I think we found out today: magic!
Obama got the SEIU and various corporate entities involved with health care provision in a room and got them to promise to slash 150 basis points from the annual rate of increase in health care spending. How will we achieve this? Whitehouse.gov has a fact sheet which outlines the concrete proposals that came out of this meeting:
- Improving Care after Hospitalizations and Reduce Hospital Readmission Rates payments will be bundled to include the 30 days post discharge; readmitted patients will become a cash drain. If hospitals really are making patients sicker (or not bothering to make them well) because readmissions are lucrative, it should be interesting to see what lengths they will go to to avoid readmitting very ill patients.
- Reducing Medicare Overpayments to Private Insurers through Competitive Payments. Bye-bye, Medicare Advantage. Maybe. Medicare Advantage seems to cost more because it, er, provides more benefits. It also apparently has good patient satisfaction. Directly playing with senior health care can be politically dangerous.
- Reducing Drug Prices Only for Medicaid. No dollar item attached to it, probably because the savings are relatively trivial; Medicaid is a small part of the overall budget, and prescription drug prices are a small part of its budget, and an 8% decrease in a small part of a small part doesn't sound as good as Reducing Drug Prices.
- Improving Medicare and Medicaid Payment Accuracy aka the infamous Waste, Fraud, and Abuse. Traditionally much harder to get out of the system than promised by reformers, in part because the Waste, Fraud, and Abuse subsidizes other services, so if you eliminate Medicare overpayments, you suddenly get higher prices. This is why retailers do not actually attempt to push "shrinkage" to zero.
- Pay for Performance The Holy Grail of health care wonks. Good luck. Projected cost savings: $12 billion
This is all very well as political theater; politicians convene never-never working groups all the time. But, being perhaps too cynical, I suspect that the announced plan to save $2 trillion is going to be used to sell Obama's healthcare plan as if we'd already found it. Then when oh, darn, the SEIU doesn't agree to hold down wages or eliminate jobs, and pharma ratchets up the average price it charges the private sector to make sure it doesn't lose too much on its mandatory Medicaid discounts, etc, well, we'll all just have to dig into our pockets to pay for it, won't we?
I'm not sure the exact number but up to 76% of hospitals are non-profit. You might be interested to know that they almost never charge as much as they are entitled to. The goal of a non-profit is to keep revenue slightly higher than expenses. You will note that almost every non-profit hospital is now examining their revenue cycle due to falling revenue resulting from the recession. Depending on the size they are finding millions of dollars worth of charges they hadn't previously bothered to bill for.
Now, this isn't fraud they are 100% entitled to bill, they just don't usually as they have no incentive to bring in that much extra revenue in most cases.
All this hope and change is really getting me down.
We're not digging into our pockets to pay for ANYTHING. We're merely toying with how soon we want the inevitable debt/currency crisis.
"If hospitals really are making patients sicker (or not bothering to make them well) because readmissions are lucrative, it should be interesting to see what lengths they will go to to avoid readmitting very ill patients."
It is always very important to think about where the incentives lie on any curve. This move will also make hospitals desperate to reclassify re-admissions as new admissions. If they can figure out a clever way to do this reclassification then they get BOTH the 30 day post-discharge payment AND the admission cost for a new condition.
Trying to police what the primary reason for admission is will then be a nightmare as novel health concerns could still crop up but many complex conditions can be classified in all sorts of different ways!
Simply put: health care is expensive because it has high opportunity costs. A lot of smart people and a lot of expensive infrastructure is required to deliver what we expect.
I'm a frickin' patent lawyer and I understand that much economics. Somebody explain it to the Smartest Man Ever In The White House.
This is going to be heretical, but consider the following:
Culture A eats a diet of mostly vegetables, labor is mostly outdoor work, and life expectancy is shorter, so old folks just pass away.
Culture B is economically rich, consumes an extremely nutrient rich diet awash in sugar fat oils and overall volume, and after eating cheesebergers for decades, show up at the doctors demanding to be fixed. Medical system is held to a high standard of care for everybody, throwing resources at the sickest, enforced by plaintiff lawyers ready to play robin hood if they can keep 30% of a king's ransom if a leech dares to screw up.
Assuming both cultures have eliminated hygenic issues like parasites and pestilence, which culture is going to spend more on healthcare? Which culture won't spend a nickel treating systemwide heart disease, diabetes, and obesity? Hopefully Culture B is rich enough to afford its self-imposed healthcare needs, but just to pick an extreme straw man, if a culture were entirely compose of the people in Wall-E, would it surprise anybody if i) everybody spent a fortune on healthcare, ii) the medical system saw widespread rationing and patient dissatisfaction, and iii) poor medical outcomes -- you can only do so much when someone shows up with 3-4 co-morbidities.
The other fun issue: what if Culture B has a vibrant technology, biotech, and genetics startup market, which continues to come out with fancy new treatments?
In this case, Culture B could be a bunch of vegetarian fitness gods, and still be hugely expensive once they get old. Add to that the idea that "getting old" may involve expensive diseases we don't even know about that show up when you're 125, and you've got a gi-normous health care sector.
Even if we figure out ways to make it uber-efficient and squeeze every cent of waste out of the system, it'll still continue to get more expensive over time, simply because it's doing more.
In this sense, it's like energy: a growing economy will increase energy use, even if you have zero inefficiency. A population with an increasing life expectency will increase visits to the doctor.
Assuming that Culture A can afford healthcare equally along with Culture B, they spend a fortune fixing the hernias, accidentally amputated limbs, 60 pound weights dropped on feet, head injuries, sucking chest wounds, hypothermia, hyperthermia, infected cuts, etc, that come along with outdoor work. You look at dangerous jobs - they're mostly outdoor.
Although of course apparently Culture A is run by a bunch of heartless sobs who don't give a damn about their dear grandmothers ("old folks just pass away") so perhaps they don't give a damn about the injuries resulting from all that outdoor work.
In other words we can save heaps on healthcare by not spending any money on it. Amazing! Just not exactly helpful.
Tracy,
I think you will find that sedentary occupations are often just as lethal and/or injurious as physical labor, it's just that the damage occurs much more slowly and less dramatically.
But yes, you are correct (even though you were being sarcastic) that we can save heaps on healthcare by not spending money on it.
Healthcare is NOT a right -- It is an economic product governed by the same law of supply and demand as anything else we buy. Most of us accept that some people can afford a Mercedes and others can only afford a Hyundai. But when it comes to healthcare, we ALL demand the Mercedes. This is a huge economic problem with no easy solutions.
If the government provides the highest level of care possible "free" to everyone, there is no way that even our erstwhile affluent society can actually pay for it for more than a few years. The answer to that problem then becomes artificial rationing. And one way of describing artificial rationing is... "saving heaps on healthcare by not spending money on it."
We are moralizing ourselves right into the poorhouse. And THEN how good will our healthcare be?
Sorry my thesis was, all pundits start with the premise that everybody deserves the best possible healthcare at the lowest possible cost. But there's no rule of nature that both those conditions HAVE to exist -- it's just an ideal -- and society/cultural norms go a long way in making those conditions impossible to meet.
So either we spend a king's ransom bailing out everybody's health, regardless of how individuals mistreat themselves, or we have to back off notions like universal healthcare (where other compromises are involved)
Dramatic is right. It's dramatic because it's pure theater, posing for effect. It is a classic inside-the-Beltway misdirection move--appear to make a constructive gesture in order to get out in front of an issue, then steer it away from the outcome you really fear. Then, when the threat is averted, work behind the scenes to mitigate or eliminate the pain of the so-called "concession".
The health insurers are deathly afraid of any reform plan that entails a government-run system that would compete against them. They know they can't oppose reform outright, so they promise cost-containment, along with a mandate that everyone buy insurance. They'll re-jigger their numbers to look like they're holding down costs and create some crappy bare-minimum plan for the poor folks to buy with subsidized funds. Then, a couple of years later, when the dust clears, the costs will start soaring again. Only by then the government will be drowning in so much red ink from its "reform" plan, bailouts, etc., that it won't be in a position to do anything about it.
In any event, I'd bet that behind the scenes the health care fat cats are betting that Obama and the Congress won't be able to pay for this. And I think they may be right. Just last week Charlie Rangel said "NO" to taxing employer-provided coverage. There just aren't any revenue streams large enough to do the job.
What I find rather astounding is that even the so-called "health policy wonks" in the various think tanks, magazines and blogs are going ga-ga over this so-called "concession". If they put down their pom-poms for five minutes and turned on their brains, they'd realize what was happening. But they're so blinkered by the prospect of change, and Obama-mania, that they're not thinking straight.
Amen.
Then when oh, darn, the SEIU doesn't agree to hold down wages or eliminate jobs, and pharma ratchets up the average price it charges the private sector to make sure it doesn't lose too much on its mandatory Medicaid discounts, etc, well, we'll all just have to dig into our pockets to pay for it, won't we?
As opposed to letting the system go as it is, in which case we'll also have to dig into our pockets to pay for the faster-than-inflation cost increases (or go without coverage)...? We're screwed either way, but we might as well be screwed but with some hope of medical coverage for everybody.
As opposed to letting the system go as it is, in which case we'll also have to dig into our pockets to pay for the faster-than-inflation cost increases (or go without coverage)...? We're screwed either way, but we might as well be screwed but with some hope of medical coverage for everybody.
The better solution, of course, is simply introducing competition and market forces. The best antidote to price increases is competition. The fact that we use insurance to pay for everything is insane. Insurance should be for catastrophic unforeseeable events.
Notably, things that insurance doesn't cover, such as lasik, feature no notable inflation and quality increases.
The notion of government as a force for cost control and efficiency is laughable. The same folks that brought you agriculture subsidies, the DOD procurement process, unsustainable programs such as social security and medicare, and the US postal service are most assuredly not the solution to health care.
The better solution, of course, is simply introducing competition and market forces. The best antidote to price increases is competition.
