Interesting questions remain. Will the health-care co-ops be exempt from the tangle of state regulations that have resulted in near-monopolies in many areas? I presume that Democrats still want guaranteed issue and an individual mandate, but aren't these the parts that are actually going to anger constituents? In Massachussetts, more people seem to think they've been hurt by the plan than helped by it. Meanwhile, the costs are skyrocketing, and control has so far been elusive.
The core problem is this. You have four groups of uninsured people:
- Immigrants, who probably aren't going to get insured anyway. This is presumably why Massachussetts spending on the uninsured has only fallen by 40%, even though the number of uninsured people has plunged about 80%.
- Young healthy people who don't need much health care
- Working poor sick people
- Affluent people who are uninsurable because of some pre-existing condition
That means we have to dip into the pockets of Group 5: people with insurance. Either they have to pay higher premiums, or they have to pay higher taxes, or they have to get less stuff. This makes them anxious. Unfortunately, most of them are satisfied with their insurance, so the only thing that you can offer them is the relief from the fear that they'll lose their job and their insurance coverage. That's not nothing. Options are valuable. So is peace of mind. But is it worth hundreds of dollars a month to the average family?
There's a further problem if you have guaranteed issue: unless the tax penalties for failing to carry insurance are draconian, the dominant strategy is to drop your insurance, then buy insurance if and when something bad happens.
I actually agree with the progressives that health reform will be a disaster unless you can find some way to control costs. But the senior lobby freaks out when you suggest it. So far the only that Massachussetts has actually managed to pass has been shaving benefits for immigrants. That doesn't bode well.
A partial solution for #1: when a person shows up to the ER without evidence of citizenship, call immigration. They can be deported after receiving treatment. We can then bill their home country for the cost of their treatment, or deduct it from foreign aid if they refuse to pay.
Isn't that essentially the same as turning them away?
Do you have evidence of citizenship on you? Right now? Not in a drawer somewhere, or in your glove compartment, but right now on your body? Cause when you're having a heart attack, you don't have time to go hunting for paperwork.
Note that your driver's license is not evidence of citizenship, nor is a library card. There are two pieces of paper that are usually accepted as proof of citizenship. A US Passport and a birth certificate from a US state are considered proof of citizenship. Nothing else is.
Also, what about foreign tourists legally in the US who have medical emergencies? And do you really want to kill immigrants who avoid medical care because of fearing deportation?
Obviously I intended my 3 sentence post as a complete description of a proposed policy, down to the last implementation detail. I certainly did not intend it as a vague general proposal, subject to carefully working out the details to avoid bad results in various edge cases.
I also obviously intended to deport H1B holders, green card holders, etc if they ever have a medical emergency.
Regarding people who don't bring a passport, drivers license or insurance card (yes, we could relax rules about what constitutes proof of citizenship for this purpose only) to the hospital: after being released, an immigration agent escorts them to their home to view proof of citizenship.
Regarding your "kill immigrants" red herring, I'm assuming illegal aliens are not suicidal and will get treatment when their life is in danger. But I guess I'm just assuming that illegal immigrants are not too stupid to live (which you do seem to be assuming).
I do not know, nor am I able to, the list of symptoms which if untreated are life threatening. If I faced a severe threat of deportation (including losing my family) from reporting a symptom to a doctor, I would very likely refrain from doing so unless I had something incredibly life threatening (and if it might cause my family to be deported, I might risk dying to save them that).
Further, your proposal in any form is a massive invasion of personal privacy, and would lead to absolutely nightmarish scenarios for millions of people. My mother for example is an immigrant from Romania. She has to rely on a single sheet of paper from the 1960s to prove her citizenship. If she can't find that paper (or she's unconscious, which happens with ER visits), you can't call around to find proof of the birth certificate. Should she (a naturalized US citizen) then have to rely on 40+ year old records from the INS being legible and not missing to avoid being deported to a country she fled to avoid massive repression?
It is wrong to threaten people with government investigations for engaging in the perfectly legal and moral activity of seeking medical help. No amount of nuance could make such a policy be anything but morally reprehensible.
Peter, perhaps you don't know the list of symptoms which are life threatening. However, all the evidence suggests that people are capable of making such decisions. The RAND experiment shows that when given financial incentives to use less care, people will consume 30% less medicine with no affect on mortality or health.
Incidentally, you don't necessarily lose your family when you get deported. They can come with you (even the "anchor baby").
No, you can wait for her to regain consciousness and be released from the hospital. I figured that was implied by the words "deported after receiving treatment", but again you seem to want to take my 3 line post as a detailed description of a policy proposal. Obviously further safeguards (including the right to call DHS for records) are also needed.
Fun fact: I've never met an immigrant who did not know where their papers were, along with the photocopies of the papers and their place of issue. This really won't be a problem for the vast majority of legal immigrants.
Let me repeat: there are edge cases which must be carefully thought through. I'm proposing a careful investigation which affords the person every opportunity to prove their citizenship or legal residence.
Incidentally, you don't need to threaten people with investigation for getting health care. If you want to restrict the investigation to people who accept health care they aren't paying for (i.e., people without insurance who don't pay their bill), I've got no objection. Or are you seriously suggesting we can't impose citizenship requirements for public services?
A couple of questions:
1) It's hard to imagine that chasing down everyone who can't show papers at the door of the ER will be cheap. How much will this cost?
2) How do you avoid the adverse public health consequences of discouraging people with, say TB or swine flu, from seeking prompt medical attention? Effectively deputizing hospital staffers as de facto INS agents is really not a place we should go.
