Medicare For All! (But . . . why would you want that?)

Medicare For All! (But . . . why would you want that?)
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Sen. Sanders (Ind. VT) has proposed “Medicare For All”.

 

Now, that is NOT exactly what he is proposing. What is Sen. Sanders proposing? In fact, what is “Medicare” or for that matter, what is “Medicaid” and how do they relate to Sen. Sanders proposal?

 

Now, let’s examine what all this means.

 

  1. What is Sen. Sanders proposing?

 

What Sen. Sanders is proposing is NOT strictly speaking “Medicare for All,” as it is not Medicare as that program exists now. (See Section 2, below, for an explanation of Medicare as the program exist now.)

 

Sanders's plan would offer first dollar coverage for physician services, hospital care and optical and dental services.  It would shutter the existing Medicare and Medicaid programs after a transition period  and transfer their patients into the new program.  It would also prohibit employers from offering plans of their own.  It would, however, leave the present Veterans Administration ("VA") facilities in place as well as those of the Bureau of Indian Affairs ("BIA"). 

 

It is interesting to note that Canadian Medicare does not offer optical or dental benefits.  It is also worth noting that many socialized medicine systems require, at least nominal, co-pays to control utilization. 

 

Sanders says generally that the expected $138 trillion cost per year would be paid for by a 2.2 percent tax on households and increased taxes on more affluent Americans and increased estate taxes.  Sanders' proposed "Medicare for all" differs significantly from the current Medicare system. 

 

  1. What is Medicare (and why is it doing all these terrible things to healthcare?)

 

Medicare Part A and Part B is a circa 1966 BlueCross/Blue Shield 80-20 Plan. With Part A (Hospital Services) and Part B (Physician Services), Medicare pays 80% of the bill, with the patient (you) being responsible for 20%.

 

To illustrate, if your bill is $100,000.00, Medicare pays $80,000.00 but you are responsible for paying $20,000.00. This is how indemnity insurance works. This is also one reason why managed care, which generally uses discounted fee-for-service to lower provider fees in return for patient volume, largely came to supplant indemnity insurance in the 1990s.

 

Now, in 1965, when Medicare (and Medicaid) passed, experience rated insurance was becoming a norm, where actuarially similar people had common rates and, therefore, older (and probably sicker) people were at a disadvantage and younger healthier people got a better deal. (The alternative system, pervasive before the early 1960s, was community rating, which PPACA has made a default national norm in the individual market for health insurance today).

 

In 1965, Medicare meant that people over 65 could, at least, get insurance like other people had (most people in 1965 had indemnity insurance, if they had it at all, and HMOs were still known as “Pre-paid Group Practices” and existed mostly on the West Coast [such as the “Pre-paid Group Practice of Puget Sound,” the first of these entities]).

 

Unless the patient (you) can afford a good Medi-gap Plan or have Retiree coverage you can use as a secondary payer to help cover the 20% or you are poor enough to be dual eligible for Medicaid, you probably can’t afford the 20%. For less affluent seniors, the Medicare premium takes up a larger and larger slice of monthly Social Security payments. This is not like, for example, Canadian Medicare, which is (apparently) first dollar coverage (it comes out of taxes, however).

 

Now, there is a Medicare Managed Care Plan (Part C or Medicare Advantage). It is a public/private partnership where private carriers run Medicare managed care plans. However, these plans are generally more expensive as to the premium, although they cover more. (The logic is analogous to a Silver plan versus a Bronze Plan in the Exchanges, higher premium in return for a lower deductible and broader coverage.) The other issue with these plans, as to seniors certainly, is that not everyone is healthy enough to be a participant in such a plan, which are selective based on health staus (sometimes derided as "cherry picking" healthier seniors).

 

Medicare does have a prescription drug benefit (Part D) and has since 2003. It is a complex plan (the infamous  “Doughnut Hole”) that gives less benefit than most commercial healthcare plans.  For lower income seniors who are not dual eligible with Medicaid, participating with other public programs may be advantageous for many people, such as  EPIC in NYS. You might even be able to get lower prices for prescription drugs through a discount retailer like Wal-mart.

 

Given the above, what are some other approaches to universal coverage, that might be better than either Sen. Sanders proposal, existing Medicare or PPACA?

 

  1. Would "Medicaid for all!" Work better?

 

One better approach might be Medicaid for all.

 

Medicaid is (and always has been, since 1965) a first dollar coverage program. As with what Sen. Sanders is proposing, there are no co-pays and no deductibles.   Medicaid expansion under PPACA has made being on Medicaid more acceptable and reduced any stigma.

 

Medicaid has always dealt with people of all ages, unlike Medicare which has always covered people 65 or older and the totally disabled, like end-stage renal patients.   .

 

Medicaid, like the universal Canadian Medicare program, is a state-federal program (there, federal-provincial). Many single-payer systems are NOT national programs but are administered on a more local level. Canadian Medicare is a federal-provincial program. The British National Health Care System (“NHS”) is comprised of an NHS for Scotland, an NHS for England and Wales and an NHS for Northern Ireland. The Scandinavian systems are generally administered on a local council (or, at least, regional) level.

 

Medicare has separate fee schedules for different catchment areas and is regionally administered by separate regional contractors called “Fiscal Intermediaries” but Medicare does not have the level of local (state) input that Medicaid does.

 

The real problem with Medicaid is that many doctors and allied health professionals (unlike institutional providers, like hospitals and independent diagnostic and treatment facilities [“IDTFs,” like imaging sites]) do not participate (the buzzword is “par”) with Medicaid because of the very low reimbursement. The fact that physicians and allied health professionals in private practice do not tend to par is why Medicaid clients are often relegated to seeking care at the Emergency Department (“ED”) of a community hospital, a somewhat expensive proposition for Medicaid programs.    

 

This point bears repeating:  the main disadvantage of Medicaid is that physicians often won’t participate with it (“par”).

 

Hospitals often do, especially private, not-for-profit ones that are legally required in most states to do a certain amount of charitable work. Many excellent physicians, especially specialists, par with Medicaid because hospitals with whom they have admitting privileges do.

 

Other physicians, especially primary care physicians (“PCPs”) don’t par with Medicaid because the reimbursement is less than their costs in providing the care. (Primary Care is a volume business, generally requiring 6-10 patient encounters at a Level 3 RBRVS or higher to break even.)

 

Even with Medicaid Expansion, Medicaid remains largely associated with the Emergency Department of a Community Hospital.

 

  1. Towards a Bismarck System for the Gig Economy

Generally, the most highly regarded health care systems in the world are Bismarck Systems, such as those in France, the FRG and Japan.  Those systems produce good outcomes for vastly less than the system (or, more accurately, "systems" in the US).

 

These systems are systems of mandated private insurance (in that way, similar to the Exchanges under the Patient Protection and Affordable Care Act ["PPACA" or, colloquially, "ObamaCare"]).  However, in France, the FRG and Japan, these systems are employment-based for the most part.