There is substantial price competition in the health care marketplace. Insurance companies pressure providers to sign lower cost agreements to become "participating physicians" or "participating hospitals". Corporations lean on insurance companies to keep rates down. Insurance companies lean on Big Pharma for rebates in order to get the drugs on formularies. The constant refrain from the right that there is "no competition" in health care is bogus. (And much of what the left spouts is bogus also.)
Even if there was "competition" along the lines some envision, there is the problem that unlike grain and steel, medical services aren't perfectly fungible. Let's say I decide on Dr. No as my physician based on his costs. He does a physical with x-rays, lab tests, stress test, etc. Much of that is farmed out to other providers that he has established relationships with. They may not be the low cost providers in the area. The hospital he uses may not be the lowest cost one you could go to. How can an individual gauge which services they would need over the next year, 5 years, or more and come up with a cost model that they can use to decide which mix of providers is "cheapest"? Who has the time and expertise to figure this out?
Notably, things that insurance doesn't cover, such as lasik, feature no notable inflation and quality increases.
There are falling prices in areas insurnce covers. Cataract surgery has seen prices come down. Other surgical procedures are cheaper as they become routine.
The notion of government as a force for cost control and efficiency is laughable.
Mostly true. There are a few programs that government could do to make health care more efficient.
- They could gather data on all adverse outcomes and malpractice claims, analyze them, and use the data to improve results. (My spouse's field in medicine does this and has dramatically improved outcomes over the last 20 years.) It would require that the data obtained be completely private and unable to be used in judicial or administrative cases.
- They could chair standards groups to standardize the electronic exchange of medical records among different providers - no such standard exists, which is why Obama's call for portable medical records is 8-10 years off. Even more important, they could devise a test suite to make sure the systems meet the standard. I've worked in this area and it will take 4-6 years to create the standard and publish it, several years to write code that works under it. It's a very complicated problem, and the administration seems to think it's easily solved. It isn't - there is an international standard for web pages, but no single web browser renders the test pages correctly, and web pages are simple compared to medical records.
- The current program to identify effective treatments and publish stats on how well providers follow them should be expanded and improved.
But none of this has a fast payoff or moves us toward single payer, which is where we're headed.
ObNotice: Anyone with a magic wand for improving the health care system must explain how they plan to get around Baumol's Cost Disease or they fail. (Look it up if you don't know what it is.)
+1 on the second point. Providing industry standards and ensuring transparency is one function where gov't be most useful, and does not offend my libertarian sensibilities one bit.
They could gather data on all adverse outcomes and malpractice claims, analyze them, and use the data to improve results. (My spouse's field in medicine does this and has dramatically improved outcomes over the last 20 years.) It would require that the data obtained be completely private and unable to be used in judicial or administrative cases.
I'm an anesthesiologist, too, and this is a great thing we've done - one comment I remember hearing directed at a P4P booster was something along the lines of "In my career, deaths due to anesthesia have fallen from 1 in 10000 to 1 in 150000 or less. In what world is that not performance improvement?"
However, that doesn't save any money. In fact, there's really very little we can do to save significant money except to do less.
I'm not so sure that squeezing savings out of our medical system is as impossible as Megan imagines. She suggests that the current system is operating as close to efficient as it possibly can in a rambunctuous democracy. Yet other industrialized countries spend substantially less of their GNP on health care than the US and achieve better results. Only a small fraction of this difference comes from e.g. free riding on indirect American subsidies for drug company "research".
So there is room for substantial potential savings without sacrificing quality of care. There is literally several percentage points of GNP lying on the table, hundreds of billions of dollars per year, of "Waste, Fraud, and Abuse", medical spending which leaves us still dying years before our time with staggeringly high infant mortality (for an industrialized nation).
This waste is spread throughout the health care industry and will be difficult to claw back. Too many people benefit, from doctors who make twice as much as their counterparts in other industrialized nations to insurance bureacracies and the billers who fight them who spend tens of billions a year trying to foist sick patients on the other guy to malpractice lawyers who earn their huge fees and force physicians to perform unnecessary tests. But that doesn't mean that we shouldn't try to claw it back, nor that stakeholders should not be allowed to present how they will extract their share of waste before the government hacks it away from them.
There is plenty of waste which is not subsidizing other services. Have you been to a doctor's office? One doctor will be surrounded by a huge support staff of billers who are arguing with an equally huge number of counterparts at insurance companies. Some of this work is necessary but most is not. Thats real waste, not a subsidy! These highly trained and educated people could be more gainfully employed doing real work as mortgage brokers, prison guards, or government bureaucrats and society as a whole would be better off.
These people can argue that what they do is necessary, that malpractice lawyers keep physicians honest, that insurance bureaucrats keep the lid on unnecessary spending, that doctors need their high salaries because otherwise they wouldn't go to medical school, that the "unnecessary" tests actually save lives, etc. In the abstract, these arguments might be pursuasive. But every other industrialized country gets significantly more health for substantially less money, so some aspects of our system can be improved without performing major surgery on human nature to provide us with more health, greater coverage, and for less money.
gainfully employed doing real work as mortgage brokers, prison guards, or government bureaucrats
Ah! So this entire comment is sarcasm? Damn, I'm slow today [slapping myself on the forehead]
Other countries get more *health* for substantially less money. But that doesn't mean they get better *health care*. We can deliver far less health care, but get more or less the same health outcomes, and many other countries do this.
See Robin Hansen's great article for more on this.
http://www.cato-unbound.org/2007/09/10/robin-hanson/cut-medicine-in-half/
Punch line: reducing consumption of health care by 30% does not significantly affect health outcomes.
Yet other industrialized countries spend substantially less of their GNP on health care than the US and achieve better results.
This is nonsense. There is no other country that gets better treatment outcomes than the US. The tired old liberal taking points are that the US lags behind other countries in life expectancy and infant mortality. The rest of the world uses different standards for determining live biths. A low birth weight/premature baby has a better chance of survival in the US than anywhere else in the world and the care that we provide is very expensive.
Our life expectancy is not very much lower than Canada's for example, but it doesn't matter anyway. Life expectancy is based on a whole lot of things other than the percentage of people who have health insurance.
The American System is the best system in the world for treating and healing the sick. No other country dispenses the quantity or quality of health care that we do. Our life styles, per capita productivity (i.e. how much we work), immigration policy, the distance we drive in cars every year, etc. dictate our average life expectancy much more than the rate of health insurance. If the French are healthier it is becasue they have more restrictive immigration, they eat healthier, they work less (i.e. less stress), etc.
It is legitimate to consider how we can incentivize better chosices amongst our citizenry, but giving the government control over the health care insutry won't solve any of the problems we currently have. It will merely shift the decision making to bureaucrats and give politicians yet another entitlement they can manipulate in exchange fro votes.
Jean,
I don't think "Too many people benefit, from doctors who make twice as much as their counterparts in other industrialized nations" should be one of your talking points. Asking doctors and nurses to work for less just doesn't seem like something you can sell to the American people.
My main source for my comment was this article in McKinsey quarterly: http://www.mckinsey.com/mgi/rp/healthcare/accounting_cost_healthcare.asp . They identify several areas in which the US spends too much, and I didn't want to list them all. The ones that I mentioned were among the highest, but together make up only a small fraction of the estimated $500 billion annual that the US overspends. The excess amount that we spend is divided into the following major categories:
Drugs and devices: $73B
Physician compensation: $58B
Nursing labor: $50B (because we have more nurses, not because they are overpaid)
Administration and insurance: $98B
Profits by private hospitals: $41B
These numbers were from 2003. Certainly other things would have gotten worse.
----
I was not trying to be totally sarcastic about my comment about prison guards and breaucrats. These people actually do benefit society more than billers. And billers are highly trained and educated.
The problem of overpayment of physicians is complex. Physician specialists are overpaid in part because the supply of specialists is limited by the need for them to be certified. And the certification bodies are dominated by the already certified who have an interest in limiting the supply of their potential competitors.
No, you have it wrong. Demonizing doctors is the best way to improve the medical system and medical care. Canadians do it all the time. Look how good a system we have.
Derek
Reforming the national healthcare system will be difficult and costly. Thank you for the update, Megan.
Damn the American people for indicating through elections and public opinion polling that our current healthcare system is too costly and not inclusive enough - in need of reform. How dare us, asking our president to make hard decisions. Obama should instead follow the Reagan, Bush, Clinton, and Bush model of just kicking the can down the road and hoping everything turns out peachy.
That should turn out spendidly. Or we could just invade Myanmar and pretend this conversation never happened.
We'll return Burma to the people yet!
I disagree with you on much if what you have said. I don't much feel like arguing about it though.
That said, your line "Or we could just invade Myanmar and pretend this conversation never happened" is pure brlliance, I will be using it as a tagline n conversation in the future :)
"But every other industrialized country gets significantly more health for substantially less money, so some aspects of our system can be improved without performing major surgery on human nature to provide us with more health, greater coverage, and for less money."
That may be true, but (I assume you mean european countries) people demand less, aren't as likely to sue if something goes wrong, and doctors don't make as much.
I can only speak for the european country that I've lived in, but in Germany people do use their health care system at a vigorous rate. It's true that doctors make about one third of their American counterparts. But they don't pay for medical school (well, only a fraction--some 500 euros per semester) and don't have to carry hugely expensive malpractice insurance. Additionally, in talking to friends who have practiced in both Germany and the US, what they like about practicing medicine in Germany is that you don't have to worry about whether a patient's insurance will cover a procedure. You can recommend the course of care that you think is best.
So when we look at German (and other nations) "health care spending" we really should be adding in a big chunk of money spent on giving a "free" education to the doctors and nurses. After all, they still spend the money, they've just shifted the expenditure from the health budget to the education budget.
Also, shooting all the lawyers would help, but we all knew that.
"This is why retailers do not actually attempt to push 'shrinkage' to zero."
A bit OT, but what do you mean by this? I assume that the marginal cost of enforcement begins to exceed the marginal benefit (there was a recent New Yorker article on this, btw). But it sounds like you're suggesting that shoplifting + employee theft somehow subsidize something else? Like low wages? I don't get it.
But it sounds like you're suggesting that shoplifting + employee theft somehow subsidize something else? Like low wages? I don't get it.