Amygdala:
1.) The costs aren't clear, since we have little information on how many patients are illegal immigrants. This article suggests California and Texas spend $2.7 billion on treating illegals in the ER. It is, however, very difficult to say since little data is collected.
http://www.usatoday.com/news/washington/2008-01-21-immigrant-healthcare_N.htm
Since most people can provide evidence of citizenship (insurance, drivers license, etc), only a small number of people need to be investigated. Further, if we deport a person with a chronic problem, we offload their future medical costs to their country of origin. We also discourage illegal immigrants from receiving unpaid care for non-life threatening problems.
Relevant question: how much does a few hours of an immigration agent's time cost? And how much does an ER visit cost?
2.) I see little evidence that this is a serious problem. Thanks to modern sanitation practices, most infectious diseases are a non-starter.
A small number of people aren't costing the system $2.7 billion, or at least not in a situation where sending an agent to a home will make a difference. Sending someone back is worthwhile financially (from a US perspective) if it's unlikely he or she will return, which is perhaps likely to be true for people racking up an enormous bill, but likely less likely for someone who remains able-bodied. As long as economic prospects remain dreadful to the south, people will continue to come here by whatever means.
It's not just about how much that INS agent's time is worth. If there were more than enough of them, that would be the major consideration. But since they are chronically short-staffed, what won't that agent be doing in favor of chasing down former patients for their papers or to escorting them back from whence they came?
You may not see infectious diseases as a problem, but they continue to be and do not always respect national borders. Immigrants, legal and not, from TB-endemic parts of the world are a high-risk group in this country. There is also some evidence that undocumented immigrants are symptomatic longer before coming to medical attention than legal immigrants and citizens. This puts those individuals' regular contacts at risk as well.
I don't mean to nitpick; just trying to point out that solutions should be considered carefully for unintended consequences as worrisome as the problems they are attempting so solve.
Presumably the agent will be chasing down healthy illegal immigrants instead of sick ones.
So then the question becomes, which is easier? Investigating a person in a hospital who has no insurance or ID, or following the usual INS investigative procedures? I'd speculate that investigating the person in the hospital is more likely to be successful than a typical investigation.
But you are right, maybe there are unintended consequences. I'm not opposed to killing the program if it fails. That's something the government should do far more often than it actually does.
As for infectious disease, I'd really like to see evidence that it is a serious problem (besides breathless news reports, of course). Swine/avian flu were both duds.
What I linked regarding infectious diseases were not breathless news reports, but the CDC and one of the leading journals in the field.
It's far too early to declare swine flu over. Therein lies a good part of the problem with public health. When it doesn't work, as happened with SARS, they are demonized (and I would point out that it was the PRC that let the world down with SARS, and not the WHO, CDC, or Health Canada). When they get it right and contain a major threat, people yawn and claim the threat was overblown.
And yes, there have been instances were that has happened. The fact remains that the world was overdue for pandemic flu, based on the history of such epidemics, and that this one has gone global. Right now we're relatively lucky that it seems to be less virulent than prior outbreaks, 1919 in particular. May it be ever thus, but that doesn't mean the global public health community overreacted.
Returning to TB, the WHO noted in 2006 that 4% of strains were XDR, aka extremely drug resistant. It's a scary bug, one that has been a nightmare in the places in which it first evolved (South Africa and eastern Europe). It can spread person to person or develop from inadequate treatment of MDR (multi-drug resistant) TB. And that is where not erecting barriers to medical care, regardless of legal status, comes in. The study I linked in my prior post indicating that undocumented workers have been coughing [up mycobacteria] longer than other immigrants and citizens is exactly what you don't want for keeping TB in check. Similarly, you don't want someone who was diagnosed and then, say, visited by the INS, taking their TB meds spottily for a month or two, then falling out of care, because that's how antibiotic resistance develops. Maybe the person is here legally but the spouse isn't and fear gets the better of them or the many other reasons that kind of knock on the door scares people. Civil libertarian concerns aside, it's bad public health policy.
The point is that health care workers are not the INS and there are valid public health reasons why they should not be.
Am I the only one who actually read, "after receiving treatment" in the above post? Please explain how "after receiving treatment" means "turn them away" or "kill immigrants"? Or is it some people are just really quick to assume the absolute worse about someone posting policies that are not favorable to illegal immigrants?
SamX,
I assume Bergamot's point is, if you deport a group of people for visiting a hospital, they probably won't visit a hospital (which is basically what would happen if you actually made a policy of turning said people away).
Telling assumption that everyone without citizenship is illegal.Are we endoring the free market here, or some kind of corportatism? Because really, I forget the difference sometimes.
About an hour and 40 minutes before you wrote this post (2:44 pm to be precise), I (sarcastically) clarified that my 3 line post on is not a complete policy proposal. In particular, I acknowledged that provisions must be made for (among other things) non-citizens legally in this country.
I'm really not sure what this has to do with free markets or corporatism. The perfect free market position (which I don't hold) would advocate unrestricted immigration together with removing the right to free ER care at the expense of others. I advocated neither position.
Megan made the same error of logic you did, so that was partly directed at her. When people make those kinds of errors, its symptomatic of unexamined assumptions. In this case you both seem to be assuming that citizenship also by implication entails entitlement to certain economic outcomes and that non-citizenship means you have to fend for yourself - that's a corporatist position, not a libertarian one.
Um, the belief that citizenship implies certain special privilages is a nationalist position. It has nothing to do with corporatism.
Corporatism is a belief in government by various "natural" interest groups (businesses, labor unions, ethnic organizations, etc). I.e., individuals are not represented in government, only groups are.
As I said, the libertarian/market position would hold that neither citizens nor non-citizens are entitled to health care that they cannot pay for.
Please look up the definition of the words you are using before continuing this discussion.
http://en.wikipedia.org/wiki/Corporatism
http://en.wikipedia.org/wiki/Nationalism
http://en.wikipedia.org/wiki/Libertarianism
Both Megan and Ninja Zombie make the same (imho incorrect) assumption that the immigrants are to be deported - they all should be immediately legalized and pay taxes.
