I'm really not going to too happy to be told there isn't much demand in the market for the treatment she needs. We all need medical care sometime and generally we need more as we get older, but how many people really make informed choices as to what their needs are and where/how is the best, most cost-effective way to treat them?

Finally, let's be honest about how insurance companies work. They do whatever they can to avoid or minimize payouts. That's the cause for which you are paying astronomical administrative costs.

erp said...

Peter, I must not have been clear. People should make their own decisions about their health insurance. We naturally do not know what our future health care needs may be and like you, would go into penury should any of our seven grandchildren require it.

I'm really surprised that no one here has commented on the VA which in its 80 year existence has squandered gazillions of tax dollars while causing untold misery to our veterans. Why would anyone think single payer for every citizen would do any better?

Peter said...

Why would anyone think single payer for every citizen would do any better?

Because in some respects it can. My understanding of the VA is that they are government owned and operated, and that the staff are public employees (doctors too?). This means they are subject to the universal laws of bureaucracy with consequent declining efficiency, maintenance and public relations issues. Single payer has its own problems, timely access being the big one, especially when it is monopolistic and completely free, but it's simply not accurate to lump public medical insurance in with public health operation and management under the rubric of "socialized medicine". Nor is the first a necessary slippery slope to the second. Canada has had public insurance for half a century and there had never been a political impetus to move to public control of medical services.

Bret didn't really answer my question, which was whether he thinks Obamacare or single payer is the lesser evil. In any event, my point isn't to tout single payer, it's to point out that a lot of free-market analysis doesn't really apply to healthcare for quite a few reasons. I find a lot of conservative arguments about markets and choice, etc. dance up in rarified ideological air without being well-grounded in the realities of healthcare for most citizens and deflect from the underlying political question that has to be answered: Is it a public responsibility to ensure that any citizen who needs at least basic medical care gets it somehow, and if so, how?

erp said...

Peter, at the risk of being tiresomely repetitious. Everyone in the past did get to see a doctor. Emergency rooms had to see everybody and anybody regardless of whether they had insurance or not or whether they had a cent to their name.

That is no longer the case.

There were also free clinics where medical people and other volunteers freely gave of their time and treasure to help the less fortunate.

That has been co-opted.

I know this for a fact because I was one of those non-medical volunteers who dealt with computer records, etc. My husband and I also donated from our personnel funds for various needs as they arose as did many others. We all try to still help by responding to needs as identified by those people working in the medical field, churches, etc. -- sorta an underground system, so the feds don't tap into that too.

I'm not kidding!

Harry Eagar said...

erp, I don't go into hospital myself but my wife does frequently. She gets excellent care in Hawaii but when we are visiting in Florida she has had to go into North Florida Regional several times.

Care was excellent, the hospitalist was foreign-born and excellent, and my wife's personal doctors were very attentive.

I will observe that, across all kinds of business, some customers tend to get excellent service and others tend always to get less good service. You catch more flies with honey than with vinegar, my mother says.

+ + +

On the subject of what makes a bill catastrophic, there are lots of surveys about how much money Americans have or can raise. $5,000 is way outside the range of most, and with pay at $10 an hour or less for tens of millions, this is no surprise.

erp said...

Harry, are you saying that your wife's own doctor administered to her in the hospital and she had a hospitalist dedicated to her case? Sorry but that's not how it works.

Hey Skipper said...

I hate having to play catchup.

I wonder how much this post relates to The $317,000 Question.


[harry:] You would have been on firmer ground if you had said that health care services are very unevenly distributed and Obamacare does nothing immediately to even them out -- although Obamacare or, better yet, universal insurance would over time tend to even it [sic] out.

Why?

That claim — even as unqualified as it is — doesn't stand up well to inspection. On a previous thread (which my google-fu wasn't sufficient to find), you made a similar claim. However, it didn't bear up under inspection. Australia — single payer — has exactly the same access problems.

Health care services are unevenly distributed because people are unevenly distributed. Without further explanation from you, I am completely at sea as to comprehending how something that is people-based could, never mind should, be distributed while completely ignoring the distribution of people upon which it is based.

Maybe you could provide an example?

This raises another question. The central assumption to single payer is that health care is a positive right owed by society to all its members. On the face of it, that is difficult to argue against.