Two things: The sort of people you can hire for low wages often include a number of petty criminals and morons; to weed them all out, you'd have to pay more. Also, honest and well-to-do customers might resent overly intrusive store security and would be willing to pay a little bit more to avoid being treated like a criminal regularly. So allowing a certain level of theft provides a "subsidy" by keeping wages low and keeping the wealthier people spending money at your store.
My daughter worked in retail at a popular mall chain store that catered to teens. They had several rotating racks of cheap junk earrings and the like that they expected to have moderate shrinkage on. The profit margins were high enough to not impact the bottom line much. The stuff they cared about was watched by a rover (clothing) or in kept in locked cases (jewelry) with strict procedures for handling. If you didn't follow the case procedures to the letter, you could be fired.
The intellectual dishonesty of progressives on the cost of healthcare reform reminds me of nothing so much as the intellectual dishonesty of neocons on the cost of the war in Iraq.
The only explanation I can think of is that at some point in a debate, policy advocates' self-images becomes so intertwined with winning that they can convince themselves of anything, no matter how improbable, as long as it leads to the desired result.
The USA simply HAS to improve/transform their system. All this 'fiddling about'. It is supposed to be the richest country in the world and it cant look after its people's health fairly. Paying higher taxes is worth every cent for a secure system where you get unlimited treatment. I know, i'm from Australia. I spent some time in the US and the health situation is the most fearsome'scary situation ever. Cost!! I paid $250 for a 5min doc consult and $90 for antibiotics. I would pay a maximum of $30 for the consult here and $15 for the drugs. For hospital treatment of course we pay nothing. But, as my US friends discovered our taxes are not that high anyhow. We pay 1.5% medicare levy, 2.5% if high income.I was informed you guys pay 6% and get nothing for it. But you guys can talk and rave as much as you want, your system STINKS bigtime and its WORTH every cent to fix it.I mean, people over there DIE, because they havent/cant pay medical bills and hospitals withhold treatment for this. Unbelievable!! That would NEVER happen here, and if it did there would be a huge outcry.Stop all the waffling and FIX it for god's sake.
I paid $250 for a 5min doc consult and $90 for antibiotics. I would pay a maximum of $30 for the consult here and $15 for the drugs.Er, why so much? A typical visit to a physician should be in the $100 range for up-front fees, less if you tell them you'll pay cash in return for a discount. And the antibiotics are, unfortunately, really much closer to the US price in most cases - penicillins, in particular, are available in a wide variety of generic formulations that still cost $60+ per regimen.
Was it a hotel doctor by any chance?
I'm a Canadian citizen and returned to Canada for a visit. Went to emergency for an issue, waited almost 4 hours, saw the doctor for 5 minutes and was billed $750.
If I was a paid-up resident it would have been 'free' other than the 40% of taxes that goes to healthcare.
I have lived in the UK, Canada and Singapore, and tried all of their systems. I have found the private system in Singapore the most professional and cost-effective.
This is an area where I have to wonder how much we can trust any of these figures. Not just Obama's but anybody's.
The fact is, in the most important sense, we already have national health care. Anybody can go to a hospital emergency room and get treatment regardless of their ability to pay. So there's no reason to think that insuring an additional 15% of Americans will cause a 15% increase in medical costs. That's the same sort of accounting trick used by the RIAA to call every illegal download a lost sale (when in reality very few of them are) or the MTA to call every use of an unlimited metrocard a lost fare (when at least some represent train rides that would not otherwise have been taken).
The cost of medical care will go up, but not necessarily all that much. Meanwhile, how is the money employers are paying into the system accounted for? How much of the "increase" is cost shifting from employers who are paying it now to the government, who will be paying it then? At least when our tax dollars pay for it, we'll have a better idea of how much it's costin us (because most people with employer-provided coverage think of it as free, not recognizing that they are paid less as a result).
This is not an argument in favor of national health care. It is merely recognition of certain issues that are left out of the discussion.
At least when our tax dollars pay for it, we'll have a better idea of how much it's costin us (because most people with employer-provided coverage think of it as free, not recognizing that they are paid less as a result).
As opposed to people with government health care, who are scrupulous about accounting for the sources of the money in their own mind.
As I have said many times, the root of our health care "crisis" is a cultural expectation that health care should be paid for by someone else.
So true. Frankly, I don't know why are hospitals forced to provide emergency treatment. People have this silly cultural expectation that people shouldn't be allowed to die if they can't afford a treatment.
Once we're able shed this costly presumptions, our society will be fine.
Nice jump from "health care" to "emergency care" there.
Nice work missing the point. Let me spell it out for you: emergency care is basically urgent health care. If we are not at all responsible for other people's health, that includes emergency care.
Nice changing the point. Rob said the root of the problem is that people expect health care to be paid for by someone else. Not urgent, emergency care. Health care. As in, every time you see a doctor or fill a prescription. There is plenty of room for safety nets while still expecting people for pay for their basic health care consumption.
So, just to be clear, you're fine with the cultural expectation that we are responsible for emergency health care?
According to you and Rob, if someone has type 1 diabetes and the parents can't afford the treatments, they should not be subsidized for illness management (you know, seeing doctors or filling prescriptions). They should only show up when there's an episode of acute hypoglycemia or it's time to cut another toe.
And, like it has been said 10,000 times already, other developed countries have exactly those cultural expectations with half the costs and better results.
As I have said many times, the root of our health care "crisis" is a cultural expectation that health care should be paid for by someone else.
But that's the cultural expectation in every Western democracy. Why does it work in France, Germany, Canada, Australia, etc. but not work here?
Why do you think it works in Canada?
A couple of years ago one province mandated by law that doctors do emergency room service. There was such a shortage of doctors due to the stupidity of the 'health economists' there was a crisis.
How long is it reasonable to expect to wait for a diagnosis in for example chest pains on exertion? Is 6 months ok?
Derek
I remember that. They were sending out police to retrieve doctors who refused their assigned shifts in emergency rooms... I used it as example to point out to people that slavery was alive in well in at least some quarters of the western hemisphere...
because they don't have the population diversity, infrastructure sprawl, demographic crunch, and intentionally hamstrung education system that we do.
Astrid wrote
Good point, Astrid. But most people who hang around here know the truth: having an efficient public health care system is just IMPOSSIBLE! There's no money! Obama is a dreamer who, against all evidence, still entertains the dangerous delusion that state intervention can improve the health care system in this country.
Now, expect to hear the same old arguments as to why the U.S. pays a share of GDP that's 50% to 100% in excess of all other developed countries, with terrible results:
- we have a shorter lifespan because of our unhealthy lifestyle. Too many burgers, too little jogging. The life expectancy gap between the U.S. and EVERY single other of the 30 developed countries can be explained by the "fact" that they have better diets and lifestyles compared to ours.
- we have more black people, who, for unexplained reasons, die sooner. True, they are just 14% of people, and if they are excluded from the U.S. population the longevity gap remains. But hopefully, if we keep singling out and excluding lower longevity groups in the U.S., while not doing the same for other countries, we'll come up with a satisfactory number.
- other countries? Are you kidding me? I know a guy who went through some horrible health services ordeal in a foreign country. I'll focus on that anecdote and ignore statistics (or, for that matter, equally horrendous stories who happened in the U.S.).
- OUR PHARMA INDUSTRY PAYS FOR THE MEDICAL RESEARCH OF YOUR COUNTRY. YOU'RE A PARASITE!! Of course, the money percentage invested in research by the whole health industry doesn't come near to justifying the %GDP gap.
- don't talk about longevity. That's just one statistic among many. Sure, it looks like it's the one we should care about, but it's not really reliable because of the aforementioned burgers and black people. Did you know that the U.S. has the highest percentage of successful [insert a medical procedure here, preferably a surgery] in the world? Besides, wealthy people from all over the world come to the America just to do [another medical procedure]. Which demonstrates that our health care system is better, not on that specific procedure, but on everything.
So here you go Astrid. These are all the main "reasonable" arguments that some people have internalized to justify why they must pay through their nose for health insurance and, when they get sick, still run the risk of getting their coverage denied on some technicality and go bankrupt. Talk about brainwash.
Ridiculous. Go take a look at survival rates for cancer in the US vs other countries. After all the best measure of health care is what happens once you get sick, not life expectancy.
I'm going to be as lazy as you are, and not link my answers at at all.
What you're saying is completely misleading. Firstly, success rates depend on the type of cancer. Secondly, the average age for a cancer patient in the U.S. is much lower than in most other developed countries. Of course 40 year olds are going to survive cancer more often than 70 year olds. But the 70 year olds reached that age by not dying (of cancer, among other possible afflictions) when they were 40. When controlling for patient age, the cancer survival rates in the U.S. are not higher than in other developed countries.
Where are these numbers? Go take a look.
The larger point here is that, even if cancer survival rates for the same age group were higher in the U.S., it still doesn't make people live longer overall. Americans still die younger. See last point of my previous post.
Uh... No. A good, efficient health care service should also focus in maintaining people healthy. It's called prevention. You may have heard of it before.
If you control for other variables, the best measure is by far life expectancy. It's practically the only measure that matters.
Cancer survival rates:
http://1.bp.blogspot.com/_5aAsxFJOeMw/Rx9AuKML_9I/AAAAAAAAAjM/bKfsatD8X2k/s1600-h/five-year-cancer-survival-rates.JPG
And you can keep insisting that life expectancy is the best proxy for health care but that doesn't make it any more true. The difference in life expectancy between Hawaii (80 years) and Washington DC (72 years) is 8 years. Is that attributable to their health care systems? Or do you think that maybe, just maybe, demographics play a role?
http://www.businessweek.com/bwdaily/dnflash/content/sep2006/db20060913_099763.htm
Furthermore, should we say that the health care systems in Minnesota (78.8 year life span) and the European Union (78.7) are equivalent because of similar life expectancies?
What do you make of the fact that life expectancy in Norway at 79.8 years and Minnesota -- which has a lot of Norwegian Americans -- is a mere 1 year? Is that again solely attributable to their health care systems?
Are you beginning to realize how stupid your argument is?
Colin, you need to learn how to read comments. And to think in general.