More has to be encouraged to come (with better screening to favor educated and young).
That would solve the social security problem, as well as much bigger, more general problem we are to face around 2020: the labor shortage (as oppose to the investment shortage).
You will see developed countries competing for immigrants by then and the native for the immigrants countries being upset at the workforce leaks.
If the healthy part of the immigrant family is legalized and pays taxes (as well as the sick before becoming sick) it will cover both their med care and the hole in our med care $$
"Advocates of reform believe that the number of people in Groups 3 and 4 who are not receiving needed care is large."
Is it the belief that the number is "large", or the belief that it's growing and continuing to grow? Does it have anything to do with the belief that the number of insured who do not receive needed care is also growing? What about the concern that the employer-financed system combined with a broken individual market has made unemployment completely untenable, eroding America's cherished labor mobility?
I think that if you could demonstrate that the current system will remain the current system -- that trends will discontinue and the status quo will prevail -- you'd get a lot more support for legislative inaction.
The mean percentage of native born Americans who lack health insurance has shifted somewhere between 1 and 2 percentage points since the late eighties. The number goes up a little in bad years, and down a little in good ones, but overall, we're looking at a number that has increased by about 10% (of itself) in two decades. It's not a huge trend.
So when you say 1-2%, you actually mean 1-2% per year, and 10% over 20 years? Because your first sentence implies 1-2% over 20 years, which I find implausible.
Also, I'm beginning to be annoyed by the errnoeous distinction between "immigrants" (who are assumed to be illegal) and "native born Americans". There are vast numbers of non-native born citizens, who presumably should be counted alongside "native born Americans" since this is meant to be a democracy n'all. Plus, of course, permanent residents and temporarily resident aliens, who, since they have to pay taxes and pay for insurance should presumably be included in any program in the interests of justice (there was some cliche about taxation and .... oh, its probably not important).
Care to clarify what group of people your numbers are really for, and for that matter where you got them from?
No, 1-2% over 20 years. It was about 13.5% of native born Americans in the late 1980s; it's about 15.5% now. How big a change depends on your start and end years.
Thanks for the clarification. I would still like an explanation of the relevance of this apparently irrelevant number. Are those of us who pay US income taxes but aren't citizens not entitled to healthcare at all?
The fundamental problem here is the cost of care. Most of the debate about the government's potential ability to control expenses has become obsessed with the tactic of denying services when cost ineffective - in other words - not lowering costs, but simply refusing to pay certain costs.
What I am concerned with, however, is why certain routine medical services are so expensive. When my wife gave birth last year, I looked at the bills sent to the insurance company for the Cesarean delivery and pre-natal evaluations and my jaw dropped to the floor - it was over $30K! You start to think about it, "Well, lets give the surgeon a $1,000, another for the Anesthesiologist, another for nurses, another for the staff, a few for hospital, a few for malpractice, etc..." but you won't get halfway there. Compared to the price of having this done privately in one of the other developed countries - it's completely out of the ballpark.
It all seems somehow mysterious. You come to the conclusion that in American health care costs, "I can understand A, B, and C, but there's some big X-factor in that number, some gigantic unknown expense, what is it?!" The joke of an "itemized" bill doesn't identify what's really going on here either.
I've been waiting, patiently, for someone to say "The X-factor is... ", and if they can also say, "And socialist health-care doesn't have to pay it, so, even providing the same amount of care and services, many costs go 50% down." then I'm sold despite all my misgivings.
But so far, no one has explained "X", or how the government gets rid of "X" besides simply denying A-Z. Why shouldn't I be anxious?
I can tell you what one of the X factors is. Tuition fees of the doctors. In the US the incur massive debts through school, and then pass the costs to the rest of us via higher bills. In Europe, gov't pays their tuition with taxes, so the bills are lower.
Do you really believe that Doctors who have paid off their medical school bills charge lower rates?
To me the clear way to lower costs is to greatly expand our nurse practitioner program. We have the greatest nurses in the world and can easily manage the vast majority of our preventative care.
I agree, nurses do most of the important stuff anyway. That would be a great way of lowering costs. Also break the government-enforced medical school monopoly. Why should it cost $200K to get become an MD? There is no valid reason.
No, but it is among the factors that influences choice of specialty. One lesson of the Massachusetts experience is that it has confirmed what has long been suspected, that this country lacks sufficient primary care providers for the kinds of health care systems that help bend the cost curve down.
Educating and training more nurse practitioners would help. So would incentives, such as loan repayment programs, for medical school graduates who choose primary care.
And if the government pays for it the costs aren't passed on to the rest of us?
I've been waiting, patiently, for someone to say "The X-factor is... "
The X-factor is inflated demand (not some marginal cost like tuition feeds.)
Because the insurance companies have been pricing C-sections since its inception, you as a consumer have never known its true price. None of us do. If we did, some of us would flip out and demand cheaper prices, while the rest of us would keep getting $30K C-sections and spreading the cost around the pool.
Ask thee, and the Internet shall provideth.
Enter the Health Care Blue Book.
A 'standard' C-section delivery is about 8,500.
A Vaginal birth $5,935 (2-day stay, which is about what we did).
The problem is the insane billing system -- look down further in the bill, the actual amount paid to the hospital/doctor is much lower than that charged. The total that is charged to the insurance company is inflated mostly due to historical billing practices. For example, many insurance companies pay a percentage of "usual and customary" fees. Those fees are based on charges so if you lower the charge you lower the fee. Rather than negotiate a different percentage it's easier to just leave the charge high and adjust for inflation.
Also, it's illegal to charge anyone less than you charge a Medicare patient.
This is why people without an insurance company get screwed -- it's like going into a used car lot and announcing you'll pay sticker price. But that being said any doctor and hospital will negotiate a HUGE cash discount (the Amish where I trained were the best at this).
