Healthcare

It's the old addage about people who are happy to be living under a bridge eating a partridge as long as the guy next to him doesn't have a partridge to eat.

I don't think it's just that in this case. It's people seeing "freedom" as not having government interference in their lives instead of "freedom" to live their lives as they see fit. There's a huge difference. Single-payer, believe it or not increases freedom. It means you can leave your job and go to another one or even start your own and not putting yourself and your family at great risk.

^ His point was deceptively simple. Single payer does not increase freedom to choose. By paying taxes, you are in effect being forced to pay for somebody else's use of the system. That negates your freedom to choose both to pay for healthcare in the first place and/or how its spent should healthcare be needed.

There's more to freedom than merely speaking your mind or being able to move from place to place.

Tom: And you ignored the huge and important bits already mentioned. Ie not being forcibly tied to a job to ensure coverage if you get it through work. So what your taxed but you will always have coverage then. You can live where you want, work for who want, and even visit clinics of your choice.

Try that with the system you uphold.

Hate to break it to you, but under the current system, you STILL are forced to pay for other people's healthcare, either via insurance, via base prices of treatment, or via the hidden costs of unhealthy workers.

On top of that, you don't get to choose how to pay for healthcare or how it should be spent. Whatever job you get to have determines the former, and whatever disease or injury fate decides to give you determines the latter.

At best, your only real choice is whether to live crippled/impaired or sick versus being healthy, by determining whether you get the treatment you need or not. (At worst, depending on what you're afflicted with, you get to choose whether you want to live or die slowly.)

edited 12th May '11 2:56:37 PM by Jeysie

I think the point I put forward is that you might complain that you pay into a pool but paying into the pool via taxes is less costly than buying the insurance yourself. I pay roughly 3.3k into taxes that go into my healthcare. In order to obtain the same health coverage in the states, it costs me around 6k to 15k a year depending on which state I want to calculate against.

If I have more money in my pocket, that's more freedom because I get to do more things. I need the healthcare no matter what so with such an inelastic good with only one way to provide to me, what freedom is there to let me choose between private insurers that'll charge me way more money? That's not freedom whatsoever.

edited 12th May '11 2:57:44 PM by breadloaf

Yeah. Most people would actually have MORE choice and control over their health care in a public system versus a private one. Or at least the current private one that currently exists in the US. Not to mention more money in their pockets.

Don't you guys get it, they want the FREEDOM to pay more money, and to make the rest of us pay more money, because that's FREEDOM.

Why does it feel like a chain?

I'm reminded of the males who insist on getting their car insurance with "female-only" providers like Diamond or Sheila's Wheels. Legally they're not allowed to exclude men, but they are allow to charge them insanely high rates that they do not need to pay. These people could get much lower rates elsewhere, and are openly told this, but, presumably because they think it's hilarious, insist on going with those companies.

This ls little different and no more sane. With the US system you pay vastly more for a vastly inferior rate of healthcare, and your desire for "freedom" aside from being an insane deluded lie, is highly dangerous to those you would deny healthcare to. Ie, those who desperately want it but can't afford it.

I'm sorry, but opposition to universal healthcare is rather close to moral bankruptcy to me, becuase of the sheer weight of societal problems and ill-health you're essentially legitimising by opposing the clear obvious and proven-effective solution.

I happen to believe that while our process is broken, it wouldn't be that hard to fix. The most important issue is to control the spiring cost of healthcare. The reason that healthcare costs keeping accelerating in the US is because incentives in the system reward doctors for delivering more services, that is Medicare, Medicaid, and most health insurance policies pay doctors per patient per service. Individual patients are often "capitated"- this is a limit on how much the doctor can collect on each patient, for a particular treatment. This creates an incentive to look for reasons to deliver more expensive types of services to more patients.

The solution to this is to change the incentives in the system. Doctors should be paid for healing patients (or improving their health outcomes), not just for services delivered. This would create an incentive to deliver only services that are actually needed. Another reform would be to charge patients a small fee, adjusted for income, for every service delivered. This would encourage patients to shop around for more cost-effective options. It would be important to enact both of these reforms together so that patients are not harmed by looking for the cheapest treatment (because the doctor gets screwed if the patient doesn't improve).

These reforms would require the development of new, more accurate metrics that would allow us to estimate the contribution of a particular treatment to a patient's overall health. That would be difficult and controversial, but not impossible to resolve, if enough effort were put into it. Right now we actually dont know very much about this, almost all medical research concerns the effect of treatments on specific ailments, not overall health status.

If these changes were put into place, the semi-privatized, semi-public system we now have in the US would work perfectly well. Market forces would be carefully aligned with patient health needs, and competition between health care providers would promote the development of new cost-effective treatments. I think it would be a far better fit for less money than trying to convert the US into some sort of single payer system.