 

Although employment-based insurance became common in the US during (primarily to avoid war-time wage and price controls) and after (largely due to union activism) World War II, it never became universal since many Americans were either self-employed or insured by small businesses that could not afford to provide such coverage.

 

Things like the 1973 HMO Act were an attempt to promote affordable coverage in this market.

 

This trend towards self-employment or employment in small businesses has increased since those days, notably with the rise of the "Gig Economy."  Given this, PPACA's allowing insurance coverage to be available outside the scope of W-2 Employment, either through Medicaid Expansion or the Exchanges, was a positive trend.

 

However, the Exchanges also reduce the buying power the individual has in the health care market as the individual acts alone and not as part of a group.  A business, even a small one, could often get a better deal on an "off the shelf" group plan and larger businesses could often set up self-insured plans of their own under the Employee Retirement Income Security Act ("ERISA").

 

The current Graham-Cassidy PPACA Repeal Bill seeks to take the money allocated to PPACA (both Medicaid Expansion and the Exchanges) and give it as block grants to the states to use to develop competing models of health systems delivery and finance.  Graham-Cassidy increases the money that people can put away in Health Savings Accounts ("HSAs"), which are important given PPACA's bias towards high-deductible insurance (PPACA's seeming hostility towards HSAs was an inexcusable design flaw) and counteracts a flaw in Medicaid that tended to overfund profligate Medicaid spending in states like NYS and CA.

 

While making the system less a top-down federal program, Graham-Cassidy tends to make it a top-down state program.

 

In my opinion, the better approach would be to privatize PPACA funding into competing not-for profit Multi-employer Welfare Arrangements (“MEWAs”) under ERISA that would: 1) manage HSAs (mandated HSAs are the backbone of the excellent system in Singapore) for their participants and beneficiaries’ primary care needs; 2) design a plan of managed care insurance that would cover those illnesses relevant to their participants and beneficiaries needs; and 3) offer group high-deductible insurance for “Black Swan” Medical events.

 

As to group coverage under the Health Insurance Portability and Accountability Act of 1996, pre-existing conditions are not an absolute bar to coverage (substituting a waiting period) and as a system of multiple coverage would tend to overcome the life-time limit issue. As a self-insured ERISA plan, participants and beneficiaries  could design their own plan to meet their needs and preempt state laws that might require “bells and whistles” that were outside the needs of the participants and beneficiaries, thus reducing costs.

 

 

By allocating people who are Medicaid clients to these Plans, they could wean this population off using the ED and help them find medical homes. If Medicaid reimbursement remained low, it would come as a package with patients for whom the reimbursement would be higher. Part of this money could also be used to fund this population’s HSAs (which, again, are the basis for the excellent health care system in Singapore).

 

By having competing not-for-profit plans, people could join better or more appropriate plans during open enrollment periods. By removing this coverage from the ambit of employment, there would be less of a fiduciary tension between the needs of the plan sponsor as an  employer and the needs of the participants and beneficiaries.

 

This approach would also mean that the big buyers would be groups of patients, rather than employers or governments for whom providing health care is not a core task. Along that line, this would give patients greater market power in a market where both providers and payers are consolidating.

   

 

 

Comments

George N Romey Added Sep 19, 2017 - 1:59pm
As I understand your article healthcare providers are reluctant to take Medicaid because of low reimbursement amounts. Something needs to change. Possibly large buying co ops that will challenge ever increasing bigger healthcare companies.
John Minehan Added Sep 19, 2017 - 2:08pm
"Possibly large buying co ops that will challenge ever increasing bigger healthcare companies.."
 
This is a big issue that I think is missed both by "Medicare for all!" and Graham-Cassidy. 
John Minehan Added Sep 19, 2017 - 2:11pm
"As I understand your article healthcare providers are reluctant to take Medicaid because of low reimbursement amounts."
 
Especially in Primary Care, which is a volume business.
 
Funding HSAs might be a better fit here, as the PCP can charge a lower rate if he or she does not have to do the "prompt payment dance" to get paid. 
Dino Manalis Added Sep 19, 2017 - 2:41pm
Sanders is dreaming, Medicare is already facing financial difficulties.  Instead of tinkering with the insurance, we have to reduce providers' expenses first, like import foreign prescription drugs and cap medical malpractice compensation, to lower insurance premiums long term.  The health care costs are the main problem, which bankrupt people, we don't want to bankrupt the country either!
John Minehan Added Sep 19, 2017 - 4:15pm
The malpractice premium issue is an important one for doctors. The prescription drug issue is more important for patients, except in a few cases.
 
Importing may be less useful than good group rates based on volume deals with powerful wholesalers, like Sam's Club.  
Nasty Added Sep 19, 2017 - 4:17pm
Americans cannot accept the idea, that their Medical care is so ridiculously expensive because it is a protected market.
 
Let Capitalism reign! Why can't drugs that have sold in Europe to millions be sold in USA?
Reason: US Pharmaceuticals control regulation. Regulation says all drugs must be tested and approved for sale. Who does the expensive testing,
 US Pharmaceuticals.
 
Why can't European Insurance be sold in USA? Reason: USA Insurance writes the regulations.
 
Why can't a Doctor from France practice in USA? Reason: They must have a USA license. Who approves MD licensing? USA Doctors.
 
Bottom line: International Medical Insurance(Which is good around the world, EXCEPT USA) could fly you to Thailand overnight, perform replacement surgery, with the best doctors in the world, and fly you back to USA for half the price of domestic care. And do it in less time than it takes to get USA Insurance to approve domestic care!
 
You are being HAD, American people! You don't need better USA Insurance, you need Affordable care!
 
Medical care for everyone is a myth. The means do not exist! Not to mention cost if the means did exist.
Thomas Sutrina Added Sep 19, 2017 - 4:24pm
Obama Care and Medicare for all both are universal health care.  the $6000 deductible of Obama Care would be similar effect as the 20% that the patent covers.  $6000 is 20% of a $30,000 medical bill.  So any major hospital visit will exceed this value.    What would happen in almost instantly is that the 20% would only apply to the middle and wealthy class and the poor would not have to cover the 20%.  Medicaid would come back to life to save the poor.  
 
This is a step away from national health care which would happen before the first year.   This is a scam to get at the real end results National Health Care.  Canadian or British Health Care.  
 
 http://www.investors.com/politics/editorials/canada-wait-times-deadly-and-take-longer-than-ever/
 
http://www.cnn.com/2015/09/02/politics/va-inspector-general-report/index.html
John Minehan Added Sep 19, 2017 - 4:35pm
"Why can't European Insurance be sold in USA? Reason: USA Insurance writes the regulations."
 