The numbers you've linked on cancer survival rates have the problem I mentioned before: they are not controlled for age of cancer incidence, which is very low in the U.S.
Let me repeat this untill it gets through your thick skull: comparing cancer data without average age of onset is pretty useless.
Those are two particularly bad examples.
Hawaii is a pioneer state in health care: since 1974, it requires employers to provide health care for all workers who do more than 20 hours a week. It seems they are reaping what they sew.
The District of Columbia has the highest crime rate in the country, and 3% of the residents are HIV positive. AIDS It's considered an epidemic in D.C.
But, if you control for other factors, of course life expectancy is the best proxy for all health care. This doesn't mean that health care is the only factor that determines longevity.
You linked this list of life expectancy by state:
http://www.businessweek.com/bwdaily/dnflash/content/sep2006/db20060913_099763.htm
Compare with the statistics of uninsured by state:
http://www.statehealthfacts.org/comparemaptable.jsp?ind=130&cat=3
There's obviously a high negative correlation between number of uninsured and life expectancy. It's not a perfect correlation, but it's remarkably high.
Now, the U.S. is number 38 in life expectancy around the world, in spite of having, by far, the greatest expenses as % percentage of GDP. Could it possibly be that the number of uninsured and underinsured, or the general quality of health care, has something to do with this?
Minnesota is pretty good for the U.S. But the comparison is absurd. You're comparing one system (Minnesota) with an average of many systems (EU). In the EU there are some member states with a longer life expectancy than Minnesota, but there are also some poor former iron curtain countries (Hungary, Poland, Slovenia, etc). The latter have a worse life expectancy than Minnesota.
If you make an average of the heights between NBA players and pygmies, they'll probably have the average of an U.S. citizen. But this would be a pretty stupid average, wouldn't it?
I like how you go from "best proxy" to "solely attributable".
First of all, Minnesota is the second state with less uninsured in the U.S. (tied with... Hawaii!) and the second state with higher life expectancy. That said, you should realize that "a mere 1 year" is not a small difference in life expectancy. 1 year more and the U.S. would pass from number 38 to 26. One year less and the U.S. would be behind Barbados. This is especially true for higher life expectancies, naturally.
The numbers you've linked on cancer survival rates have the problem I mentioned before: they are not controlled for age of cancer incidence, which is very low in the U.S.
Let me repeat this untill it gets through your thick skull: comparing cancer data without average age of onset is pretty useless.
Despite your lack of any data or links to back this up I will go ahead and assume it is true. This fact, however, exposes the absurdity to looking at life expectancy rates as it shows that people in different countries don't get sick at the same rates. Thus, comparing across countries isn't the apples to apples comparison some people would like it to be.
Hawaii is a pioneer state in health care: since 1974, it requires employers to provide health care for all workers who do more than 20 hours a week. It seems they are reaping what they sew.
Hawaii has had a longer life expectancy than the United States since 1950. Even within Hawaii life expectancy among ethnic Chinese is 83 years while ethnic Hawaiians is at 71 years. But demographics don't matter right?
The District of Columbia has the highest crime rate in the country, and 3% of the residents are HIV positive. AIDS It's considered an epidemic in D.C.
Well, yes. DC has different behavior norms than most of the rest of the country. Behavior influences health outcomes. You're starting to catch on.
Now, the U.S. is number 38 in life expectancy around the world, in spite of having, by far, the greatest expenses as % percentage of GDP. Could it possibly be that the number of uninsured and underinsured, or the general quality of health care, has something to do with this?
I'm sure it has some impact. But this notion that it is the massive, overwhelming determinant that you think it is is not at all clear. Simply pointing towards life expectancies as evidence of superior health systems is absurd.
Minnesota is pretty good for the U.S. But the comparison is absurd. You're comparing one system (Minnesota) with an average of many systems (EU). In the EU there are some member states with a longer life expectancy than Minnesota, but there are also some poor former iron curtain countries (Hungary, Poland, Slovenia, etc). The latter have a worse life expectancy than Minnesota.
If you make an average of the heights between NBA players and pygmies, they'll probably have the average of an U.S. citizen. But this would be a pretty stupid average, wouldn't it?
But given that all EU countries have public health care systems shouldn't they outperform MN since universal health care is superior?
But leaving that aside, just go ahead and compare MN with Denmark or Finland, where it is superior to both. Does that mean that Denmark and Finland should adopt the MN health system?
This argument that life expectancy rates demonstrate the superiority of medical care is ridiculous and lazy.
Colin insists:
I'll repeat a previous point - "best proxy" doesn't mean "solely attributable". All your arguments rely on demonstrating that it's not just health care that influences life expectancy. Gee, thanks. But nobody said that. The thing is, when the U.S. is country number 38 in longevity, lower than the vast majority of developed countries with their wildly different lifestyles, ethnic groups, climates, etc., it's pretty hard to find any other explanation besides the one that is staring you in the face - a great percentage of the population uninsured and underinsured.
But evidently if there's a lethal epidemy (or any other abnormal cause of mortality) affecting 3% of the population, as in D.C., that's going to diminish life expectancy.
What you conveniently ignored in your reply: the correlation between percentage of uninsured and longevity inside the U.S. Isn't this strange? Of course, correlation doesn't imply causation and all that. On the other hand, not getting treated when you have a disease seems pretty believable as a cause of premature death.
Moving on:
71 is the life expectancy of Hawaiian men. You compared it with 83 for ethnic Chinese men and women, with women, of course, enlarging the difference (they live, in average, 6 years longer). Besides, Asian-Americans have median household income higher than any group in the U.S., and longevity is known to increase with income level.
But of course you can always point to the most extreme cases of longevity in ethnic groups and say "See? Demographics matter!", while ignoring the larger point: Hawaii, not just the ethnic Chinese, has greater longevity than any other American state. It has also the smallest number of uninsured, and this pattern is seen in other States in the U.S., like Massachusetts, Rhode Island, Connecticut, etc where the ethnic chinese population is very low. Maybe you can come with an individual explanation for every one of these States. Ever heard of Occam's Razor?
Let me quote from this site.
"Life expectancy in Hawai'i has improved dramatically since 1910 when it was less than 44 years. It was not until 1950 that life expectancy in Hawai'i surpassed that of the United States. It has continued to exceed the U.S. life expectancy ever since. Gains in life expectancy every 10 years mirror major developments in public health and medicine."
Well, it seems health care has something to do with this after all.
"Since statehood, the largest life expectancy increase, of almost four years, occurred between 1970 and 1980."
Mandatory health care for workers was introduced in Hawaii in... wait for it... 1974! Just another one of those remarkable coincidences.
Now you're just supporting my arguments. Minnesota is the 3rd State with less uninsured between ages 19-64. The percentage is almost half the national average (11% vs. 19,7%). So it seems the second best, most covered State in the U.S. can do slightly better than the worst countries in Occidental Europe. By the way, Finland is pretty close to Minnesota, and Denmark spends half the U.S. in %GDP. That's half of the U.S. average. Minnesota almost surely spends a lot more than this average.
Not if you include underdeveloped ex-iron curtain countries in the statistics, since their infrastructure is crumbling and they can't afford decent universal care yet. Unlike, you know, one of the richest countries in the world. I have no idea what kind of health care system they have in Angola, but I'm sure it won't compete with the U.S. anytime soon, no matter the system implemented.
So you can nitpick and fuss and talk about incomparability all you want. The facts remain:
Inside the U.S., in general States with more coverage have higher longevity. The U.S. pays more than any other country in health care as a proportion of GDP, often twice what other countries pay. It's 38th in life expectancy. The people of 37 very different countries in terms of ethnicity, diet, climate, demographic profile, etc. live longer. They all have one thing in common: generalized access to health care.
I'll repeat a previous point - "best proxy" doesn't mean "solely attributable". All your arguments rely on demonstrating that it's not just health care that influences life expectancy. Gee, thanks. But nobody said that. The thing is, when the U.S. is country number 38 in longevity, lower than the vast majority of developed countries with their wildly different lifestyles, ethnic groups, climates, etc., it's pretty hard to find any other explanation besides the one that is staring you in the face - a great percentage of the population uninsured and underinsured.
No, actually you can find all kinds of explanations. How about the fact that Americans murder each other at higher rates than those other countries? Or the fact that we drive more while Europeans are more likely to use public transport? You're more likely to be killed driving to the grocery store in suburban USA than walking in a less car-centric, and more pedestrian friendly European city. Indeed, in 1997 Denmark had 495 traffic fatalities out of a population of 5.275 million for a fatality of 1 per 10,656 while in 1994 the US had 40,676 fatalities out of a population of around 260 million for a fatality rate of 1 per 6,392.
We are of course fatter than any other country, with obesity rates of 30.6% that is more than double that of Canada and triple that of the Netherlands.
Unlike most European countries we also border on a third world country that exports millions of its citizens. Mexican immigrants, for all for all of their virtues, tend to be poorer, and the poor tend to die faster than the rich.
You want to play a game where you both acknowledge that health care isn't the only determinant of health outcomes while also insisting that our health care system is to blame for the differences.
You also want to talk about how insurance coverage correlates with life expectancy. Well, here's another correlation: the rich tend to live longer than the poor. While being rich is almost a guarantee that you have insurance, it usually also means that you have different behavioral patterns that the poor and are probably less likely to drink, smoke and be overweight.
Indeed, going back to Minnesota it is notable that they also have among the lowest poverty rates in the country.
This notion that health care systems can simply be examined via life expectancy rates is simplistic and counter-productive, failing to take into account very different demographic and cultural factors. This is especially true when you consider that a 2 year increase in life expectancy would vault the US into the top 15.
This, of course, is not a defense of the current US system, which can absolutely be improved upon through the introduction of market forces to bring down prices and expand availability. But the life expectancy stats you like to trot out are hardly the damning evidence you think them to be.
One more item:
http://health.dailynewscentral.com/content/view/0002418/42/
The primary cause of the disparities between racial and geographic groups is early death from chronic disease and injuries, an analysis of data from the Census Bureau and the National Center for Health Statistics showed.