But going beyond that facile assumption, and it becomes less obvious.

Accepting the assertion, that means that the state must provide the same health care to everyone, regardless of time or place. In the real world, what sense would it make to have exactly the same access to healthcare in Dunmovin, California (yes, a real place) as in Los Angeles?

It gets worse. Again, accepting the assertion, is access to healthcare any more of a human right than food, transportation, or shelter? If universal government provision is the best answer for the former, then why not the latter?

Where morality is tethered to reality, the historical fact that doing so never works should carry some weight.

Hey Skipper said...

Also, Medicare payments have been steadily cut, a project of rightwingers primarily, although even leftwingers have played in because everyone (but me) wants lower total health expenditures.

Perhaps you should read more about Medicare.

Here's something to think about: If the US went to single payer, it could cover everybody for less than it spends now to cover around 85%. And save at least one-fifth of 17%.

No, it couldn't. You ignore so much here that it is difficult to cover the entire territory.

For instance, I'm going to bet that the cost comparison is between the US and the UK, comparing total US healthcare costs against the NHS budget.

Among many problems with that comparison is this: UK healthcare costs include private provision plus the NHS.

Also, it ignores a far more important means of containing healthcare costs than just the marginal decrease in admin costs.

Care to guess what it is?


Something like 20% of US health expenditure is spent on administration above the like costs in other modern states, with zero application to providing health care. It is the equivalent of endlessly digging holes and filling them up again.

No, that isn't true. In the US, admin overhead is about 25% of total expenditures. The UK's NHS admin overhead is 13%. (Working from memory.) Assuming the NHS is the gold standard, then the US's admin excess is around 12%, not 20%.

Further, your assertion that this amounts to endlessly digging holes seems rather divorced from reality. Healthcare is a big, expensive, problem. Thinking that such a thing can be run — unless chaos counts as being run — without admin overhead is an appeal to magic.

[Bret:] I certainly don't think that they should be subsidizing higher-income people, so funding catastrophic health care (i.e. very high deductible health care) from the progressive tax system makes sense and is the only solution that I see that makes sense. That may make me a bad libertarian, but I don't much care.

That rather torpedoes the healthcare as right argument.

Bret said...

Peter asks: "Is it a public responsibility to ensure that any citizen who needs at least basic medical care gets it somehow, and if so, how?"

No. The "public" may choose to provide whatever it wants to whomever it thinks ought to receive its "generosity", but I absolutely reject the notion that it's the "public's" responsibility. And if you think healthcare for others is a responsibility, then why would we not also provide it for every last person on earth? Why would that responsibility stop at this thing called a national border. Why not stop at a state border or a county border or a city border or a property border? What's magical about this responsibility and the national border?

erp said...

The One Worlders have already begged the question. We are our brother's keepers.

Anybody else in a blinding fury about Obama's remarks yesterday?

Here's what Truman said: “That bomb caused the Japanese to surrender, and it stopped the war. I don’t care what the crybabies say now, because they didn’t have to make the decision.”

If Trump makes a strong statement denouncing Obama, I may change my mind about staying away from the polls in November.

Bret said...

erp,

Japan is one of our best allies in the world right now. To lean on the side of being apologetic for dropping a nuke on them while visiting Hiroshima doesn't seem like that terrible of diplomacy to me. What's he gonna say? "Well, after all, you deserved it?"

erp said...

... he should have played golf with his buds and kept his mouth closed.

Bret said...

That I agree with. But once he was there, he pretty much had to say something more-or-less along the lines of what he did say.

erp said...

Couldn't disagree more.

Peter said...

Welcome to 2016, erp. Who cares whether the President defends past wars? I'll bet the majority is only dimly aware of what it was all about. What's really important is whether he can make the country proud by calming a crying baby.

Bret:

Note I did not ask whether everybody has a right to healthcare. The omission was intentional because I was trying to take the issue out of the rarefied air of abstracts. Let's be practical here. My concern is that conservatives are spinning their wheels and losing elections by taking on public opinion on a highly-charged emotional issue they will inevitably lose. I simply don't believe the majority will accept a sick child or even adult who can't find treatment, anymore than they would accept an uneducated child who can't afford school fees. I wouldn't and I'm a conservative. With all the low-hanging fruit out there about the problems of big government and creeping statism, there is a shooting-oneself-in-the-foot side to this.