Largely because it is a completely different system or the most part.  Why can't you drive on the rights side of the road in Great Britain or why do you need a transformer to run US appliances in the FRG?
John Minehan Added Sep 19, 2017 - 4:37pm
Thomas Sutrina,
 
Not for the first time, I think you made a good point but I'm not quite able to figure out what you mean.  Wish I had a better answer.
John G Added Sep 19, 2017 - 4:45pm
The reduction in costs for a full Medicare for All system would almost certainly require substantial tax cuts.
Nasty Added Sep 19, 2017 - 4:46pm
Minehan.
I should have known better than to talk sense to you!
John G Added Sep 19, 2017 - 5:01pm
Nasty. Medical care for everyone is a myth. The means do not exist! 
They could, but probably not under capitalism.
Nasty Added Sep 19, 2017 - 5:31pm
Cost prohibitive John G.  350 million Americans!
A general consensus by Primary Physicians is they can handle 1500 patients load @ 25 per day.
That means 234,000 PCP needed. It is estimated that under the Present System, by 2025 there will be a shortage of 44,000. And that is just Primary care. Then they refer to Specialists, and all need at least 10 technicians as support, plus labratories.
 
I don't have time to collect accurate numbers, but they would be staggering. People like Bernie think if the wish it, it will happen.
Nasty Added Sep 19, 2017 - 5:35pm
It would appear from my interviews with practicing PCPs, that, in a practice comprised of a wide range of patient ages and problems, that there should be about 1,000 or fewer patients. Fifteen hundred might be acceptable for a practice with many healthy younger patients or one organized along the precepts of a team approach. For a geriatric oriented practice, 400-500 should be the maximum.

 
 

I started a discussion on LinkedIn asking the question, “How many patients can a PCP safely care for each day?” This was based on a post by target="_blank">Dr. Luis Collar. There were over 50 responses. The answer, of course, was, “It depends.” It depends on the mix of patients and their needs. But the respondents focused on time and the importance of time to fully and compassionately treat each patient properly. The patent needs “faith in the doctor, which when present slashes the illness in half.” Developing faith takes time.
An article in the Annals of Family Medicine sought to estimate a reasonable sized patient panel for a PCP with team-based task delegation consistent with the patient centered medical home model. Using published estimates of the time needed by a PCP to provide preventive, chronic and acute care they modeled how panel sizes would change if some portion of the work in each of the three categories was delegated to team members. If there was no delegation of work, as has been typical in PCP practices for decades, their data suggest that a patient panel size of about 983 is the maximum, not too far from my own estimate above of 1,000. They then assumed varying levels of delegation to the team. Their model panels with team-based delegation ranged from 1,387 to 1,947 patients. This analysis suggests that a primary care physician can care for more than 1,000 patients provided he or she practices as part of a well-oiled team-based practice
http://www.kevinmd.com/blog/2014/05/many-patients-can-primary-care-physician-care.html
John Minehan Added Sep 19, 2017 - 5:49pm
As a function of reimbursement, most PCPs these days lean heavily on extenders, such as NPs and PAs.
 
The general rule in the industry to be financially solvent is 6-10 Level3s or better per hour.  "Incident to" is a big help . . . . 
John G Added Sep 19, 2017 - 6:33pm
Nasty. Cost prohibitive John G.  350 million Americans!
A general consensus by Primary Physicians is they can handle 1500 patients load @ 25 per day.
I'm confused by your comment. You say cost is the issue. But then give examples of the future resource shortfalls. 
Which is it?
My comment was about resources in fact. The resources could relatively easily be addressed for future needs. But under neoliberal capitalism probably not.
And certainly not under a privatised health and education system.
The magic Market doesn't do that.
Michael Burke Added Sep 19, 2017 - 6:34pm
John--very good overview and some useful ideas. Medicaid for all, if the reimbursement rates could be fixed (and optometry services included--dental already are--these are two of the four most common reasons people miss work--teeth and eyes), might well be a good starting point. i think the major reason HSAs were not integrated in the ACA has to do with who uses them--mostly people who can afford to and who are interested in the tax savings that accrue. Most poor and working class folks simply don't have the disposable income.
 
Medicaid, BTW, pays Medicare premiums for the elderly poor, too, something we don't always remember. And Medicaid pays for most of the nursing home care in the US. I helped develop portions of the military's TRICARE model, which i think could also function as a national insurance program, mutatis mutandis (like premium costs and adding some dental/vision coverage).
 
One other point--speaking as a former employer of hundreds of Germans, my organization collected premiums only for the various insurance carriers--we had nothing to do with coverage levels or any other aspect of care--those were set by law--it just made premium collecting easier for the insurance companies. I would prefer that sort of system to the british national health system.
 
Finally, I wonder how many employers would like to get out of the healthcare business completely--I believe the majority of companies are self-insured (65% is the number that sticks in my head) and use insurance companies to administer a program that the company really pays for. 
Thomas Sutrina Added Sep 19, 2017 - 6:35pm
Medicare For All is effectively single payer health care since the 80% paid by the government means they set the rules.  The amount of taxes the citizens will pay for health care is determined by the average health of the population as a group.  Since the vast majority of a population believe they spend little on health care the tax burden they will accept is less then the need.
 
All national health care programs have discovered that they can not tax at a level the meets needs.  As the failures of their system is to meet needs become known by the citizens the government have been able it increase taxes but still less then is needed.  Again the public will not accept the actual total cost as real.  
 
This is the dilemma that can not be overcome.  
John Minehan Added Sep 19, 2017 - 7:03pm
"Medicare For All is effectively single payer health care since the 80% paid by the government means they set the rules."
 
Two points: 
 
1) Medicare for All, as proposed by Sen. Sanders, would be full on single payer; and
 
2) would not be a BC/BS model 80-20 indemnity plan, like current Parts A & B.
 
Medicare is currently, as a client of mine points out, the "gold standard for health care finance as private insurers use hard copy or digitized CMS Form 1500s fro billing, bill in terms of CPTs and ICD-10 codes and borrow a lot of procedures from the Medicare and Medicaid Regs and Handbooks.  Most importantly, reimbursement for discounted fee-for-service  is negotiated in terms of a percentage of the Medicare fee for each given covered CPTs in that given catchment area.
 
John Minehan Added Sep 19, 2017 - 7:25pm
Prof. Burke:
 
The Exchanges afforded a lot of employers a way out of offering coverage.  In Fact, PPACA does not make it very easy to start new (as opposed to continuing  existing, grandfathered small group plans).
 
A lot of private companies went to High Deductible Plans in the 2000s and early 2010s, such as GEs self-insured plans.  The overarching lesson learned was not to do it unless you afforded HSAs to put away the money to meet the deductibles.
 
For people with less money, funding the HSAs was not uncommon.
 
Dual eligibility, for people who can't afford a good Medi-gap plan and who are not able to afford or medically qualify for a Part C Plan, is a big blessing.  
 
Legally, as Medicaid is the payer of last resort for LTC for everyone, I have always thought Ryan's idea of Medicaid Block Grants would die in a fusillade of equal protection litigation.  Graham-Cassidy could side step this ONLY by pertaining to the expanded Medicaid funding, but let's see.  
 