I like the idea of paying out according to health outcomes. I'm not sure of the whole surpay thing although if you don't leave out check-ups and other preventative measures then it's a non-starter IMO. (I think the ability for consumers to "shop around" when it comes to health care is woefully limited under the best circumstances)

But hells bells, at least it's a suggestion.

The problem with paying by outcomes is that it encourages doctors to only accept patients without health problems, and to discourage and avoid patients they think are likely to have them.

Lots of metrics work great until you make peoples' earning dependent on them.

I wouldn't encourage a system that assigns or adjusts the salaries of doctors and other medical professions based on health results. This would cause the entire field to potentially collapse if there was to be a new plague (by which I mean any disease that causes damage that compares with the plague) because the very people most capable of combatting the disease and preventing its spread would be out of work or feeling betrayed.

Health results are too subject to circumstance for this kind of a system to work.

Instead, provide the best healthcare possible and make sure that Universities and other institutions that carry out R&D (and, of course, treatment) are well funded and enjoy great liberty, but are also rigorously inspected and reviewed.

I respectfully disagree. If a patient has no problems, they cant improve. No improvement, less pay. The most lucrative situation would be finding a very sick patient, that a doctor can cure. I advocate a baseline level of pay per service per patient, and a bonus above that for improved outcomes. Obviously the scale would be different for each condition. In some cases, end of life for example, the goal isn't a cure, but increasing comfort. And I would ask the American Medical Association and other professional agencies to contribute to the payment plan. Thus these would be pay scales that the medical profession itself had approved. As I said, this would be a lot of work, but not impossible.

De Marquis: I could get behind that plan. But it still doesn't fix cost of care.

I… Think I agree with De Marquis, though with the caveat that some kind of baseline pay for work only would be needed for certain procedures that aren't usually supposed to heal anyone (such as regularly scheduled diagnosis.) Also, leaving some kind of residual copay… That wouldn't work for the very poorest patients, perhaps rendering some kind of small proportional credit (rather than debit) for saving money over the default option, like a bounty?

@Tuefel: It fixes cost of care by removing the incentives for delivering ever more expensive services. Also by rewarding procedures that heal the patient faster. The only thing I left out was preventive care, but that's easy to work in. Its just a matter of setting up a schedule of payments that pays most for the type and amount of procedures that we believe works the best.

@Eric: That sounds good. Although no one is so poor that they cant pay a buck. And paying something, anything, actually empowers the patient. People are more assertive about their health care when they invest something in it, and when patients get involved in decisions about their care, costs should go down while quality of care goes up (because people tend to pick the least invasive treatment that will deliver the quality of life they want, and less invasive procedures cost less). So while we don't want to burden the poor, it's important that they have an incentive to be assertive in their own care.

I disagree with any metric. They're evil. They can be used to study how well your healthcare system is doing but I disagree with actually using any to adjust pay.

If you base metrics on amount healed, a good analog is a programmer who has a metric to fix more bugs. So what does he do? Find the most idiotic and pointless bugs to fix and find lots of them. The code that he writes in fact gets worse because he spends so much time on stupid stuff. Doctors would find patients, invent totally inane health problems and then "fix" them to get paid.

People pay into a single insurance fund, you have a definite pie of money upon which you draw, the doctors know the total pool. You spend out based on medical priority according to the doctors. The encouragement is to use the money they have as efficiently as possible. You use metrics to measure the overall health of society. If it's not working well, you look into the medical field's managers and see what problems exist. There's no easy cut-dry solution to managing things well. You have to find people who are well skilled in medicine and are good at managing people to just tweak the system constantly to make sure it is running smoothly.

I would suggest though, for healthcare, we could separate it out from the main budget so that people know exactly how much they're paying for their insurance. Afterall, it's a single-payer system and it makes our remaining taxes more clear. On the other hand, we might want it in the general pool in case of shortfall/windfall for any particular year.

edited 13th May '11 7:44:14 AM by breadloaf

I can verify this one, with an example from the bank I used to work in, as a teller. This was a few years ago, so I don't know if it's changed, though I assume it's the same. They had a metric for complaints, because customers who received a letter saying "we're really sorry about the service, we're improving and it won't happen again" score the bank much higher on customer surveys than those who didn't receive such a letter. The problem is, since we were always striving to "get it right first time" and provide excellent service, there weren't always genuine reasons to send such letters.

So we were told that any time we said sorry for anything we had to log it as a complaint, so the member of staff responsible would have the excuse to write out. The logic was that mistakes would happen anyway, so it was just a case of apologising when they did. But at the same time, our performance and thus bonuses included not making mistakes and providing excellent service. So we were either deliberately making minor mistakes so we could send such letters (thus completely undermining the idea of actually giving good service), or else sending them for such criminally negligent service as dropping our pens.