If you don't believe there is a public responsibility to ensure the provision of basic healthcare, why do people like erp and others opposed to public healthcare make such a big deal about charitable medical care?

erp said...

We aren't making a Big Deal? We're out there helping people using our own time and and our dime.

You care about people without health insurance getting help when they're sick and I'm telling you that they were getting help without a massive bureaucracy that only exists to serve its own needs.

Justify the VA and we'll talk.

Peter said...

You're missing my point. If the government decided to publically fund a program to ensure everybody had cars or computers or even home ownership, the opposition would be a principled one that these things should be left to the market. Implied in that would be there is no entitlement to any of those and that obtaining them is a matter of individual responsibility. Some may not have them, but that is life. Nobody would argue there is no need for those programs because there are huge charitable endeavors making sure everyone has access to them. I'm suggesting the reason for this is that most people believe there is some kind of public responsibility here and that good health is not primarily a function of individual foresight, responsibility and resiliency.

I'm too old and experienced a blogger to fall for the trap that if I don't agree with you on some aspect of healthcare, I must defend the VA.

erp said...

Yes, you must defend the VA when you lobbying that all our healthcare be based on that model which in addition to spending billions of dollars has resulted in pain and suffering among our veterans and their families.

I'm a lot older than you and experienced not only blogging, but cursed with an uncanny ability to connect the dots. Also, not being insane, I don't expect a different result when I do the same thing over and over.

Socialism results in Venezuela, first time and every time.

Peter said...

Oh yeah? My age and experience can take on your age and experience any day. Wanna step outside?

There is no shortage of healthcare models in the West and even in the States that involve very heavy public investments. How long do you give us until we all become Venezuelas? Will it be before or after we all succumb to climate change?

erp said...

Doubt it.

I’ve got at least 25 years on you and you probably have at least 50 lbs on me. Lucky for you I only have half my brain (if that?) left and it’s on stand-by mode.

I think we’re past the point of no return on becoming Venezuela. Kids today don’t even consider working as a path to a life spent playing games on their devices.

Climate change is apparently just another ruse to rile up the rubes.

On the bright side we are experiencing that perfect day in June a couple of days early.

Still waiting for your analysis of why new state-run healthcare won't be like the old state-run healthcare aka the VA? Please don't dally, I never know when the synapses will give out totally.

Bret said...

Peter wrote: "If you don't believe there is a public responsibility..."

"Public responsibility" is not identical to "Federal government responsibility." But, in any event, I don't think it's a "responsibility," rather it's basically a human kindness, a charitable act.

I think that difference is possibly essential for civilization. If I see someone who needs help, I have the urge to help them. If I see someone who demands something from me (because it's a right of his or a "responsibility" of mine), my instinct is to tell them to "f**k off" or, at best, I resent the hell out of them. I don't think I'm alone in that, and widespread resentment of each other I think is very damaging.

Up there in the great white north, y'all are more homogeneous, especially ideologically, so centralizing things like healthcare breeds less resentment.

In case you haven't noticed, Americans' resentment of each other is growing exponentially, and it seems to me that could be problematic or even catastrophic, not only for this country but also the world.

Peter said...

That's a good point, Bret. There is a big difference politically between implementing a big new public program and getting rid of one that's been around for decades.

Hey Skipper said...

[Bret:] That I agree with. But once he was there, he pretty much had to say something more-or-less along the lines of what he did say.

Which is all the reason needed for not going in the first place.

[Peter:] My concern is that conservatives are spinning their wheels and losing elections by taking on public opinion on a highly-charged emotional issue they will inevitably lose. I simply don't believe the majority will accept a sick child or even adult who can't find treatment, anymore than they would accept an uneducated child who can't afford school fees.

You are right, except for the majority part. I'd go once step further and say totality.

But that raises an unquestioned assumption. Completely granting that the US healthcare was shambolic before the ACA, with one exception, I am not aware of sick people being unable to find treatment.

That exception being mental illness.

I'm suggesting the reason for this is that most people believe there is some kind of public responsibility here and that good health is not primarily a function of individual foresight, responsibility and resiliency.