 
John G Added Sep 19, 2017 - 8:13pm
All national health care programs have discovered that they can not tax at a level the meets needs. 
The reductions in costs of a Medicare for All system in the USA would almost certainly require tax cuts to maintain aggregate demand.
Saint George Added Sep 19, 2017 - 11:09pm
There are no reductions in costs of state-funded, single-payer, or socialized medicare systems. None. The fact that Joe Citizen might pay zero dollars for surgery does NOT mean that the procedure has no COSTS attached to it. To think so is simply moonbat-retarded.
John G Added Sep 19, 2017 - 11:20pm
The cost reductions of Medicare for All would be in the order of 30% immediately and rising into the future.
John G Added Sep 19, 2017 - 11:21pm
"US Says No Money for Social Programs, But '$700 Billion to Kill People? Yeah That We Have'
"Note 'where will the money come from?' deficit trolls will be silent on this $700 billion defense spending bill."
https://www.commondreams.org/news/2017/09/19/us-says-no-money-social-programs-700-billion-kill-people-yeah-we-have
Saint George Added Sep 20, 2017 - 12:02am
There are no reductions in costs of state-funded, single-payer, or socialized medicare systems. None. Not here. Not in the UK. Not in Canada. Not in the former Soviet Union. Not in communist China. Not in North Korea. Nowhere.
 
The fact that Joe Patient might pay 30% less — or even nothing — does NOT mean that the procedure has no COSTS attached to it; costs that obviously have to be borne by someone even if they're not borne by Joe Patient.
 
To believe that anything people want and need is free-for-the-asking at the point-of-delivery is simply moonbat-retarded.
John G Added Sep 20, 2017 - 12:26am
The overall cost reductions to the economy for Medicare for All would be in the region of 30% immediately, rising into the future.
That would almost certainly necessitate tax cuts.
Saint George Added Sep 20, 2017 - 4:02am
There are no reductions in costs of state-funded, single-payer, or socialized medicare systems. None. Not here. Not in the UK. Not in Canada. Not in the former Soviet Union. Not in communist China. Not in North Korea. Nowhere.
 
The fact that Joe Patient might pay 30% less — or even nothing — does NOT mean that the procedure has no COSTS attached to it; costs that obviously have to be borne by someone even if they're not borne by Joe Patient.
 
To believe that anything people want and need is free-for-the-asking at the point-of-delivery is simply moonbat-retarded.
John G Added Sep 20, 2017 - 4:04am
Logical fallacies are only that.
Thomas Sutrina Added Sep 20, 2017 - 9:30am
John G. there is no incentive to reduce cost in a national health care system.  The problem is very simple and we have it in price set by medicare and medicaid.  The use experts to determine the price and where do they get the experts.   THE EXPERTS COME FROM THE PROVIDERS OF THE SERVICE.   The providers of the service always think that they are worth more each time they meet to set price.  That is why medical costs have increased faster then inflation.  Other reason is that government requires paper work and that cost is added also.  The only time medicaid and medicare has reduced cost is when the politicians twist the arms of the experts or replace them with accountants.  
 
The politicians can not increase taxes.   So the solution is to reduce the services provided.  And the easiest way to do that is to not start the paper work for services.  Patients wait to get into the office of the providers where the paper work is created.  I have posted on WB the delay times for services in Canada and England.  We know that the VA uses that approach for the national health care system for solders that have left the military.  The active military do not have this problem because their value.   A non-active solders is of no value to the government.  They only produce costs.  No incentive to provide services. 
John Minehan Added Sep 20, 2017 - 11:54am
"One other point--speaking as a former employer of hundreds of Germans, my organization collected premiums only for the various insurance carriers--we had nothing to do with coverage levels or any other aspect of care--those were set by law--it just made premium collecting easier for the insurance companies. I would prefer that sort of system to the british national health system."
 
Although the French version of a Bismarck System is general considered to be the best in the world, I have often thought the Model in the FRG/BRD is a better fit for the US, with the competing Sickness Funds.  HRC and Ira Magaziner had that in mind with their "HillaryCare" Plan.
 
That was a fairly workable plan for reform, but doing it from "on high," without building a base of support first, was politically maladroit  (perhaps typically so for HRC).
 
Michael Burke Added Sep 20, 2017 - 12:04pm
Interestingly enough, three Army officers helped develop the 1990s Hillarycare--it became the basis for the TRICARE model that replaced CHAMPUS in 1995--I did the cost-sharing part of that when i worked in the Pentagon on the Army Staff--my officemate and I developed the idea of an enrollment fee for retired military, the first time anyone had ever been charged up front for access to military medical care.  We did it so that junior enlisted did not have to pay a co-pay for family members.
 
There was a base of support for Hillary's idea--when she briefed it to Congress, Bob Dole said it was a "healthcare plan we can live with"-- until the Republican donors got together and started airing the Harry and Louise ads--extraordinarily effective in undermining support.
John Minehan Added Sep 20, 2017 - 12:41pm
The big problem was the insurance companies, which were the first stake holders picked off during the development of PPACA.  (PPACA was developed with far more political skill but MUCH less knowledge of the Healthcare System, as with high deductible insurance targeted for people of modest means without provision for HSAs to help pay the deductibles.)
 
A big problem with the system, post ACA, is the Exchange model leaves participant and beneficiary market power atomized while both providers and payers are consolidating.
 
Self-insured MEWAs, analogous to the German "Sickness Funds" could balance this equation, driving down prices, improving services and helping to develop acceptable "price points" in the system. 
 
The new payment models in PPACA have been one of the less heralded failures of the approach.  If you want a new approach to payment, perhaps one based on quality and not of time, that will only happen if prices over all are reduced by informed buyers and sellers have to take new approaches to avoid commodification.   
Thomas Sutrina Added Sep 20, 2017 - 1:49pm
You have accepted the fact that government determines who and what health care will be provided to patents.  This is the problem.  Government needs will be satisfied before patents if money or most of the money passes through their hands.  And government always in the end treats the citizens as a group because in is impossible to do otherwise.  Their many be classes of groups but still thousands of people are in each group or more.  
 
Government needs is to have the economy work and their capacity to defend the nation.   So unproductive people will always receive the least care.  Those with difficult problems will always be few in number so the loss of those productive people will not effect the overall group they are in.  The will receive less care.  Ebb and flow of the levels of patents will mean that some patents will not receive care because demand at the point they need it will be higher then the capacity of the system.   The government can accept a small percentage of loss in people that can meet the goals of the government.
 
This is backed up actual experience.  Just look at the rules for treating a major accident or natural disaster or even war.  The above rules apply.    There is not reason that a national health care system run by the government will not follow the same approach.  No reason for government to think out of the box.
 
Your discussing the rule of who will be left to die as chosen by government.   Think out of the box and consider how the free enterprise system would work will.  Competition to get the money of patents.   They have to be alive to get their money.   Government gets paid alive or dead.    
 