Asian-American women living in Bergen County, NJ, enjoy the greatest life expectancy in the US, at 91 years. American Indians in South Dakota have the worst, at 58 years.
The differences were attributed to a combination of injuries and such preventable risk factors as smoking, alcohol, obesity, high blood pressure, elevated cholesterol, diet and physical inactivity -- particularly among people from 15 years to 59 years of age. They were not due to income, insurance, infant mortality, AIDS or violence, said the study's lead investigator, Christopher J.L. Murray, director of the Harvard Initiative for Global Health.
Most public health initiatives target children and the elderly, he noted.
The study looked at life expectancy by geographical areas as well. Hawaii led the 50 states and Washington, DC, with an average life span of 80 years, while DC trailed at 72 years.
Personal choices could be more important than access to medical care in improving life expectancy, Dr. Murray noted. Half of the people who have high-blood pressure fail to get it controlled, two-thirds of those with high cholesterol do not get medication to lower it, and two-thirds of diabetics fail to manage the disease, in spite of the fact that 85 percent of the population overall has health insurance.
Colin
Now you're getting somewhere. You talk about other factors that influence life expectancy. You're quite right. But we should not dismiss life expectancy as a statistic because of other factors. We should control for these other factors and quantify their influence.
There's stats here for 2002. For instance, Accidents make up roughly 43,000 deaths out of 2,400,000 (roughly 1.8% of annual deaths). Just for traffic, there's roughly 134 deaths per million in the U.S., compared to 93 deaths per million in EU (2004 number). Now, 44% more deaths sounds like a lot, but it's not going to make much of an impact on the final number, since accidents are a relatively small cause of death overall. I didn't bother because it's a smaller factor, but you can do the same for homicides in other countries vs. the United States. I expect the conclusions to be pretty similar.
Check this out. Quote - "Lithe and sophisticated Europeans laughing at American fatties across the Atlantic is becoming a thing of the past, with EU fat rates catching up and in some cases exceeding those of the US."
Mexico is poor, but life expectancy is 75.84, less than 2.5 years away from the U.S. average Immigrants that come to Europe usually have a shorter life span in their home countries than Mexico (e.g. Russia, Ukraine, Algeria, Morocco, Turkey). More importantly, Hispanic longevity this can also be controlled for , and apparently the gap is very small (see table 2). Up untial some time ago, some people thought Hispanics even lived longer, but that doesn't seem to be the case.
That's right. Because when one discounts the other major factors, it seems the U.S. longevity still comes up short. Remember that being, say, in the top 10 countries with higher life expectancy in the world should not be an unrealistic goal for a country with the resources, technology and wealth of the U.S.
Income, as you correctly observe, makes a difference in other ways besides health care. But Virginia, for instance, has a pretty low poverty rate but bellow average life expectancy. Coincidentally, it has a much higher percentage of uninsured than other higher life expectancy States.
Internationally, remember that Europeans smoke more than Americans both in relative population and for the same income level. I could bet they also drink more, but I don't really know about that.
2 years is a lot when you're talking about developed countries. And it's a lot in a person's life too.
You point out that factors of risk make a difference in life expectancy. I agree with this. I completely disagree that they make life expectancy useless as a health care performance measure, because risk factors can be taken into account and controlled. And when you make some effort to control them, they just don't seem to be responsible by the U.S. gap relatively to the rest of the world.
Life expectancy has the inconvenience of confounding causes, but it also has the advantage of evaluating overall health care, reflecting the treatment of all illnesses as well as prevention, unlike other measures of medical performance.
An aside: don't forget that 25 million people are estimated as underinsured in the U.S. as of 2007. Managing chronic diseases or risk factors can be expensive for these people. Besides, are people in the U.S. more careless than in other countries?
You're repeating a trivial point. Of course genetic differences matter. Of course income matters. Women live more than men. Some ethnic populations live more than others. And so on. Obviously, if you pile up all the advantages in one side (Asian-American women in wealthy New Jersey) and all the disadvantages in the other, you're going to get a big difference.
But what are you saying exactly? That it is a combination of all these factors that accounts for the U.S. having a shorter life expectancy than the other 37 countries? There is no systematic difference between any of these factors and all, or even most, of the other 37 countries. On the contrary: most of the other countries have smaller average as well as median incomes; they have a high variety of ethnic groups, from East Asian to White Caucasian to Hispanic to Arabic; and they have pretty much ratio of women to men, one would expect. Taking out the 14% black population (while keeping the 3% Asian population and not controlling for income levels), life expectancy goes up by a measly 5 months. The rest is something else.
The biggest jump in life expectancy in Hawaii coincided with the introduction of mandatory worker health care in the 70s, although they had the "ethnic advantages" before. Likewise, South Korea had a big jump in average height, in the last few years, and this is commonly attributed to the dramatic rise in the quality of life.
Individual choices and genetic makeup can account for most of the individual variance while being negligible for a diverse population. Take height, for instance. Most of the variance of height is genetic, and there are a lot of differences across race, gender, you name it. Still, in spite of this, developed countries have, in general, higher averages in population height. Sure, there's the pygmies, there's the Dinka, and still height is very useful as a measure of poverty and health care, because an important part of the average, not individual, height, is influenced by non-genetic factors.
Now you're getting somewhere. You talk about other factors that influence life expectancy. You're quite right. But we should not dismiss life expectancy as a statistic because of other factors. We should control for these other factors and quantify their influence.
By all means, let's do so. If you have some stats that control for all of the differences between the US and the other countries we are talking about I would love to see them.
With regard to the homicide/accident stats I should have been clearer. By themselves they have only a trivial impact on life expectancy. I used them rather as examples of a seeming broader American propensity towards behavior that corresponds with lowered life expectancy.
Quote - "Lithe and sophisticated Europeans laughing at American fatties across the Atlantic is becoming a thing of the past, with EU fat rates catching up and in some cases exceeding those of the US."
That's fine, but the stats remain:
http://www.nationmaster.com/graph/hea_obe-health-obesity
We are double that of Canada, triple that of Holland and ten times that of Japan. Japan, BTW, is a particularly interesting example where it beats Canada in life expectancy by almost 2 full years even though they are both highly developed countries with universal health care.
That's right. Because when one discounts the other major factors, it seems the U.S. longevity still comes up short. Remember that being, say, in the top 10 countries with higher life expectancy in the world should not be an unrealistic goal for a country with the resources, technology and wealth of the U.S.
Again, if you have the data that discounts for such factors I would love to read it.
You point out that factors of risk make a difference in life expectancy. I agree with this. I completely disagree that they make life expectancy useless as a health care performance measure, because risk factors can be taken into account and controlled. And when you make some effort to control them, they just don't seem to be responsible by the U.S. gap relatively to the rest of the world.
Let's just look at the data then.
You're repeating a trivial point. Of course genetic differences matter. Of course income matters.
If these are so bleedin' obvious then why are you so married to the life expectancy metric given that you acknowledge other factors come into play in determining them?
But what are you saying exactly? That it is a combination of all these factors that accounts for the U.S. having a shorter life expectancy than the other 37 countries?
I'm saying that these are not apples to apples comparisons given the differences in other factors that contribute to health outcomes. If Americans and Europeans all smoked, were obese, alcoholic, did drugs, etc. etc. at the same rates then life expectancy might be a better metric for evaluating health care systems. But that doesn't seem to be the case.
If the life expectancy were greater it might be a more persuasive point, but again an increase in 2.5 years puts us in the top 10 where you think we should be. But as stated before, this is similar to the difference between Japan and Canada, and I am not sure the explanation for that particular gap has to do with their health care systems.
On the contrary: most of the other countries have smaller average as well as median incomes; they have a high variety of ethnic groups, from East Asian to White Caucasian to Hispanic to Arabic; and they have pretty much ratio of women to men, one would expect.
Well, yes, many of them do have lower income. However, while that may be the case my experience has been that a middle class person in, say, Holland, has similar behavior patterns as a middle class person in the US. It is those behavior patterns that are more important than the actual income.
The US also has a more diverse population than most of those countries (certainly for Japan).
Taking out the 14% black population (while keeping the 3% Asian population and not controlling for income levels), life expectancy goes up by a measly 5 months.
I am confused. The 2 year gap between the US and the top 15 countries is a major big deal but a 5 month improvement -- almost half a year -- is trivial?
Lastly, I don't think that your height analogy holds because, as the data from the Harvard researchers show, personal choices have such a great impact. To repeat:
The differences were attributed to a combination of injuries and such preventable risk factors as smoking, alcohol, obesity, high blood pressure, elevated cholesterol, diet and physical inactivity -- particularly among people from 15 years to 59 years of age. They were not due to income, insurance, infant mortality, AIDS or violence, said the study's lead investigator, Christopher J.L. Murray, director of the Harvard Initiative for Global Health.
...Personal choices could be more important than access to medical care in improving life expectancy, Dr. Murray noted. Half of the people who have high-blood pressure fail to get it controlled, two-thirds of those with high cholesterol do not get medication to lower it, and two-thirds of diabetics fail to manage the disease, in spite of the fact that 85 percent of the population overall has health insurance.
Lots of people making lots of bad decisions will bring down their life expectancy.
Height is mainly a product of genetics and access to nutrition. Few people choose not to eat so height is a good measure of prosperity. (although I believe that Europeans are taller than Americans even with a typically lower income, something that I think some have theorized as tied to poor American dietary habits)
Well, looks like I screwed up the html tags on that one. Hope you can still decipher. That's what I get for not previewing first.
Frankly, I don't know why are hospitals forced to provide emergency treatment.
Frankly, I don't know why you've gone off on a tangent unrelated to my point. You buy food and shelter from the money in your paycheck; it is not considered normal for your employer to deliver dinner to you or provide an apartment for you (although obviously some employers do so for particular occupations). Additionally, insurance is usually purchased (with earnings) to protect against an unlikely but devastating event (fire, crash). Health care suffers from a "crisis" because 1) "insurance" is used for routine expenses that shouldn't be insured against, and 2) people don't see the price of that "insurance" because their employer delivers it directly.