Good point.

There is no shortage of healthcare models in the West and even in the States that involve very heavy public investments. How long do you give us until we all become Venezuelas?

Oh, how about 20 years?

Okay, a bit of an exaggeration. But if the general contention is true, that socialized anything stifles innovation, then over some period of time, the difference between where socialized medicine will be, and could have been, might very well approximate the difference between where the US and Cuba are now.

Peter said...

But if the general contention is true, that socialized anything stifles innovation...

OK, let's accept that. From that, would it not follow that socialized medical insurance stifles innovation in the field of medical insurance? What I'm not getting is the leap to concluding it stifles innovation in actual medical care. If the government nationalized automobile insurance, why would that lead to a decline in innovation in the automobile industry?

It would be helpful to see a thorough study comparing the Canadian and British experience, but absent that, I can only speak for Canada. As everyone knows, there are chronic access (wait time) problems for non-urgent care (not to mention shifting parameters of what is urgent, what constitutes "elective" treatment, etc.). But it would be wrong to conclude the care itself is substandard once you get to it. It would also be wrong to just assume the access problems are on a one-way decline, because there has been progress on that front in many places over the past several years. As I keep repeating, doctors are self-employed and hospitals privately run, which means they, not the government, determine their own priorities, budgets, etc. Canadian hospitals engage in massive private fundraising, which is something I presume outfits like the VA don't. There are some areas like heart treatment and pediatrics where Canada is a world leader.

Plus innovation is just one of several objectives in such a politically sensitive area where the public perception is of necessity rather than choice. Back to cars. My province (Quebec)has a partial nationalized automobile insurance scheme for personal injury (not property damage). All drivers pay into it annually. Basic medical, therapeutic, home assistance and lost employment benefits flow from an accident without regard to fault. Property damage is paid by private insurance and for very serious and catastrophic accidents, the tort system kicks in beyond the statutory benefits.

As an lawyer with experience fighting insurance companies, I can spot the advantages quickly, and they are major. The benefits flow immediately as they are needed irrespective of fault--no waiting for years spent fighting insurance companies denying liability or even declining to pay anything at all until the total claim is quantified, which can take a lot of time. The downside is that you have to fit your claim into the rules of a large bureaucracy. About ten years ago my wife suffered a whiplash injury and found herself in the strange position of being denied things she reasonably needed but encouraged by a sympathetic bureaucrat to claim things she didn't to compensate. Cute in small doses, but I thought it was a classic example of how bureaucracy corrupts. However, I am unaware of anyone who has ever suggested the scheme is holding back the development of safer, cheaper, more efficient cars.

Hey Skipper said...

OK, let's accept that. From that, would it not follow that socialized medical insurance stifles innovation in the field of medical insurance? What I'm not getting is the leap to concluding it stifles innovation in actual medical care.

Peter, I'm sorry, I didn't make myself clear. I was referring to single-payer healthcare systems, like, say, the NHS. My contention is to the extent that healthcare itself is socialized, then innovation will suffer. Just as if the government were to effectively nationalize car production, a la British Leyland.

QED.

My province (Quebec)has a partial nationalized automobile insurance scheme for personal injury (not property damage).

Hmmm. I didn't know that. Interesting. Kind of makes sense. Perhaps analogously, it makes sense to have a nationalized insurance scheme that everyone pays into for catastrophic coverage, where the definition of catastrophic is correlated to income and wealth. Given my admittedly privileged economic circumstances, I can see no problems, off hand, with the expectation that I should be able to arrange for a greater amount of self-insurance than people far less lucky than I. To take that one step further, I think it might make sense for it to be a flat tax; progressivity would come about from the higher cap for better off people.

That would help answer the $317,000 question, greatly reduce moral hazard and adverse selection, eliminate employer lock, and eliminate the moral objections that some have to the ACA's requirement that everyone fund everything.

Of course, since I'm typing off the tip of my head, I could be completely barking, too.

Peter said...

Yes, we seem to have a chronic problem of talking at cross-purposes on this subject. To me, single-payer refers to who pays the bills, not necessarily who controls and manages the actual care.