Welfare will always exist because if government at some level does not provide for those in need people will loose confidence in the government and it will collapse.  Local communities in colonial American provided welfare.  The founders believe that welfare is best provided by neighbors that know those in need by name.   
John Minehan Added Sep 20, 2017 - 2:02pm
Thomas, let's put this in other terms, "He who pays the piper calls the tune."
John G Added Sep 20, 2017 - 2:36pm
Sutrina. You know less than zero about economics.
Thomas Sutrina Added Sep 20, 2017 - 3:52pm
John G. you know less then zero about the realities of how government work.
John Minehan Added Sep 20, 2017 - 4:16pm
Got rid of my two screwed up posts, not sure why the tech blew up . . . .
Saint George Added Sep 20, 2017 - 5:05pm
Moonbat stupidities are exactly that: stupidities of a very special kind.
John G Added Sep 20, 2017 - 6:53pm
All the wingnuts moaning about social spending should do John Rawls' Veil of Ignorance exercise.
Most of them probably aren't capable though.
John G Added Sep 20, 2017 - 8:20pm
Governments that issue their own currency don't 'need to be paid'.
Taxes are paid with money spent into the private sector by government.
 
Saint George Added Sep 20, 2017 - 10:29pm
Tossed word salad with white-ant vinaigrette.
 
Moonbat stupidities are exactly that: stupidities of a very special kind.
Katharine Otto Added Sep 22, 2017 - 12:20pm
John,
A good, obviously well researched article, but in all these scenarios, insurance gets most of the money, whether people are sick or not.  When people (or governments) are paying for insurance, they have to skimp on care.
 
Insurance creates a need for itself, and one of the reasons doctors and hospitals are stretched is because of it.  If we were to conceptualize the problem in a health rather than disease model, we might realize disease is not a given, and those who lead healthy lifestyles should not be forced to subsidize--through insurance--those who don't.  
 
I'm very unconventional in that I don't believe in prescriptions or patents.  The whole system turns on the doctor's signature.  Even NPs and PAs are required to work under a doctor's supervision.  Drug laws are a violation of personal rights, according to me, but I can't convince other people of that.  They want to shift responsibility for their lives and health to someone they can then blame (and sue) when anything bad happens.  People are way over-medicated and often don't know what they are on or what the meds are for.  This is the result of insurance, prescriptions, and patents and the nanny state that thrives on keeping citizens in a perpetual state of dependency.
 
Doctors are saps to put up with a system that tells them what to do, how to do it, and how much it will pay.  Doctors shy away from Medicaid patients, because they are often the least healthy, most labor-intensive, and quickest to sue.  
 
Bottom line is if you are paying for insurance rather than care, you deserve to get the treatment. 
 
John Minehan Added Sep 22, 2017 - 12:50pm
A lot of what you are talking about drives the movement towards Direct Primary Care, but Direct Pay for Specialty and Hospital services is more of an outlier.
 
Given the fact that co-pays for PCP services are going up and the transaction costs of haggling with the third party payer for the balance are also going up, I think most primary care services will be "cash and carry" in the near term.  I think that benefits both docs and patients.
 
The harder transition is specialty and hospital services, the Time article to the contrary.  Which is why I'd like to see patients contracting for medical services as part of a Plan that meets their needs rather than relying on either governments or employers.   
John Minehan Added Sep 22, 2017 - 12:57pm
"Even NPs and PAs are required to work under a doctor's supervision."
 
At least in NYS (and at least since 2014), that is much less true of NPs who are now seen as more autonomous providers, they basically need to have a standing Ben Casey/ Dr. Zorba or Dr. Killdare/Dr. Gillespie  relationship with a physician, rather than chart reviews or direct supervision, both of which are required for PAs who are more clearly treated as "Extenders."  
John Minehan Added Sep 22, 2017 - 1:21pm
Another aspect of this is what I consider a key question in healthcare: Who has the legitimacy to tell someone  "No?"
 
After OIF-1 and Katrina, it is not the USG.  After animus reflected in Helen Hunt's diatribe in As Good As It Gets, it also still isn't the HMO industry.
 
It has to get back to the doctor and the patient with as few intermediaries as possible.
 
I don't think either Graham-Cassidy or Medicare For All! address (or even contemplate) this question.
 
The Charlie Gard situation is an indicator.  No, nothing could have been done.  However, the fact that the parents really did not seem to trust the NHS (nor the doctors, who are NHS employees) was telling and it is no better here.      
 
 
wsucram15 Added Sep 22, 2017 - 2:20pm
I dont care what anyone says.  I have seen what happens with catastrophic health events where heath insurance was allowed to cancel and costs were deflected to the patient due to the law in a state. The patient died which is unacceptable.
I have also live with a lifelong disability and seen the effect over the years even with employers insurance regarding pre-existing conditions.  I have not seen a change until 2010, too many people have gone bankrupt, gone without healthcare or even medicines which are overpriced by sometimes up to 10 and even 12x of other countries.
The major reason I never accepted a job paying over a certain amount is because I had to pay 1300 a month for my 3 regular medicines.  I was able to get a card from the pharmaceutical companies making under a certain amount.   No insurance that has to be born by the state will be able to cover the high expenses of medical. 
 
Any person at any time can develop a disease which could be determined pre-existing such as some forms of cancer. Remember that.
 
Block grants will not work, and universal health care in the US should be something we do for everyone. No other developed country does not have some form of controlled pricing healthcare.  Even healthcare providers are for this, to steady the market.
 
John Minehan Added Sep 22, 2017 - 2:36pm
"I have also live with a lifelong disability and seen the effect over the years even with employers insurance regarding pre-existing conditions."
 
Since 1996 and with or without a lapse in coverage?  (Instead of paid FML, the most useful thing for most people might be underwritten COBRA coverage.)
 
The better approach would be non-employer-based groups.   
Thomas Sutrina Added Sep 22, 2017 - 2:39pm
Graham-Cassidy only destroys the funding of regulated no choice health care, Obama Care.  The strings attached to it if you opt out of the Obama Care regulations will replace those regulations by others so that the state actually pays more money.  
 
So what happens afterward  when health insurance is a waste land?  They counties without insurance options covers the majority of the country.   We get bernie sanders / 2008 Hillary Clinton single payer,  which is managed by a monopoly of insurance companies.  That is exactly what Obama Care did in the first place.  Create a regulated utility called Health Care, a monopoly for insurance companies.  The is bate and switch people.   
 
In a government monopoly the consumers have almost no influence in the quality or cost.  The only have one or a few choices and those have to follow such strict rules that their prices are almost identical.  They can not fail unless the regulators set the price below costs.   Then what happens is what happened at the VA.  The amount of services provided is reduced to balance with the total amount paid.  And since the amount paid is independent of the patents a balance can occur.   People die or do not get the proper care.
 
May I remind Americans that our GOP politicians are saying this is a, “take or leave it" situation for Graham Cassidy.   It is not Americans.  We do not have to accept government monopoly.  Option 3, "Free Market health Care," recall that for 8 yrs they promising to repeal ACA and give us free market health care.  and we met their requirement by flipped 1000 legislature seats in Congress and the states.  
 