People who complain they "can't afford" good "insurance" are really complaining that they don't earn enough to pay for all the medical care they want to consume (plus overhead and profits for insurers). They want somebody else to pay for it. We would thing this was absurd if they were talking about food or housing, but thanks to this cultural blind spot, we behave as though this complaint is perfectly rational.
Phrased that way, it's clear why we "reform" is so difficult: we can subsidize consumption in excess of earning by some small number of people, whether Congressmen or the very poor, but we cannot subsidize consumption in excess of earning for the whole country at once, because we can't spend more than we earn.
The only way to cut costs is, in the end, to cut consumption.
An aside on quality: rather than employing a Byzantine bureaucracy to measure outcomes and refuse procedures with low success, wouldn't it be more convenient to simply expect that the patient would do so? Who is better positioned to ensure a good outcome than the patient? Who is better positioned to make a cost/benefit determination?
I guess you're kind of new to health care discussions. There are a lot of costs in health care that are not related to medical assistance. One such cost is the Byzantine bureaucracy created by private insurance. You see, most people in the U.S. are pretty much hardwired to think that government=wasteful bureaucracy and private business=low cost efficiency. That is simply not the case in health care. The U.S. system is way more bureaucratic and costly compared to other countries' state-run systems (or at least systems in which the state modifies some market rules), and it performs considerably worst.
Problem: the cost of administration of private insurance isn't that big as a percentage of GDP, and it also doesn't explain the rate of cost inflation.
I was answering to Rob's points
a) a government provided insurance would increase bureaucracy
b) the only way to cut health care expenses is to cut consumption
They are both false.
Administration costs don't explain everything, there are other problems with health care in the U.S. But, unless memory fails, private insurer's bureaucracy was responsible for something like 15% of total costs, as opposed to 2%-3% in state run services. That's a lot.
I don't believe I've ever said that government would increase bureaucracy; my point is that it won't reduce it. That 15% is buying the insurance companies something, most likely fraud prevention. If government becomes the insurance company, then it will need to buy the same thing (with the exception of some fraction of the actuaries).
But as for cutting costs: cut admin down to 0% and you haven't dealt with the zooming costs. What's left? Cutting consumption.
It's fraud prevention, searching for preexisting conditions, processing individual cases to filter which people are worth covering, etc.
Remember that this money is spent by the insurer, not to prevent the cost of treatment, but to pass the cost to somebody else. If the coverage is mandatory, the incentive for these costs would disappear.
Well, cutting them to 0% would pay for a great deal of people who aren't covered right now. Negotiating drug prices with pharmaceuticals would cut the costs even more.
An universal health care system with co-payments would incentivize people not to make superfluous consumption.
And this is a good argument to move away from the insurance model towards a fee for service.
Colin, you're being silly again. Insurance is not that hard a concept.
Health care uses an insurance model (either provided by privates or government) everywhere in the world because health expenses are completely unpredictable. You can instantly die in a traffic accident, or you can have a condition that is unaffordable to 99.9% of the population. Hence insurance.
Health care uses an insurance model (either provided by privates or government) everywhere in the world because health expenses are completely unpredictable.
Car breakdowns are also unpredictable. So are toilet clogs. But you still shop around. Not all health care is emergency in nature.
Toilet clogs may be unpredictable, but as expenses they are predictably affordable. There's no out of the blue $300,000 toilet clog fix.
Again, no $300,000 mandatory car breakdown (well, there is, but if you have it you probably have the money to fix it). Car breakdowns are as expensive as buying another car, at the most. Plus, you can live without a car. If you absolutely need transportation, you can buy a cheaper used car that takes care of that. Not so with fatal or some chronic diseases.
The cost of Government paid health care, except for coverage and care for people who do not now have it, is not a new cost. For the cost of care moved from individuals or private insurers to, for example, a single payer plan, the overall cost of health care to society does not change. It is converted from premiums and individual paymetn to taxes - higher taxes - but not to a new cost.
One thing I find rather confusing about health care costs in general is the degree to which what I *mostly* need my insurer for is to negotiate lower rates with providers.
For example, I recently had some blood work done, retail cost: $700, cost to my insurer: $60.
Going back through my medical records, the cost of my medical care at retail is frankly more than I can comfortably afford, but the amount my insurer reimburses my providers (10-30% of retail) I could comfortably afford out of pocket.
I wonder how many other folks would find the same thing if they looked closely. If it weren't for the discount mania from medicare and the insurers, I suspect many folks would find that they could get by with just catastrophic coverage... and then a lot of this would resolve itself.
Despite being a free-market fundamentalist, since Obama is already remaking America in his image anyway, I wouldn't mind seeing him crush the AMA cartel. Or admit more foreign-trained doctors. Or even denounce the AMA until it lowers its standards and make medical school a less onerous experience.
I've been repeatedly shocked by the delta between insurance reimbursements and retail prices. Doctors should be free to charge whatever prices they like, but the pricing dynamic suggests something is limiting supply -- perhaps the AMA manipulating the market -- to ensure a high standard of living for its members.
I don't think the delta between retail and insurance is a matter of doctor supply and demand. It's a matter of insurers and (more importantly) medicare *demanding* they get at least an x% discount from the providers. The net result is that because *so* much of medical spending comes through these intermediaries, you have to mark up to mark down. If most insurers demand a 90% discount on lab tests, you have to set the retail price at 10x your market clearing price.
Incidentally this happens in a lot of other business to business fields as well... large customers demand discounts, so you mark up to mark down, which means you have to provide discounts to even more customers... etc, etc,etc. The problem here is that most insurance (and medicare) contracts are written so as to *preclude* the provider simply charging retail customers 10% of list (not that the insurers or medicare are evil, they just don't want to be gauged by having a retail price no one pays be the basis for their discount).
My rough familiarity with the Medicare system (CMS and medpac) is that they amass care cost data and set reimb rates to target zero profitability. Private insurers would think differently but would get to a similar conclusion. But I wouldn't be surprised if they tried a stupid rule like you described above (eg arbitrarily high discount to a higher sticker price to pretend they are saving money).
Reimbursement systems all suck. There's no way to mechanically hard code responses for all the ways doctors and patients game the system, although Medicare/insurance really tries (at huge admin expense). So the gaming drives med costs up, and the payors default to knee-jerk rate cuts that have all manner of collateral damage, like what you would be describing.
Reimbursements by monolithic payors also don't ration care efficiently. Perhaps (wave 'hope and change' wand) a market in healthcare would solve the above? Admittedly not an original idea.
This is how the system works for us, to some degree. Our insurance is a high deductible HSA policy (that means we have an account we put tax free dollars into, that can be used to cover medical care We can bank the money for ourselves so you're incented to spend little, unlike FSAs). We pay for the first 4k of sick-care (as opposed to various wellness visits: all pediatric well visits, maternity care, etc.) out of pocket no matter what. However, that 4k goes very very far for us, because we still get the insurer's negotiated rate. So the insurer knocks that lab work price down from $600 to $200, and we pay that $200.
This even works on the prescription side--we have no "insurance" coverage for the prescription for the first 4k dollars either, but we get their negotiated deals with the pharmacies.
I would love to go this route, except that I have some optional things (Lasik, etc) that I wanted to do. By law, you can't have an HSA and a FSA at the same time. Since I can sock away more in my FSA for the optional things than I can put away in the HSA (as my employers plan is set up) I opted to go the FSA route.
I listened to the video of the announcement just now. What an embarrassing display of stupidity, but the thing is that the media will likely eat it up without ever questioning the promises.
Either Obama is a moron, or he thinks we are, and either answer is scary.
I knew Magical Mystery Tour, and this is no Magical Mystery Tour. Perhaps a better analogy would be to say that we are being led like the son in Life is Beautiful.
There are a lot of costs in health care that are not related to medical assistance. One such cost is the Byzantine bureaucracy created by private insurance.
This is a common trope, but like many such tropes, it makes no sense. The bureaucracy created by private insurance exists for one reason: to lower costs. Private insurers have elaborate billing schemes and referral rules, and fight to avoid paying claims they deem unworthy, because doing so keeps their costs down. Anyone fussing about the high cost of medical insurance should be throwing parties for the claim-deniers. They're trying to fight waste, fraud, and abuse, and also keep premiums affordable (and profits high, it must be said).
If that bureaucracy was truly "wasteful," in the sense of costing more than it saves the company in unpaid fraudulent or medically useless claims, then some clever MBA would fire everyone in the claims department and crush the competition with low premiums and high profits.
The government system will need a similar bureaucracy or it will be open to abuse by over-billing doctors and over-consuming patients. The government system can eliminate some of the actuaries (because they'll take anyone, so no need to classify patients) but it will still need a hefty number of care-denying bureaucrats.
Bottom line: your premiums must be more than the sum of the care you consume plus the overhead and profits (which are typically only a few percent of the total). If you're asking for more than that, you're asking for a handout.
Why does it work in France, Germany, Canada, Australia, etc. but not work here?
It doesn't work there. Waiting times are often long, some procedures are simply unavailable to people who are "too" old or sick, and costs are (like Medicare and Social Security in the US) unsustainable in the long run.
One thing I find rather confusing about health care costs in general is the degree to which what I *mostly* need my insurer for is to negotiate lower rates with providers.
That's simple: the price they charge non-insured people includes a hefty risk premium because so many uninsureds don't pay at all. Insurance providers get lower rates because they guarantee payment. Trying bringing literal cash to an appointment and wave it at the doctor while demanding a discount.
It doesn't work there. Waiting times are often long, some procedures are simply unavailable to people who are "too" old or sick, and costs are (like Medicare and Social Security in the US) unsustainable in the long run.
Well, my mother had to wait six months for cataract surgery right here in the USA, so I'm not really open to the notion that long waiting times are a feature only of non-American health-care systems.
And the unavailability of procedures is common here in the U.S. The difference is that here, procedures are simply unavailable to people who are "too" poor, sick, unemployed, or have run afoul of the health insurance companies' byzantine rules and regulations.
In any event, any evaluation of a health care system that ignores cost, number of people covered, and general health of the populace isn't to be taken seriously. All you've done is demonstrated that you can prove anything by choosing your criteria carefully.