Lest I sound like I'm shilling for Canadian healthcare, I'll repeat what I've said earlier. It's really too bad Americans and Canadians are so exclusively aware of each other's systems and so well-versed in horror stories from the other side of the border. Both could benefit from a greater awareness of the mixed systems in some European and other countries.

Bret said...

Peter wrote: "However, I am unaware of anyone who has ever suggested the scheme is holding back the development of safer, cheaper, more efficient cars."

Canada makes cars?

I will suggest something similar. A similar scheme worldwide (or possibly even just nationwide in the US) would ultimately hold back the development of safer, cheaper, more efficient cars. Because once such a scheme is in place it would inevitably be followed by diktats regarding what cars must and must not have, which in the long run would slow innovation.

Hey Skipper said...

[Bret:] Canada makes cars?

A great many, in fact.

Peter said...

Really, Bret.

Bret said...

Ok, live & learn.

The rest of my comment is still applicable since Quebec is still a relatively small number of people.

Peter said...

I can't imagine what you are going on about, Bret. Why, just last month we picked up this state-of-the-art baby for a cool eighty grand. Keep your hands off our public insurance.

erp said...

Does it work with the corn syrup we get at the pump now?

Hey Skipper said...

[Peter:] Yes, we seem to have a chronic problem of talking at cross-purposes on this subject. To me, single-payer refers to who pays the bills, not necessarily who controls and manages the actual care.

I agree that your use is more accurate.

However, so far as I can tell, when progressives use the term, they actually mean single provider -- the state produces medical care.

IIRC, that was the NHS (one of their models) before the contradictions got out of hand. Why they don't learn from that is yet another mystery for the ages.

Howard said...

However, so far as I can tell, when progressives use the term, they actually mean single provider -- the state produces medical care.

BULLS-EYE!

Howard said...

FYI - Hey Skipper - I'm not forced to deal with Captcha if logged in to google/blogger.

Bret said...

Ahhh. That would explain why I don't have to deal with CAPTCHA either.

Hey Skipper said...

I'm logged on, and it is all captcha, all the damn time.

Hey Skipper said...

Ok. Well, except for that very last time.

erp said...

Skipper,

Lately, whichever of my devices I'm using needs to be restarted frequently so it can regain its senses. The i-Pad has the effrontery to declare it checked mail yesterday and stops dead right there ... apparently it sees no reason to tediously repeat the tiresome process again today.

I'm thinking all the snooping from every point on the compass and the satellites is slowing things down and making them a bit crotchety.

Just saying :-)

Hey Skipper said...

erp:

Here is a weirdly little known secret to fix such shenanigans:

Hold down the Sleep/Wake switch until "Slide to Power Off" appears. Then push and hold the Home button until the home screen reappears.

That forces a rewrite of RAM, and, in the couple weeks since I have learned it, deals with app buffoonery far quicker than a restart does.

erp said...

Skipper, thanks. I'll ask the neighbor child that deals with my ipad to take care of this for me -- I hesitate to deal with the spawn of the devil since nothing about it makes sense to me brain-washed as I am by MS.

Howard said...

Using the healthcare control ratchet...

erp said...

... which is why most of the physicians we know, many of whom are well below retirement age, are opting out. In their places, we'll get PA's and NP's and whatever other cheaper professionals come down the pike or the foreign educated who will get pushed through the licensing process unlike foreign educated physicians in the past who were given a very hard time qualifying for licenses. No matter how impressive their credentials, it was practically impossible short of going back to medical school.

I wouldn't be surprised if private clinics pop up in places like Cuba where those who can afford it will be able to bypass the cattle pens and enjoy excellent medical treatment in luxurious surroundings.

Clovis e Adri said...

Erp,

---
I wouldn't be surprised if private clinics pop up in places like Cuba where those who can afford it will be able to bypass the cattle pens and enjoy excellent medical treatment in luxurious surroundings.
---

Now that would be comically ironic, wouldn't it?

erp said...

Ironic? No, business as usual because the clinics would be owned by crony capitalist Americanos. I think a lot of lefties, especially in the media, who looooooove Cuba so much, have bought fabulous beachfront and mountain properties at bargain basement prices in return for their very public support of el jefe. I knew a lot of Cubanos when I was working at the college and they waxed eloquent on the beauty of the island.