Tell your GOP representative or even a Democrat representative that you will flip their seat if they do not give us what we want.  You may put up candidate that lie to us but if we find that they are your candidate your ads will stop working.  You will find the cost of purchasing elections will continue to rise as we get more angry.
John Minehan Added Sep 22, 2017 - 2:44pm
 ". . .and universal health care in the US should be something we do for everyone."
 
But, the real question is "how?" 
Thomas Sutrina Added Sep 22, 2017 - 2:58pm
Some say what about pre existing conditions.  The states before Obama care start state funded insurance for those very very small portion of the population.  Why do we have to have our costs raised to pay for them?   illegals should be sent home and we get a two for.  More jobs for americans and less government sending on welfare.
 You will say that they make America better.  That is true for legal immigrants but uneducated immigrants as with uneducated Americans when they flood the market lower cost below the poverty limit for starting jobs that they take.  So they also get welfare.  
 
DACA children and their families and extended families.  Stop chain migration.  One major thing must happen.  The standard for an American is clearly interpreted by the supreme court for the 14th Amendment.  American Indians like the illegals entering this country come from a different society and culture.  Indians were born here but until congress in 1924 made all Indians citizen they had to be naturalized.  All illegal including DACA need to go in front of a judge that will determine if they meet the requirements.  Elk v. Wilkins, 112 U.S. 94 " “subject to the jurisdiction” of the United States, “The evident meaning of these last words is, not merely subject in some respect or degree to the jurisdiction of the United States, but completely subject to their political jurisdiction, and owing them direct and immediate allegiance.” "
John Minehan Added Sep 22, 2017 - 3:06pm
"The states before Obama care start state funded insurance for those very very small portion of the population."
 
Which is a lot less efficient process than the protections offered in group plans under HIPAA. 
John G Added Sep 22, 2017 - 5:12pm
This tactic of making Medicare for All sound too complicated to achieve is really boring.
John Minehan Added Sep 22, 2017 - 5:21pm
The first part is likely accurate, the second clause is ungrammatical.
Thomas Sutrina Added Sep 22, 2017 - 6:14pm
John M., you asked, ". . .and universal health care in the US should be something we do for everyone. . . . But, the real question is "how?""  That answer is simple IMPOSSIBLE.  And all the countries that have tried have failed to different levels.  It is like saying we can eliminate poverty.    With both the measure of success keeps changing so that success is never possible, IS IMPOSSIBLE.  
 
The patents has no reason not obtain health care, and the provider has no reason to not provide the most expensive care and aim at the absolute best results for a perfect universal health care system.  This totally ignores the principles of demand and supply as a functions of cost since the cost is zero the demand will be infinite and since payment is infinite supply will be infinite.  IMPOSSIBLE.
 
Since that can not happen then who determines what is supplied?  Do we let a government bureaucrat determine that?  What we get is the USSR economy that collapse because bureaucrats determined that.  What we get is Argentina, Greece, Cuba, China, North Korea, and Venezuela.   If every bureaucrat was not corrupt, wanted the best for every person and was brilliant the top 1% of humans the only difference would be how long it takes to collapse if they made 100% of the economic decisions.    
 
The key that Socialist of all flavors refuse to accept is that spontaneous order, "the result of human actions of self-interest, not of human design," produces the best results.  Language, life on earth, and the internet are other examples of spontaneous order.  The problem is that planning is not dynamic enough or detail enough to take into account EVERYTHING.  Game theory is the closes man has come to understanding spontaneous order, "The Fatal Conceit, Hayek notably wrote that "a game is indeed a clear instance of a process wherein obedience to common rules by elements pursuing different and even conflicting purposes results in overall order."
 
Thus a free market health care for the majority of the population which will include catastrophic insurance and welfare credit care for health care and public purchased catastrophic insurance for them and out right paying for pre-existing conditions for those at the start that can not purchase insurance would balance needs with cost.  The free market would determine the highest cost benefit balance for over vast majority of people. 
John Minehan Added Sep 22, 2017 - 6:27pm
Gee, German, France, Canada and Singapore all do it, using a variety of different methods.
 
 
John G Added Sep 22, 2017 - 6:28pm
'Spontaneous interaction' won't train the doctors etc or build the infrastructure that will be needed 10, 15 and 20 years into the future.
And why can't wingnuts understand supply and demand?
John Minehan Added Sep 22, 2017 - 7:08pm
"'Spontaneous interaction' won't train the doctors etc or build the infrastructure that will be needed 10, 15 and 20 years into the future.
And why can't wingnuts understand supply and demand?"
 
"Spontaneous interaction" prompts people to seek seats in medical schools as opposed to studying, say, computer science based on perceived increasing demand and opportunity.  And, as to infrastructure, a free market approach allows  infrastructure to develop in response to demand.
 
The VA System is a case in point.  The system is actually quite good, they have data on their patients, in many cases, going back to when they first joined at about 17.  But, the system runs on a budget system, not on a market system. 
 
If you are in upstate NY where there is enough census such that there are sufficient facilities, built up over time, it works well.  If you are in Arizona, however, where the numbers of vets are rising and there is no profit incentive to meet the demand and you are waiting on a bureaucratic process to allocate budget, well, we saw how that works. 
 
On the other hand, some things require human action, for example, possibly expanding the scope of practice of NPs (as NYS did in 2014) to recognize the level of autonomous work that these providers were capable of doing. 
John G Added Sep 22, 2017 - 8:02pm
 a free market approach allows  infrastructure to develop in response to demand.
Only in an indoctrinated capitalist world would a statement like that have currency.
Stephen Hunter Added Sep 22, 2017 - 8:08pm
Well thought out article John. Canada has a lot more private pay than most think. What we do have though, are no worries about having to pay for essential healthcare services. It is stressful enough just being ill, but to have the added worry of co pays or no pays- WOW! 
If all it is going to cost you is a 2.2% tax increase on the affluent- DO IT!!!
John Minehan Added Sep 22, 2017 - 8:49pm
Stephen, thanks, I've heard that about Canada from a number of them, including providers and administrators.
 
I don't think the coat or revenue aspects of the Sanders proposal make a lot of sense. But I also don't think either Graham-Cassidy or PPACA are3 workable.  
Katharine Otto Added Sep 22, 2017 - 9:49pm
John M,
I think it is possible to have free medical care for basic conditions, along the lines of the VA system.  Like you, I believe the VA model is good, or was, before Tricare wedged its way in the door.  The VA remains a training ground for doctors and all health care workers.  As such, it could help keep costs low, if the bureaucracy could be minimized.  You know I posted a blog about that on WB, because you were a commentator.
 
Another reason the health care system costs so much is technology.  Every hospital has to have its own linear accelerator, PET scanner, and the latest equipment. They have to use the equipment to justify the costs, even though the tests are not always necessary.  Lab tests are also overused, because insurance will pay for them, and doctors are overly afraid of missing something significant.
 