The bureaucracy created by private insurance exists for one reason: to lower costs.
Insurance providers get lower rates because they guarantee payment.
Your first paragraph contradicts this one. The problem is that insurance does not guarantee payment for services rendered. It requires massive billing staffs to receive partial payments from insurance companies. The burden is laid on the doctor's offices, not on the patients or purchasers of the health plans. The externality of processing claims this way is borne by doctor's offices and patients not the insurance companies.
It doesn't work there. Waiting times are often long, some procedures are simply unavailable to people who are "too" old or sick, and costs are (like Medicare and Social Security in the US) unsustainable in the long run.
And yet they manage to achieve better health outcomes than us with less money. There aren't wait lists in the US? I can go see my doctor tomorrow, and not have to schedule an appointment a month or so in advance? People don't have their surgeries scheduled 3-4 months in advance? We just don't call it a wait list, we call it "The first available appointment is two months from now"
I called a doctor this morning at a practice I've never been a patient of before at 8am. They were willing to see me at 10am, but I couldn't make it till 2pm. I saw a physician, got an x-ray, had it read, got blood drawn, and filled my prescription by 4pm.
Waiting lists... not so much...
Is that right? That never, ever happens in Europe.
Seriously, man. I could tell you that anecdotal evidence is very weak. Instead, I'll just tell you that, in most practices of most hospitals in Portugal and France (the ones I know better), you see the doctor in the same day or the next day.
Waiting lists are reserved for a few procedures.
Nimed,
Please note, I wasn't making a particular argument about European healthcare, because while my background there is admittedly sparse, it's just good enough to know that the health care system in France is a lot different from the one in Germany is a lot different from the one in Britain (as I side note, I get the slight sense that the anglo-sphere is the slow child when it comes to running socialized medical systems, everyone seems to like the non-english speaking western european systems better than either Canada or the UK).
Please note, I never got anywhere near a hospital in my adventures today... the doctors office I went to had onsite it's own x-ray, MRI, and CT scan... the lab that did the blood draw was next door.
I'm aware of what the value of anecdotal evidence is (and is not). The thing is I keep hearing about delays in getting to see doctors in the US, and I believe it happens sometimes, but I have to wonder what the root cause is... because the only time I've ever encountered any significant delay in getting to see a physician for anything was when I insisted on seeing a particular physician who happened to be the leading guy in his field in the region... I was willing to wait for the best in that case. My experiences with medicine in the US have generally been quite similar to what I described above, in each of the four different states I've lived in.
Fair enough, hagbard. Looks like I reflexively attributed to you a position you didn't hold.
I must confess ignorance to what are the causes for the existence and length of waiting lists in the U.S. They seem to vary wildly from State to State.
As to your impressions regarding anglo-saxon countries, I agree. But here again the causes elude me. I did hear many experts say wonders about Australian health care.
That's simple: the price they charge non-insured people includes a hefty risk premium because so many uninsureds don't pay at all.
While your suggestion makes some sense... every provider I've been to in the last decade requires payment at the time of service if you do not have insurance (ie, cash on the barrel). In fact I've recently noticed signs requiring payment *before* services are rendered for non-insured payers.
When you get paid up front, there's very little risk.
Additionally, because reimbursement by insurers is by no means guaranteed for a given claim, and typically in the presence of a deductible the provider must recover from the patient, I don't see insured patients being lower risk than non-insured patients who paid before you saw them...
Other people have pointed out the main error in your comment - confusing cost to the insurance company with total cost of a health service. Bureaucracies decrease cost for the insurer but increase overall cost.
But there's also this
This is completely false. The real reason prices are extremely high for the uninsured is just because they often have no alternative but to pay. It's a simple (and shameful) case of bargaining power.
By this logic, prices for food and other goods necessary for life should also be sky high. Yet they aren't. Is it possible your theory is flawed?
You are uninsured. You have an accident. You rush to (or are transported to) the nearest hospital. In these circumstances you're not in a position to inquire about the prices, haggle and possibly change hospitals. There's some urgency, you see? What happens is they treat you, they present the bill and you pay. How's this process similar to food or clothing consumption?
Other essential goods, of course, have much lower costs than medical assistance. Evidently, the price of a good or service isn't solely determined by bargaining power. But, now that you mention it, there are some cases in which retailers take advantage of temporary food scarcity (some boat tours come to mind) to double triple snack prices.
Hello all. I am actually a healthcare analyst in my real life.
Two things to consider. The Devil says that there are three options in healthcare: quality, access and cost effectiveness. You can pick two. Western Europe and Canada have chosen quality and cost effectiveness at the expense of access: they pay high taxes, treat their docs like civil servants, ration access, slow-walk new technology and control drug and device prices. If you are in your late 70s and develop an expensive condition, see ya.
Yes, America spends 16% of its GDP on healthcare. The reasons? High admin costs (700+ private plans), no rationing of drug prices, no rationing of care in the final year of life (25% of Medicare spending), highly paid docs and nurses, etc. We also have high quality and fairly easy access.
I agree that our system needs overhauling. But there will be a price: our healthcare industry actually employs many Americans and as we make the system more efficient, we will put more people on the dole. As we ration drug prices, we will drain capital out of biotech and pharma industries. As we reduce hospital readmits and ration care at the end of life, we will close hospitals and fire more people.
No free lunch ya know.
But there will be a price: our healthcare industry actually employs many Americans and as we make the system more efficient, we will put more people on the dole. As we ration drug prices, we will drain capital out of biotech and pharma industries. As we reduce hospital readmits and ration care at the end of life, we will close hospitals and fire more people.
Health care reform should achieve cost reductions, which means people will have more money to spend elsewhere. The spending on those industries will provide employment for these workers (although granted workers are not perfectly fungible).
Your observation is nothing more than the creative destruction that is constantly occurring.
Other people have pointed out the main error in your comment - confusing cost to the insurance company with total cost of a health service. Bureaucracies decrease cost for the insurer but increase overall cost.
It requires massive billing staffs to receive partial payments from insurance companies. The burden is laid on the doctor's offices, not on the patients or purchasers of the health plans. The externality of processing claims this way is borne by doctor's offices and patients not the insurance companies.
If the billing staff costs the doctors more than they get in payment from the insurance company, they are perfectly free to tell the insurance company (and its patients) to take a hike and can their billers.
The tussle between billers and insurance company claims departments is certainly wasteful in the sense that it would be unnecessary in a perfect world. But a government system will not fix the problem because it will become a tussle between billers and the government claims department for exactly the same reasons.
The real reason prices are extremely high for the uninsured is just because they often have no alternative but to pay.
Their other alternative is to say "screw you and your overcharging" and go to a different doctor (unless you've been dragged in by an ambulance, in which case the risk premium explanation is still the most likely). Really, am I the only one here who has ever held up handful of $20 bills and told the doctor "I'll give you this, but no more"? They generally say yes to that.
The unavailability of procedures is common here in the U.S. The difference is that here, procedures are simply unavailable to people who are "too" poor, sick, unemployed, or have run afoul of the health insurance companies' byzantine rules and regulations
Yes, that is entirely true. If you want to keep costs down, you must reduce consumption; right now we ration in a somewhat crazy patchwork involving who your employer is; other countries ration by government fiat. Pick your poison, because free lunches are not on offer.
a government system will not fix the problem because it will become a tussle between billers and the government claims department for exactly the same reasons
To be completely honest, it will fix the problem -- if the government also becomes the service provider. I believe it largely is in the UK, and they don't seem to be too happy. I'd rather have the problem than the fix.
right now we ration in a somewhat crazy patchwork involving who your employer is; other countries ration by government fiat
And I still don't see what's so wrong with fee for service + lump-sum insurance against specific conditions + subsidies for those who cannot afford the insurance available on the open market. Then again, I also don't see what's so wrong with letting both the investment banks and the buggy-whip manufacturers fail on their own dime.
Really, am I the only one here who has ever held up handful of $20 bills and told the doctor "I'll give you this, but no more"
I'll raise you one: when I was sans insurance for a while (COBRA ran out), my daughter's pediatrician simply charged me his bottom-line discounted price -- not once or twice, but as a matter of routine -- without any prompting or haggling on my end.
But you see, that's not what happens. Countries with universal health care have much lower administrative costs, because they don't have to investigate claims. So a government system has in fact "fixed the problem" - the total cost is lower.
By what miracle does substituting the government for a private insurers eliminate fraud and waste without the need for investigation of claims? And why is Medicare fraud a crime if it never happens?
And I still don't see what's so wrong with fee for service + lump-sum insurance against specific conditions + subsidies for those who cannot afford the insurance available on the open market.
That works for me, but as I pointed out above, it runs contrary to the cultural expectation that medical care should be free.
And I can tell you from prior experience that free medical care is worth every penny you pay for it!
You are uninsured. You have an accident. You rush to (or are transported to) the nearest hospital. In these circumstances you're not in a position to inquire about the prices, haggle and possibly change hospitals. There's some urgency, you see? What happens is they treat you, they present the bill and you pay.
Why do you keep coming back to emergency care to rebut points totally unrelated to emergencies? We could have the feds pay for 100% of every real emergency (i.e., gunshots and car crashes, not illegal immigrants with colds) and it wouldn't end the "crisis" we face.
Two reasons
1 - Emergency care is health care. Should it be available for those who can't afford it? Because that's the cultural expectation we have today. I just want to make sure of what you're saying.
2 - Most uninsured people, when faced with high the high costs of medical service for the uninsured, postpone their visit to the hospital. Two things may happen; either they get better/remain stable, or they get worse enough for an emergency.
Well, I certainly never tried that. But I would guess their acceptance kind of depends on your condition.
Isn't it nice when you depend on the doctor being a pal? If it happens to be a guy that's trying to act according to the market, then you're screwed.
You're from Texas, right Max? Nice State. Life expectancy 76.7 years old. That's 5 months less than Brunei. And Texas has 30% of the population uninsured. Humm...
And "the undocumented percentage" is probably close to the same 30%... so what?