Well, that's what the HCBB says a "fair" cost should be - and they claim it's based on what local doctors accept from insurance companies - though, what I am supposed to believe - the website or my lying eyes? And what could be the purpose of routinely charging a 300% premium knowing that the insurance company is only going to knock it down again?
I had the exact same experience and reaction. My wife gave birth to our son a little over a year ago via C-Section (which I am not exactly sure she needed, she and the baby weren't in any distress he just wasn't progressing), and the total bill was something like $40,000.
But part of the deal is that the number isn't actually real. It is like the face value of tuition they charge at colleges nowadays. When I went to college in the 90's, the face value of tuition at the Univeristy I attended was $26,000 annually. However the actual average payment by a student (Total Tuition received divided by number of students) was about $13,000.
Similarily they charged my insurer $40,000, but they got some large automatic discount (I don't recall the exact percentage). They don't expect to receive anything like $40,000 on average, it is really just a point for negotiations.
This is a nonsensical practice that is a big part of the problem since it sticker-shocks people into absolute reliance on the insurance company/employer to provide for every health care service they receive. Instead of "single-payer", I'd like to see "single-billing", where doctors actually publish their prices for services and charge all comers the same rate. Subsidies for the poor would be better done directly than hidden as shadow-taxes in everyone else's inflated bills.
I had LASIK eye-surgery a decade ago and, unlike every other medical experience I've ever had - it was the only office that actually worked like a normal business. In contrast, I took my wife to a pre-natal center for an Amniocentesis that we were paying for out-of-pocket, and, since they dealt financially almost exclusively with insurance companies, I kid you not - they couldn't tell me what the self-paying price would be in advance because they did not know and, at any rate, it was their policy not to disclose their pricing!
I'd like a free market in health care too - let me know if you see one!
Infertility treatment works under a free-market system, since it is rarely covered by insurance (and is often very limited when it is), and there is substantial competition in the market due to its elective nature. The business aspect is highly functional, and clinics can give you a reasonably approximate cost of a standard IVF cycle over the phone. Most clinics even offer a package deal of sorts (you pay a set fee which entitles you to up to three IVF cycles), and some even offer a money-back guarantee to selected patients with a good chance of success.
LASIK and infertility treatments aren't emergency or life-saving treatments. They are elective and more analogous to making a large purchase than when you arrive in the ER after a car crash or with a ruptured appendix or when you have just found out the biopsy came back cancer.
There is ample room for having market forces play more of a role in health care (the opacity of charges being a great example). However, with suppliers (doctors) so strongly controlling demand (whether you should have a procedure) and information about things besides cost not flowing freely, health care lacks important elements of a real free market.
As an aside, one of the truly awful consequences of hospital bills so often being several-fold higher than what Medicare or private insurers pay is that uninsured patients get bills reflecting that inflated price. They don't always know that many hospitals, if asked, will cut that price to what third-party payers pay. It's crazy.
A lot of necessary medical care is also performed on a non-emergency basis and could potentially function in the same market-based fashion. To name a few examples, prenatal care, well-child visits, orthopedic surgeries like hip replacements and ACL repairs, and other outpatient surgeries like gallbladder removals and tonsillectomies and laparoscopies. Even cancer is not necessarily a good example, because treatment is often a somewhat longer-term affair, and patients already do a certain amount of doctor-shopping based on non-financial reasons.
I happen to have rather complicated health issues of various sorts, and I've cost my insurance company well into the six figures already. The majority of it has been performed on an elective basis (meaning scheduled in advance), and would have permitted market-based choice. Certainly, not all health care can work this way -- childbirth in particular is one I'm familiar with, because a perfectly normal delivery can turn into hundreds of thousands of dollars in literally minutes. However, there's plenty of opportunity for expansion of markets in various areas of health care.
US doctors (and nurses) make about twice the OECD average.
Even if you assume they are going to pay $20K for 20 years to pay off med school, there is a lot more pay differential to explain.
Frankly, the other OECD countries "negotiate" rates with their doctors, and of course the government wins.
Another factor is that the US also has the lowest percentage of out-of-pocket medical costs than any other OECD country, thus reducing consumer downward pressure on prices.
The average educational debt of an American medical student graduating two years ago was just under $140K.
If it sounds like $20K/year would cover that, it might not. When I was a resident, most loans could be deferred until after residency. That's less true now, so that while residents work under regulations that essentially preclude moonlighting, their loan balances continue to rise from interest charges.
Doctors are hardly going broke, but it skews the distribution of physicians away from primary care, where they are desperately needed and toward becoming specialists, some of which are in short supply but others of which are not.
Exactly. This has always been the problem with the present group of health reformers going back to the early 90s- the people with insurance are not idiots; they understand that the promises to the uninsured/uninsurable must come out of the pockets of those with insurance (or those who don't actually need it). If the reformers continue with the "cover more people with better care, and almost everyone can spend less" argument, opposition will continue to grow.
But the day fast approaches when the insured will see their take home pay seriously eroded to cover the cost of increasingly more restrictive coverage. It is already happening, but has not yet hit enough of us insured folks. When it really kicks in, the difference between the insured and un-/under-insured will be small. But will we then understand that healthcare is no different than any other limited resource? It, too, has to be rationed using prices, queues, or some other mechanism. In the end, our choice is not between the status-quo and proposed health care reforms (neither recognize that we cannot satisfy unlimited demands for health care). Our choice is simpler than that: do you want to make your own decisions about how to ration health care for you and your family, or do you want an insurance company or government panel to make the decisions for you? A real reform that puts rationing in the hands of individuals (with govt assistance for lower income Americans) is outlined in the latest issue of The Atlantic.
Health care is one use for resources, not a resource in itself. You can get as much as you're willing to pay for. In other words, available health care grows as we divert more resources towards it.