Patented pharmaceuticals, and over-use of medications raises costs, and neither doctors nor patients are well informed about medications and side effects.  There are so many new meds coming down the pike every day, no one can keep up, and no one knows long-term effects, drug interactions, or even how well these meds work.
 
If basic care for most people were provided, outlier and specialty cases presumably would cost significantly less.  I do think patents on medications should be curtailed or generics given preference in any public health care system.  In fact, I believe everyone should get used to using the generic nomenclature, rather than brand names, if only to educate people about the chemistry of meds and to reduce confusion.
 
Regarding NPs prescribing:  NPs may be able to prescribe in New York, but it sounds like they still have to have a professional association with an MD, so in fact, the MD is responsible (and subject to lawsuit) if anything goes wrong.  If the NP could function totally autonomously--and pay the associated malpractice insurance--it would put less stress on the doctors.
 
John Minehan Added Sep 22, 2017 - 10:12pm
"Regarding NPs prescribing:  NPs may be able to prescribe in New York, but it sounds like they still have to have a professional association with an MD, so in fact, the MD is responsible (and subject to lawsuit) if anything goes wrong.  If the NP could function totally autonomously--and pay the associated malpractice insurance--it would put less stress on the doctors."
 
It's a very loose relationship, more like Dr. Zorba and Ben Casey, if you are old enough to remember that cultural artifact; mentor-protégée kind of thing.
 
PAs still have to be countersigned under the NYS Ed Law.
 
"There are so many new meds coming down the pike every day, no one can keep up, and no one knows long-term effects, drug interactions, or even how well these meds work."
 
Which is why I have often wondered if the best "Gatekeeper," in a strict HMO model, would not be a pharmacist.
 
It would be tough under state licensure laws and most MCOs compliance people would be in vapor lock but it might protect patients and give docs a significant resource, for the reason you state.  Pharmacy Departments in hospitals are famous for looking at lab results on patients to see what the metabolites are to see if the patient is properly absorbing the meds.  Might be nice to get this input with Outpatients, too.
 
Given what I do for a living, it is easier to be a patient, knowing to request generics and knowing that, while a name-brand drug may not be on a formulary, something substantially similar probably is.  With the M&A in Healthcare and the rise of purchasing coops for hospitals over the last 20 years, formularies are a very political issue with organized medical staffs.          
  
Jeffry Gilbert Added Sep 22, 2017 - 10:20pm
DUHmericans can spend $700B on welfare for the MIC but goddamn it you get sick you die. 
 
Seems as though death is DUHmerica's goal in all things. 
 
The author has a clear bias but it can't be said he doesn't research his topic.
John Minehan Added Sep 22, 2017 - 10:20pm
"Every hospital has to have its own linear accelerator, PET scanner, and the latest equipment."
 
Which is a good thing, particularly in imaging.  If you need to rule out something dire, you don't want to ride 80 miles to a magnet.
 
On the other hand, a hospital or,  even, practice, wants to do a detailed capital budgeting process before making that kind of acquisition.  One thing that can help is a Stark/AKS compliant service agreement with another practice to see if your patients need the service and if your staff can handle the modality.
 
Demand tends to work better than CONs.   
John G Added Sep 23, 2017 - 3:06am
I don't think the coat or revenue aspects of the Sanders proposal make a lot of sense. 
How so?
This should be interesting.
Saint George Added Sep 23, 2017 - 3:29am
Aside from the truism that socialized medicine is itself a joke, here are some jokes about socialized medicine:
 
"Dear Sir:

The results from the lab work confirm that the red ring around your Johnson was not cancer.

It was lipstick.

We apologize for the amputation."
 
* * *
 
To get the following joke, you need to know two things:

1) The median wait for a hip-replacement in Canada is 52 weeks!

2) While private medicine is nominally prohibited in Canada, the government itself uses private clinics for (among others) prison inmates.

A Canadian prisoner asks his cellmate, "What are you in for?"
His answer: "Hip replacement."
 
[And just in case you were wondering, the answer is yes: many Canadian hip-fracture patients come to the U.S. for hip replacements. Apparently, a "free" hip replacement at the cost of waiting 52 weeks in pain isn't much of an enticement.]
Saint George Added Sep 23, 2017 - 3:31am
What we do have though, are no worries about having to pay for essential healthcare services.
 
Even better than that:
 
When you have to wait a year for a procedure, you just hunker down to the U.S. where you get it right away.
Stephen Hunter Added Sep 23, 2017 - 8:01am
Not sure where you are getting your information, but my father in law had 2 knee and 2 shoulder replacements all done within 2 years. And there were no worries about who is paying for it. 
The wait times are grossly over hyped and I think are just blind justification for saying "our system is better". Clutching at straws folks.
Take it from someone who has been in the Cdn system all their life, raised 2 children, buried 2 parents, and never had to wait very long to see the family doctor or get admitted to ER. 
John Minehan Added Sep 23, 2017 - 9:38am
"Take it from someone who has been in the Cdn system all their life, raised 2 children, buried 2 parents, and never had to wait very long to see the family doctor or get admitted to ER."
 
Please correct me if I'm wrong, Stephen, but the last part of that made me think of it, isn't the Canadian system more oriented towards primary care as opposed to interventional medicine? 
John Minehan Added Sep 23, 2017 - 9:45am
I worked for a wise old health care executive about 20 years ago who used to say: 1) "Form follows finance;" and 2) "It's the covered lives, stupid."
 
As to the first point, Canada emphasizes primary care and has a lot of primary care.  US emphasizes interventional medicine and has a lot of interventional medicine.
 
As to the second point, at least the US system would benefit from finance more directly benefiting the "covered lives" also known as "patients.'
John Minehan Added Sep 23, 2017 - 9:52am
If "form follows finance," what does finance follow?
 
Maybe that should be epidemiology, what causes "Morbidity & Mortality" (the M&Ms") in this particular society?
 
If you are in Thailand, where acute, infectious disease is a problem, maybe your needs are best met by something like the "30 Baht Program."
 
Maybe in the US, where chronic disease based on life style is the main epidemiological threat, maybe the most efficient use of public funds in health care might be in educating the public. 
Thomas Sutrina Added Sep 23, 2017 - 10:56am
The wait times in Canada are published as a average.  If you look at them in different regions they vary significantly.  The more rural area has from my scan of the data wait longer.   Above the VA has a similar problem from snow bird moving south in their old age to areas where the VA served a much smaller community.    
 
This shows that when dollars follow the patent the response is quicker.  Money to adjust in areas needing growth are their and areas that need to shrink do to less patents shrink due to less money, facilities are closed.   This is what a free market does.
John Minehan Added Sep 23, 2017 - 11:48am
"Money to adjust in areas needing growth are their and areas that need to shrink do to less patents shrink due to less money, facilities are closed.   This is what a free market does."
 