Life expectancy as a measurement for health care is truly silly, when averaged across the whole population. In my circles there is an expression: "hospital-wide average temperature" (I am translating from Russian here, bear with me). Assumption being, it includes the morgue.
Max, I would point out just how imbecile your arguments are, but I'm not going to waste my time discussing with someone which doesn't discuss in good faith and labels people who disagree with him as "the enemy".
If you don't understand the risks of relying on nice doctors for treating your own daughter when insurance fails, nothing anybody says will make a difference. I hope she moves out soon, though, for her sake.
Emergency care is health care. Should it be available for those who can't afford it?
Emergency care--by which I mean actual fell-off-a-ladder-and-now-have-intracranial-bleeding care--should be available to whomever needs it, because there isn't time in a real emergency to ask about how somebody is going to pay. And uninsured people who receive it should work their asses off and sell their possessions to pay for it afterwards. How much is your life worth? Shouldn't the guy who kept you alive get paid? We should regard failing to pay a hospital for your care with the same disdain as we currently regard shoplifting or armed robbery.
If you can't pay it, then I'd favor a government program so that the hospital doesn't have to take the hit. But the IRS should get to collect from you (subject to, say, bankruptcy or similar debt relief).
I'm actually far less hostile to some kind of universal insurance program that I appear. But I'd want it to be an insurance program, i.e. protection from unexpected, devastating financial losses, and perhaps also a welfare program, paying costs that poor individuals can't pay. What I don't like is a middle-class handout, by which the real costs of routine and ordinary care are cleverly hidden from people who then develop an entitlement mentality. That's more or less the system we have now, and governmentizing it will only make the problem worse.
I agree. But there are universal health care models that deal with these problems. One way to deal with them is through co-payments. The size of co-payments should be inversely proportional to the efficacy of a treatment for a particular condition. This way people would be deterred from engaging in superfluous consumption.
The size of co-payments should be inversely proportional to the efficacy of a treatment for a particular condition.
Oh, that will never be subject to political manipulation or demagoguery.
But, note that what you propose is essentially a form of rationing by efficacy. That is, you aim to control costs by refusing to pay for treatments deemed unworthy. No so unlike an HMO, hmmm...
Trying bringing literal cash to an appointment and wave it at the doctor while demanding a discount.
This hasn't been my experience so far, although I admit I didn't demand a discount. My non-confrontational upbringing doesn't allow for bartering.
Recently my girlfriend and I were at a restaurant and she swallowed something sharp in her meal. She coughed up a little blood afterward, and was still having stomach pains two days later. We called a number of doctors in the area, none of whom could make an appointment to see her for at least a week, and they told her to go to the ER. At the ER we only had to wait about 30 minutes before a doctor saw her, took some x-rays, and told her that she seemed fine. Checking out we asked to pay cash for the services, as she doesn't have insurance. They couldn't do that, in fact they couldn't even tell us how much the bill was. Instead (we found out later) they automatically send patient bills to collections. So far we have received bills from three different providers, for a total amount of $1200.
My non-confrontational upbringing doesn't allow for bartering
Uh... I'm not sure about actual bartering at the doctor's office ;-)
Bet you didn't know this? Our fearless leader and Michael Moore let this out of their examples of Nation health plans. They left out that in some of the praised National Plans, people actually take care of some of their own responsibilities.
It is also weird that our propaganda masters forgot to tell us that most Europeans also pay for "top up" insurance to pay for what the plans do not pay.
Hidden costs are normal when you see National Health care expenditures. You only see government costs but they most always leave out the out of pocket cost to the citizens. Costs such as "top up" insurance, co-pays and co-insurance. In France they pay for doctor educations and 40% of doctors taxes are paid for them. Costs that are not included in the health care expenditures report but with out them the French plan as it is today would not work.
Guess what else? In the countries that require you purchase insurance, if you have no insurance you have broken the law. Therefore, an illegal alien that tries to get "free care" will get a visit from the authorities.
France........
Like every other nation, France is wrestling with runaway health-care inflation. That has led to some hefty tax hikes, and France is now considering U.S.-style health-maintenance organization tactics to rein in costs.
Subscription to the general French social security system (except in some specific cases) gives rights only to the basic health insurance coverage which reimburses usually only part of medical expenses.
Regardless on whether you are insured in France or in your home country, you are generally required to pay medical expenses as they occur, e.g. when visiting a doctor, buying prescribed medicines and for medical tests. Then you can ask to be reimbursed by your health insurer.
Types of payment vary: doctors usually prefer payment by check and some organisations might not accept cash. Only in some cases - such as some hospitalisations or if you are covered by specific heath coverage - you may be exempt from advance payment.
If you are subscribed to the French social security, you need to send a completed form (feuille de soins) to your CPAM (Caisse Primaire d'Assurance Maladie).
Reimbursement takes usually 2-3 weeks and you can check on-line on www.ameli.fr (you should receive access information in the documentation provided by CPAM).
If you have a Carte Vital and the doctor (or a healthcare organization) is linked to the social security system, it is possible you may only pay the non-reimbursable part instead of having to claim it back afterwards.
For some medical costs (e.g. dental or orthopaedic prostheses), you must get prior approval from your CPAM to ensure subsequent reimbursement. This is why most people - nearly 85% of the population in France - choose to take a complementary private insurance (mutuelle, assurance complémentaire). This additional coverage covers partly or completely the percentage of medical costs not paid for by the general social security system. Some employers pay for some or all of an employee's supplementary coverage. In our directory, you find a list of some mutual heath insurance organizations.
France must make big changes to its health system in order to cut waste and increase efficiency, a government-commissioned report is warning. The report says citizens must pay more and doctors must alter their behaviour. Failure to do so could add 66 billion euros a year to France's public budget deficit by 2020, it adds. The warning comes after thousands of health workers protested on Thursday over staff shortages and the "creeping privatisation" of the health system. The report was written by the High Council for the Future of Health Insurance, an advisory body set up by the government as it prepares to introduce healthcare reform legislation in June.
The council also highlights the CSG welfare levy - a charge paid by workers, the unemployed and pensioners - as an area for possible reform. "The High Council is unanimous in its refusal to turn to massive indebtedness to cover the growth in health insurance expenditure," the report said. Problems in the French health system were exposed last year, when a heat wave killed around 15,000 mostly elderly people. There was also a bed shortage in hospitals in December, when a nationwide flu and bronchitis epidemic broke out.
To make all this affordable, France reimburses its doctors at a far lower rate than U.S. physicians would accept. However, French doctors don't have to pay back their crushing student loans because medical school is paid for by the state, and malpractice insurance premiums are a tiny fraction of the $55,000 a year and up that many U.S. doctors pay. That $55,000 equals the average yearly net income for French doctors, a third of what their American counterparts earn.
Then again, the French government pays two-thirds of the social security tax for most French physicians—a tax that's typically 40% of income.
Switzerland.......
Depending on your insurance scheme, you will either be put in a general ward with two to four beds (standard cover), a two-bed room (half private) or a single room (private). Note that standard cover does not give you the right to choose your doctor, this may be important as not all doctors may speak your language.
Hospitals in Switzerland aren’t cheap! All hospital fees have to be paid for either by you or your insurance company. There is no such thing as ‘free treatment’ in Switzerland (even in the case of emergencies). If the decision is up to you whether or not to go into the hospital, you should first talk to your insurance company.
After visiting a hospital or doctor, you will receive a bill which you should pay within the specified period (usually around 30 days). You then send a copy to your insurance company, which will reimburse the percentage covered by your insurance scheme. If you are not resident in Switzerland and don’t have any sufficient health insurance, hospitals can require a deposit upon your admittance, which may range from CHF 2000 to 10,000.
Health insurance - Public and private health insurance in Switzerland
According to the Health Insurance Act ( Krankenversicherungsgesetz - KVG) every person living in Switzerland is obliged to take out a basic health insurance policy ( Grundversicherung). Note that in Switzerland, sickness insurance will normally not be arranged by your employer. You have the responsibility of contacting providers and arranging the insurance yourself. Only if your employer has an agreement with a specific insurer and pays part of your premiums (which rarely happens), will you be forced to choose a specific provider.
Health insurance premiums in Switzerland are not dependent on income, but are calculated based on your personal risk profile. However, the Swiss Confederation subsidizes premiums for low-income individuals/families. In 2004, the basic insurance premium was around CHF 250/month.
Swiss insurance schemes only cover individuals, not families as in some other European social security schemes. You will therefore have to insure each household member, including children.
If you only have a compulsory basic insurance scheme, you are obliged to make a contribution towards your total annual medical cost, up to a certain limit per year. This ‘franchise’ is calculated as a percentage of your total annual medical costs and capped at a yearly limit.
About 40% of the Swiss population chose to top-up their insurance cover. This is commonly in order to have more comfortable accommodation during a hospital stay or wider choice of treatments.
The Swiss have operated with a mandate since 1996. Uninsured rates are low (estimated at below 1 percent in Switzerland). An additional 1.5 percent is insured but behind on premium payments.
Switzerland imposes much higher cost-sharing, including deductibles and coinsurance than the Netherlands."
"Switzerland, 12 percent of the population is enrolled in HMOs or other managed care plans.
The Swiss have operated with a mandate since 1996. Uninsured rates are low (estimated at below 1 percent in Switzerland). An additional 1.5 percent is insured but behind on premium payments.
Switzerland imposes much higher cost-sharing, including deductibles and coinsurance than the Netherlands.
The Swiss insurance system (7.5 million people) is highly decentralized, with plans operating and setting premiums at the canton level (26 divisions). In Switzerland, only nonprofit insurers may participate. The 10 largest of some 85 carriers insure 80 percent of the population.
Swiss insurance risk equalization efforts adjust only for age and sex factors at the moment.
Currently, Swiss premiums vary widely by health risks of insured pools across the country and within regions.
A nationwide diagnosis-related group (DRG) system (SwissDRG) will be introduced in 2012. Cantons finance more than 50 percent of hospital costs either directly or through DRGs
I have about 50 pages more from research I did on all the different plans. I am not going to stop until people start to realize the elected officials are fooling them.