Thanks for the clarification. As we divert more resources to health care, that leaves less available for other goods that we value. Thus, the seriously eroded take home pay that we will all begin to experience if we continue with the current growth of resources devoted to health care. Proposed reforms will not solve that problem.
Maybe I just read the wrong blogs, but I get the impression from what I see that nobody, of any political persuasion, has made a serious proposal to increase the number of doctors we have. With the population growing, and the elderly population growing even faster, wouldn't doing things to get more doctors out there on the front lines be a good idea? Instead, we have medical schools with tough admission standards and no increase in class size, and, apparently, no suggestions at all for changing this.
Suppose we did, somehow, manage to insure all those uninsured people, and suppose that somebody invents a magic potion that lets us do this at no cost. Would that really help? Who would treat those people? Is my doctor going to start working 80 hours a week instead of 60?
I see that nobody, of any political persuasion, has made a serious proposal to increase the number of doctors we have
There's little you can do - it is a thankless job that is becoming more and more marginalized by an ungrateful public and punitive justice system. When I was in grad school, I took classes at a nearby med school. The common stat I heard was that the average doctor will get sued at least once in his/her lifetime. Yes, there are repeat offenders who skew that stat, but that has got to be a scary prospect for any incoming med student. But I am sure the trial lawyers would LOVE to open up the admissions standards at med schools across the country
With all the crap that they put up with, we expect doctors to be both charitable and perfect (I know of no other occupation where if you make a mistake, you typically end up being sued for millions of dollars.) Why would people flock to this type of job? Most people would answer "the money, of course." Well, from medical school up and until residency completion, there's not much money in practicing medicine. Add the prospect of a law suit, and you can see why their are few incentives.
High costs are not simply a function of low supply on the practioner side. In many cases where oversupply is an issue, inflated costs are still seen, because of the payment model. Producing more docotors is not the solution.
Nonsense. For every 3 qualified applicants to medical school, 1 will be accepted.
The real problem is that doctor-hours (an hour of labor by a doctor) are a scarce commodity. Playing games with health insurance can only redistribute doctor-hours, taking from some and giving to others. The only way to treat more people is to increase the number of doctor-hours or find substitutes for doctor-hours (e.g., nurse practitioner-hours).
That's not the only way. More efficient systems of care would free us up to be doctors, rather than chasing down lab results, arguing with HMO clerks, filling out another authorization form because the old one (circa last week) is no longer accepted, etc. In addition to taking clinicians (nurse practitioners deal with the same insanity) away from the bedside and out of the exam room, all of that wasted effort fosters burnout.
Gotta agree with Alan. Doctor services are basically saturated and demand for their time is approximately fixed. If this is not a recipe for bloated prices then I don't understand the basic principles of economics. One solution would be to increase supply as mentioned above. Another is to introduce price controls.
Well, some of the "radical libertarian" persuasion have suggested reducing licensing requirements for doctors, so there's that. But, well, I think most people (radical libertarian or not) figure that supply & demand at least sort of works here, and if there's a lot more demand for doctors, more people will go to medical school as salaries go up. So I guess I don't understand your question
Medical school enrollment is near saturation. They have to turn down 2 of every 3 qualified applicants because the resources (instructors, classroom space, lab facilities, etc.) aren't there. It's not as simple as "let in more students".
How inelastic are those factors? (Seriously -- not a rhetorical question.) Is there a reason more resources couldn't be devoted to producing medical personnel? E.g., more medical schools, larger ones, etc? (I'm ignoring cost issues and assuming willingness to pay.) Obviously not tomorrow, but in a decade or three, how hard are those limits?
Build more medical schools.
If they are not being built, find out why.
You can't solve a doctor shortage by simply building more medical schools, because doctors only spend two years of the 8-10 years of training in the classroom.
The second two years of medical school, and the four years of residency, and the optional fellowships, are all spent in the hospital. An attending physician must always be present to supervise residents and med students and to conduct grand rounds. In order for residents to gain the necessary experience with a wide variety of conditions, the teaching hospital must be a large one -- rural community hospitals don't see enough patients. Teaching hospitals are also unique in that the attending physicians are actually employees of the hospital, and therefore are required to supervise and teach as part of their jobs. Private-practice physicians have privileges at a given hospital, but they're not its employees, and hospitals can't easily force them to do the grunt-work of training and monitoring residents.
Even if you increased medical school enrollments, you'd still have substantial difficulties in providing them with the practical training necessary to become full-fledged doctors.
The US has a fairly low number of doctors per capita compared with other OECD countries.
It is true that most other OECD countries have government-paid medical education (whether this is included in total health care cost comparisons is not clear to me...but assume $10K-$20K per doctor per year costs to finance medical school loans for 10-20 years).
Foreign doctors must do residency years in the US before becoming licensed here, even if they were a licensed and practical doctor overseas. It is clear to most doctors that "foreign medical graduates" who are licensed in most western countries should be fine to practice in the US, especially if they pass the USMLE test.
I suspect the US could have a much larger number of immigrant doctors if immigration policy was eased, and especially if the residency re-do requirement was dropped.
Medicare pays for most post-medical-graduate residencies in the US, and the number of "slots" has been fairly static recently, but recent medical graduates tell me that graduates are not worried about not getting a residency slot (the competition is for the "good" ones).
Do you really believe that Doctors who have paid off their medical school bills charge lower rates?
To me the clear way to lower costs is to greatly expand our nurse practitioner program. We have the greatest nurses in the world and can easily manage the vast majority of our preventative care.
We are not suffering from inflated costs because we have too few nurse practiioners.
Do you honestly believe that increasing the number of Nurse Practitioners would not lower costs?
Or to be more clear- increasing the role that nurse practitioners play. For the vast majority if things a Nurse practitioner could take the place of a primary care physician in my opinion. If you want to greatly expand coverage while also lowering costs to me nurse practitioners are clearly the direction we should be moving in.