That's a true story, and I'm absolutely certain would be replicated in this. Metrics do not work. End of discussion.

edited 13th May '11 10:42:45 AM by CaissasDeathAngel

I saw somewhere else Tom saying that a huge amount of trouble/cost in the healthcare industry comes from malpractice suits and such. I'd like to point out that this is a myth. Malpractice suits add an additional 2% to costs, nowhere near enough to justify the massive increases in cost to the average person.

Thread necroing to draw attention to it to move the topic in another thread.

So, I saw deux saying "I don't trust your sources because they cite places that are suggesting socialized medicine is a good thing." Well of course-if you're presenting medicine in favor of socialized medicine (because the actual information proves that it's cheaper, per capita, than the American system), it's likely you're supporting socialized medicine.

Honestly, insurance companies shouldn't exist in the first place. "Risk pooling" is not an actual product, so no one should be making a profit off of it. It's a valuable service, sure, but it's precisely the kind of thing that is better accomplished by the government, rather than private enterprise. See: adverse selection, economies of scale, etc.

It's actually a lot more annoying to list how healthcare is cheaper in socialised situations because it's not just one silver bullet. It's a collection of a lot things combined that make it cost around 50% of what it does in private medicine.

• Administrative costs in private insurance is quite large both due to hospitals trying to fill out the right forms, to people wasting their time filling out the right forms, to a zillion lawyers all filling out forms
• Marketing costs do make up a not-insignificant percentage of health insurance firm costs, 100% of which is gone under socialised medicine
• Bulk purchasing power, this is the only reason why Canada has slightly cheaper (and it's only slightly cheaper for the same brands, not super duper cheaper) drugs than America.
• Drive to lower costs is much stronger. Ironically, it is much stronger to the electorate if you lower costs but provide the same level of service in public healthcare systems, because unlike a private system, when your tax dollars go to something, you get angry when it isn't efficient. If you're in a private system, most people say "I'll pay someone else... and get the same shitty but somewhat less shitty service".
• Litigation decreases substantially (but as someone else said, this isn't really a huge amount of money)
• Studies show that people who have to pay out of pocket to visit the doctor are actually likely to just never ever visit the doctor. It's actually extremely less. Before someone complains about "but then people would constantly go if it were free". A guy visiting a doctor blows $100 tax dollars. Preventing a single medical issue can save you up to a quarter million in one go. That's why in the end, it ends up saving you more money because it's not physically possible to visit the doctor enough to overcome the medical complications that are prevented because of it.
• Doctor salaries and nurse salaries are reined in. Not fun for doctors, fun for taxpayers.

All of this ignores cultural traits that might lower government costs but aside from that, there's also other byproduct effects I see.

• Legalisation of generics got rammed through parliament because it made healthcare costs so much less.
• A lot of pharmaceutical aid is now done through generic drugs (although some recipient countries with super corrupt governments have tried banning the entry of such aid)
• There was a waiting line issue in Quebec at one point for hip replacement surgery. After people sued for the right to private insurance for it, they got it. A health insurance for a single purpose: hip replacement surgery. It was so costly that not a single person bought it. However, the litigation against the government spurred them to improve wait times and it went from 8 months to just a few weeks within a year of government action on the issue (without impacting anything else). So it's possible to lobby government to fix these things.

Not only do I believe we should have Single Payer run by a government entity, but I believe that private health insurance as a for-profit company is inherently immoral. Private Health insurance makes a profit by maximizing the differential between premiums and payouts. Less payouts, more profits. In other words, they make money by denying people treatments at every opportunity, and to delay and obstruct necessary treatments as long as possible.

If health care is managed by the government, I at least have (in theory) the right to petition the government and vote out the people I don't like. The only people a private company cares about is its shareholders. What power to I have to influence them? I can't find it in me to justify profits made by killing people.

Isn't like 40% of the US service economy based in the health care sector now, though? There were a lot of confusing numbers and shit thrown around during the Obamacare debate, so I'm not really sure, but if that's true, nationalizing it just might shoot the economy in the foot, no?

I mean, sure, the doctors and nurses keep their jobs, but the insurance companies all go broke. Then again, good riddance. Parasite bastards, the lot of them...

The insurance companies are rather dastardly. Insurance is one of the things where "Innovation" is not something you want. You pay into it, you get out of it. Without shifting numbers around, its not something that needs reinventing.

Also, much of the overhead is from hundreds/thousands of people who are hired purely to decipher the myriad networks of insurance companies, all with their own system made to be as confusing as possible to keep from having to pay out.