So I'm supposed to believe that the large fees are due to health care industry gouging practices? What was the profit margin for the entire industry from 2000-2008? I'd like to know.
The AMA definitely engages in some cartel behaviors. It's not the whole problem, but it's one piece.
I agree with spot. NPs are hugely cost-effective.
What? You never keep a coherent argument. You say that costs need to be controlled but you argued in a past post that controlling costs would be bad for innovation and thus should not be controlled. You swing both ways on every issue.
No, she is completely consistent. What seems to "swing both ways" is the ability of certain readers to actually understand the arguments being made.
There are many ways to control costs.
One of the biggest ones advocated in this healthcare package was negotiating down drug prices. This would be horrible for innovation.
Other ways to control costs have large constituencies against them (putting granny on an ice floe) or unpredictable.
Government controlling more healthcare dollars means the least politically harmful cost savings are pursued, which means hammering drug companies and not paying for innovation (or at least slow rolling it to contain costs).
A better way to control costs would be to change from a 3rd party pays to 1st party pays. Getting rid of the massive tax subsidies to health insurance would also help. Doing this would be very hard, but much more likely to be effective and not destroy innovation.
College education is heavily subsidised and generally follows a 3rd party pays model - education inflation is just as absurd as healthcare inflation. It's like there's some law of economics at work, but of course that can't be it!
"That means we have to dip into the pockets of Group 5: people with insurance. Either they have to pay higher premiums, or they have to pay higher taxes, or they have to get less stuff. This makes them anxious. "
You assume that reducing the price of medical care will result in "less stuff". Are you sure about that? Think about it. If you could double prices tomorrow without compromising demand would that really lead to more stuff or just wealthier doctors and insurance managers. Reducing prices from their current levels is likely to only affect the wealth of med care providers not the stuff that the insured get.
If you cut the price of everything, goods and services don't get cheaper, they disappear because no one makes/provides them. See Zimbabwe.
Repeat after me: price controls lead to shortages.
Instead of repeating libertarian dogma why don't you try thinking through the problem.
So ... you thought about the problem carefully and decided that actually, price ceilings don't lead to shortages? Since when did that become libertarian dogma? Or are you saying it's a crazy libertarian dogma that supply curves aren't always and everywhere vertical?
@ryan
Look, when applying economic principles one needs to understand the particular system. Think about it, do you really believe the demand for heart bypass surgery is going to increase if prices are reduced or that suddenly we won't have enough people who want to be docs. The med care market is kind of special. Both demand and (somewhat artificially) supply are invariant to price, at least over the range that we're concerned with (i.e. US to Canadian prices).
@ 73,d&52
So, supply and demand are both perfectly inelastic? And we just got really lucky and they happened to be at the same quantity? Kind of an odd coincidence, don't you think? And if you think that demand is perfectly inelastic, it's not really clear why you'd be worried about health care in particular, since, after all, by assumption we're getting all the health care we could possibly want. (Maybe you're just glad we've found a way to raise tax revenue with zero deadweight loss?)
I will grant that for very small price changes and for very short periods of time (e.g., tomorrow), supply and demand might be pretty inelastic. But questions with a one day time-horizon are often uninteresting and not helpful.
And yes, of course I think that the demand for lots of health services change when you change price.
@ryan
Yeah some folks will get scared off from seeing a doctor when prices get too high and some people are clearly refused treatment if they don't have insurance so yes demand is not perfectly inelastic. However degree of inelasticity is important in judging what sort of shortage we'd be talking about.
As for supply I don't know. It seems to be determined via quota that itself is determined how? Med prices have been steadily increasing in the US, has the supply of doc time also been increasing? Are there fewer per capita doctors in Canada where prices are cheaper? What does this supply curve look like?
Net migration flows of doctors to the US are definitely positive, so even absent a domestic effect supply seems to slope up. As for demand, well, as has been mentioned here & elsewhere, the RAND study is kind of the gold standard and they found a pretty significant effect on demand. Which sort of conforms to what both of us are saying: higher marginal costs make people spend less (what I'm saying) but isn't going to dissuade someone from getting something medically necessary (your heart bypass example). But like I said, if people are getting the important stuff either way, then what's the issue? (Other than distribution, but since subsidies have been shown to lead to consumption of little real value, there are much more efficient ways to get more redistribution.)
My whole aversion to any individual mandate is based on not wanting to force Group 2 to buy comprehensive medical plans. It's already hard enough for 20-somethings to get launched. Forcing people in first jobs, trainee situations, grad school etc. to buy full-featured health care plans they don't need just raises the barrier to entry for adult life and increases the odds that someone won't make the transition. I might change my tune on this if student aid for grad school (grants, not loans) got a lot more generous, but not otherwise. So here the health care debate and the education debate touch again.
I could accept a mandate for high-deductible major medical insurance, and I think that sort of policy should certainly be made more widely available to the kind of people whose routine health care costs are around $300 a year. Or even to older folks who are willing to self-insure for $5K-$10K but who want a backup for anything really expensive. But not a mandate to pre-purchase (which typically means pay for and not use) every service that a lobbying group can get a state government to declare mandatory.
I agree completely. Part of the reason I preferred Obama over Clinton was his refusal to mandate insurance coverage. Such a stance didn't help Obama politically. But it was the right thing to do.
I would love to look at the stats of how large of a percentage even college grads have to go without ideal insurance coverage for some time period in their 20's. It sucks, but it's far better than forcing a mandate and expensive insurance coverage.
I'm surprised no one has mentioned the costs associated with the one thing that has very little to do with medical care, but is required of every single doctor's office I've ever visited:
Compliance with this, that, and the other government mandate.
I'll wager that more than fifty percent of the office staff at my general practitioner's office are chaff hired to make sure some bullshit regulation is followed correctly.
From this, we get amusing practices like a sheet of sticker-paper at the front where you sign in on a sticker that's removed so the next person can't see your name and know you're visiting a doctor or for what...
Then five minutes (if you're lucky) later, after several other people have read your entry and also "signed in," the receptionist pulls your sticky and calls you up *by name* *aloud* and asks you a series of very audible questions that everyone in the waiting room can clearly hear.
Afterward, you return to your seat to await the nurse who opens the door and again, calls you by name *aloud* so everyone who wasn't in the room before now knows who you are as well.
This may not be the post for it, but I want to ask a question of the commentators.
Many of us oppose Obama's Health Care Reform, whatever you call it. We are afraid of government taking over 15% more of our lives.
We are afraid of killing the innovation that has saved so many of us.
We are afraid of creating another tremendous government boondoggle that will swallow our money into its bureaucracy.
Conversely, we are afraid of government cost-cutting that will determine what health care we are able to get.
Question (honest soul-searching on the subject): Are we quite sure that nothing good can be done? After all, even if I don't (want to) admit that France has the best health system around, surely all of us will admit that it's not much worse than American healthcare. Seems pretty good. And everyone is covered, and it doesn't seem to be outrageously expensive...
So, are there things that conservatives can support to improve the present system? Do they absolutely have to be free-market solutions? Are we too scared to do anything? Is it impossible to do anything because whoever will be hurt (bound to be somebody) will be furious and scream at townhall meetings?
Just curious what people think. It's sometimes fun to be the party of No, but I wonder if Yes is occasionally appropriate.
Pretty much everyone gets healthcare under our system too (all but about 2%). I would not object to moderate Medicaid expansion, but not a $2T national quasi-gov't-takeover "public option."
I'm very skeptical the government can do any good. Most problems do not have gov't solutions.
And no, you would not want French healthcare if you could have American instead. Massively more and better diagnostics here.
Well, I'm no conservative, but I support such radical reform that supporters of the most-supported House bill, despite claiming to be pro-reform progressives, are shown to be staunch defenders of the status-quo. Somehow, medical decartelization, a free market in health care and insurance, and a real end to the War on Drugs (with the FDA up against the wall along with the DEA) aren't quite what they had in mind.
I don’t think you’ll find anyone who would argue that the system doesn’t need improvement (although the risk of doing the wrong thing is greater than the risk of doing nothing) but I think most of us who are in the “conservative” camp would argue that a lot of the problem is that we haven’t let the market work and instead tried to direct it in certain ways and the “problems” are largely the unintended consequences of interventionist policies.
For example, health insurance is and should be there to protect people from being wiped out financially from a catastrophe (just like everything else we call “insurance”). Instead it has, through a combination of tax preference for employer-provided health insurance and State mandated benefits, become a form of “prepaid health care.” The result of this is that it is very expensive for people to buy actual insurance especially on their own. In addition since most of the mandated benefit laws are done at the State level, instead of having actual competition (like we do for nearly every other product and service we buy), we have a situation where there is an oligopoly of about three or four companies that control nearly all of the market in each State.
My main solution to this would be to (a) let people buy health insurance across State lines from any company that is licensed in any one of the 50 States, (b) give people who buy their own health insurance the same tax benefits as employers who provide it for their employees and (c) let people buy a catastrophic insurance policy without mandated benefits for routine care with a high-deductible. I’d also let small businesses and other organizations form risk pools in the form of Association Health Plans so that they could buy policies at rates comparable to what larger companies do and expand the availability of Health Savings Accounts so that people could pay for their co-pays, deductibles, routine costs, etc. with pre-tax dollars. A think all of these would require relatively minor changes (and certainly cheaper than the price tag we’ve seen) to expand insurance coverage for the majority of the uninsured.
BTW: contrary to being the “party of no,” each of these ideas I’ve just mentioned were proposed by Republicans when they last controlled Congress and blocked by Democrats. Insofar as the current set of "reforms" are being blocked, it's largely because they would make what I identified as the problem worse. It would encourage people to think of insurance as "prepaid health care" and it would limit their choices (eventually only to the "public option" or a "private" plan that is required by law to be essentially the same as the "public option").
Hello,
I appreciate this analysis, in particular the breakdown of the uninsured.
I don't think I really understand the first category, so I'll skip it.
The second category (young healthy people who don't need much health care) consists of people who nevertheless ought to have health insurance, just in case. High deductible health plans make the most sense for this group. These people deserve subsidies from taxpayers to pay for their HDHP's. It wouldn't cost very much taxpayer money to do this.
How does a high deductible plan make sense for young people who probably don't make much money? If you can't afford $500/month in premiums, the chances of being able to pay a $6000 deductible are also nil.
The idea is that in the unlikely event you have some huge medical need, the insurance company will pay everything *above* the $6K leaving you stuck with that amount owed to the hospital instead of $600K.
Get it?
I actually agree with the progressives that health reform will be a disaster unless you can find some way to control costs.
But you can't, without reducing innovation, because otherwise people keep inventing new treatments that create new costs. We spend a lot of money on things people used to just die from.
The best solution for this is massive R&D, preferably in the form of prizes focusing on treatments that reduce health costs over time (either through reduced senescence or replacing expensive treatments with cheaper ones). We need to get near the top of the cost S-curve as quickly as possible, because past a certain point costs will plateau, and eventually fall, and then this crisis will be manageable.
Historically, cost containment has not been a major priority in biomedical research. I agree that it needs to be, but doing that in a way that doesn't throw a huge wrench in good science isn't obvious to me. Not saying it can't be done, just that it will be challenge.
Okay, so I'm hot for the idea of medical co-ops, but I have no idea what is actually being proposed (in point of fact, I'm sure most of it is vague blue-sky ramblings because no political actor wants to get pinned to anything in writing). Are we talking about 501(c)(15)s for health care or what?
Thank god that the public option is still on the table so we won't have to find out about co-ops, which have all of the disadvantages and none of the benefits of a robust public option
http://seminal.firedoglake.com/diary/7322
In any case, The Republicans say no co-ops either. IOW , no to everything. So much for bipartisanship.
In other, reality based news, Stephen Hawking, Gordon Brown, and David Cameron all agree on one thing: The American right wing is lying its ass off about the British NHS, which gives quality care at a decent price to all Britons
Canadians similarly agree that the right wing is lying about their system.
Dave Krugman explains it all for everyone in this article, which explains that the goal of the various reform bills isn't single payer , but but a Swiss style 'Regulated private insurer" model
http://www.nytimes.com/2009/08/17/opinion/17krugman.html
Read these links, and learn something, folks.
The advantage of coops is that their financial interests are aligned with their members. The problem with the public plan is the same as the problem with private plans - the financial interests of the insurer and insuree are diametrically opposed.
I'm not sure what I'm supposed to learn, being as by it's own admission the former only claims to be revealing the "suggestions" of what the final co-op plan might look like, essentially echoing my own statement about "vague blue-sky ramblings because no political actor wants to get pinned to anything in writing", and I already heard the Hawking bit on NPR.
So, to your unsupported claim that "co-ops... have all of the disadvantages and none of the benefits of a robust public option", I shall simply cite an advantage, that of being actually liberal (that is, being conducive to liberty, i.e.: free and non-coercive), and a lack of disadvantage: that of centralized monopoly control subject to Hayekian and public-choice critique. At least, an advantage and disadvantage of what I would conceive of something counting as a "co-op", as opposed to a public (which always seems to mean government) option as evaluated by my own lights.
If Megan had actually read the entire article on the Massachusetts system,she would have discovered that Massachusetts has actually achieved univeral coverage and is now moving to control rising costs.
Now they most certainly have a costs problem, but they appeared to have rejected Megan's analysis and are looking instead to revamp the fee for service system. Other proposals are being made.Note to Megan : No one is proposing price controls on drugs.
More efforts were made last year in legislation that provided incentives for doctors to practice primary care, required uniform billing procedures among providers, toughened the state’s regulation of new hospital construction, and established the payment reform commission.
The commission is looking at various options, but all would do away with the fee-for-service system, which provides perverse incentives by paying physicians and hospitals for each patient visit. The changes under consideration include reimbursing for episodes of care rather than individual visits and bundling payments to groups of providers who would together take responsibility for a patient’s health.
Blue Cross and Blue Shield of Massachusetts, the state’s largest insurer, recently devised an innovative model that pays doctors a flat fee per patient, with adjustments for age, gender and health status, and then adds bonus payments for high standards of care.
Blue Cross officials say they believe that the new plans can cut the growth of premiums in half over five years and expect them to account for 15 percent of their business by June. “We’re very committed to this path because we feel it’s the only credible place to go,” said Cleve L. Killingsworth, the company’s chairman.
Capitation has potential, but is also has huge problems, even aside from the fact that doctors hate it and will lobby against it with every fiber of their beings. Capitation was tried with great success in the 1990s, except then it turned out that voters freaked out and called their congressmen and their HR departments and made the HMOs stop doing it because capitation meant it was . . . wait for it . . . harder to get procedures done.
It's not just that we hate capitation. It penalizes patients who are complicated, really ill, or both, as well as the clinicians who care for them. It sounds like the Mass Blues are trying to address this by adjusting for relevant variables. Bonuses for meeting appropriate benchmarks sound promising, too.
This is sort of reminiscent of how HealthCanada came to be. Universal coverage started at the provincial level (Saskatchewan, I believe) and eventually was federalized. As they strive to cover all of their citizens, Massachusetts and San Francisco will be places from which we can learn what works and what doesn't.
Thank you for reading my comment, simonk, even though my comment wasn't very well considered. Let me try to refine my comment a little bit, although I still might not get it right, because my understanding of this issue is limited.
Some observers have advocated that young healthy people ought to have the right to go without health insurance, because (for example) "it's still a free country". Dr. Krauthammer has expressed anger that the government would overrule young Americans' "rational decision" to forego the purchase of health insurance coverage. However, I am concerned that young people may sometimes require medical care due to unexpected illness.
A frequent counter-argument is that the young healthy uninsured person is irresponsible, because someone else will end up picking up the tab if she gets sick. But that's not my argument. I'm more concerned about the health and overall well-being of the patient herself. When a young healthy person has no health insurance whatsoever, she will probably not suffer any adverse consequences as a result, but there is a (small) risk that she could get very sick, and there is a (smaller) risk that she could end up with financially devastating medical bills. If subsidizing health insurance coverage can reduce that smaller risk to near-zero, then I think that is a worthwhile use of taxpayer money.
I've been thinking, instead of imposing penalties on uninsured Americans, why not bribe Americans to accept insurance coverage? Each low-income American could be given a generous voucher with which to purchase health insurance coverage. If he did not enroll, he would lose the voucher. But if he did enroll, he would be allowed to "keep the change" -- the total value of the voucher, minus the cost of the health insurance plan of the consumer's choice. One possible advantage of this idea is that with such a voucher program, the Medicaid program could be eliminated.
Both Megan and Ninja Zombie make the same (imho incorrect) assumption that the immigrants are to be deported - they all should be immediately legalized and pay taxes.
More has to be encouraged to come (with better screening to favor educated and young).
That would solve the social security problem, as well as much bigger, more general problem we are to face around 2020: the labor shortage (as oppose to the investment shortage).
You will see developed countries competing for immigrants by then and the native for the immigrants countries being upset at the workforce leaks.
If the healthy part of the immigrant family is legalized and pays taxes (as well as the sick before becoming sick) it will cover both their med care and the hole in our med care $$