Markets make offerings scalable to demand.  One big lesson of the VA Scandal. 
Even A Broken Clock Added Sep 23, 2017 - 1:06pm
John - very thought provoking post. One comment - from your post:
Sanders says generally that the expected $138 trillion cost per year would be paid for by a 2.2 percent tax
 
$138 Trillion per year? What is the real figure (I've not studied Sander's positions)
Thomas Sutrina Added Sep 23, 2017 - 1:33pm
I do not expect Sanders to be any more accurate then Obama.  Which means the numbers are based on what he wishes or what he thinks people will believe but never based on reality.  Just as Obama's numbers. 
 
This is a little long.  I did not want to use to small of clips of text which would skew the sources.  This is for those people that do not remember the history of ACA, Obama Care and why the GOP promised to repeal it.  ACA is a pure and simple bate and switch at best by the Dem Congress or just a scam.  I do not know since both a possible.  Here goes!
 
ABC supported as did the other media Obama and ACA bill.  But even they can be put in a position to report the truth.  "MIT economist Jonathan Gruber may not have been a household name, at least before this week, . . . Before Obamacare, he also advised the creation of a similar law in Massachusetts, sometimes called Romneycare. . . . Obamacare would not have passed if voters were smarter and the administration was more transparent about the process. . . . Gruber said in 2012, "I think what???s important to remember politically about this is, if you???re a state and you don???t set up an exchange, that means your citizens don???t get their tax credits...but your citizens still pay the taxes that support this bill. So you???re essentially saying to your citizens, you???re going to pay all the taxes to help all the other states in the country."
 
This is from another source that many of you do not like but it attaches to the ABC article above: "
"GRUBER:  This bill was written in a tortured way to make sure CBO did not score the mandate as taxes.  If CBO scored the mandate as taxes, the bill dies, okay?  So it's written to do that.  In terms of risk-rated subsidies, if you had a law which said healthy people are gonna pay in... If you made it explicit the healthy people pay in and sick people get money, it would not have passed, okay?  Lack of transparency is a huge political advantage.  And basically, you know, call it the stupidity of American voter or whatever. But basically that was really, really critical to getting the thing to pass.
RUSH:  In other words, they had to lie to you, and they relied on your stupidity. They counted on your stupidity to believe their lies such as, "You get to keep your doctor and you get to keep your health insurance plan," such as, "Your premiums are gonna come down," such as, "No they're not taxes! There's no way they're taxes. No, no, no. And you're gonna get subsidies if you can't afford it, so don't sweat it.  Everything's gonna be fine."
The media carried the lie forward, and it was all based on their belief that you are too stupid to figure out what they're doing.  All they had to do was find a way to service your ignorance and your stupidity, and they could create support for the bill.  But do you know what happened?  There has never been majority support for this bill.  That's the one thing you must never lose sight of here. Don't ever forget: They never did fool a majority of the American people.
This bill was rammed down the throats of the people this country on, what, Christmas Eve in 2010, and there wasn't one Republican vote in it."
 
 
Katharine Otto Added Sep 23, 2017 - 1:57pm
Thomas,
But for the fact that Chief Justice John G. Roberts declared the individual mandate Constitutional, based on the idea that it was a tax.  Roberts was a newbie to the Supreme Court, a Republican appointed by GW Bush.  Don't fool yourself that the Republicans opposed it.  Both Dims and Pubs are heavily influenced by the insurance lobby, as well as pharmaceutical, med tech, and other lobbies that directly and indirectly profit by expanding the captive market share.
 
Just look at how much trouble Republicans are having trying to "repeal and replace."  Trump, et al., originally campaigned on repealing, but somehow "replace" got added along the way.
Katharine Otto Added Sep 23, 2017 - 2:08pm
John M.,
The public is already being educated, by advertisers and other propaganda, and the public believes the health scare/snare racket is worth the money other people pay. Who knows what to believe?  
 
I agree with you, in theory.  It astounds me professional medical organizations don't make a bigger effort to educate the public about medical science.  I'm working on a blog about that now.  It's shameful, for instance, that people are on so many drugs that they can't name. Ask about how the Prozac (for instance) is working, they are likely to say, "Is that the little blue pill or the pink and and white capsule?" Meanwhile, doctors often don't know what the meds they prescribe look like, if they don't take them, too, or unless some drug rep has given them samples. When you're dealing with someone on ten or more meds in a 15 minute visit, this disconnect can cause major problems.  That's only one example of the dangerous and costly fragmentation of the system.
John Minehan Added Sep 23, 2017 - 2:22pm
"That's only one example of the dangerous and costly fragmentation of the system."
 
As an observer (I'm not a clinician), I think that is one of the key problems.  No one is in charge of a patient's care from end-to-end.
 
HMO's had this idea of "Gate keeper physicians" to make someone manage the care, but it seemed more a way to reduce utilization, especially out in CA where they have at-risk capitation, not discounted-fee-for-service.
 
There are too many issues with drug interactions and too many times some old person goes into a hospital and crashes since the hospitalist may not understand the medical records.  EMR/EHRs will probably help if they could come up with one that worked as well as an app on an I-phone, which they can't do to the HIPAA Privacy Rule and Common Data Set issues.   
John Minehan Added Sep 23, 2017 - 2:25pm
"$138 Trillion per year? What is the real figure (I've not studied Sander's positions)"
 
Seems low for something that comprehensive.  Also, there is a level of pent up demand, especially for a free service.   
Stephen Hunter Added Sep 23, 2017 - 2:50pm
Primary Healthcare needs to be free for the population. Not only from the human decency perspective, but also to protect the population from communicable diseases. The new superbugs have no antibiotics, so think we need to keep a handle on that by encouraging people who are sick to seek Professional care. Think about your grand-kids in 30 years, not things as they were 20 years ago. 
John Minehan Added Sep 23, 2017 - 3:17pm
"Primary Healthcare needs to be free for the population."
 
I tend to think some kind of payment makes people value it.  Many systems require at least a nominal  co-pay at Point of Service (FRG, for example. and Thailand with the 30 Baht Program). 
Thomas Sutrina Added Sep 23, 2017 - 4:33pm
Katherina O.,  I just reported that did not vote for Obama Care.  I agree with you.  and they proved it.  
They have voted for Obama type bills since January 20th when Trump took office at least once in the House and Senate.  The House approved the government regulated monopoly of heath care that was very close to the ACA government regulated monopoly.    The Senate could not pass a similar bill to the House.  
 
The Senate had less votes for a repeal only bill that was similar to the bill approved by the House and Senate in late 2015 and put on the desk of Obama in January 2016 that he VETOED.  Paul Ryan Speaker of the House had the gall to say that he would work for electing a GOP  president so that he could put this repeal only bill no a GOP presidents desk and he would sign it.   We are still waiting Speaker.  He as made all GOP Senators and Representative liers for the time in December 2010 when ACA became Law.  All of ran on repealing ACA with a free market health care system as the replacement goal.  
 
The Democrats what to be the people that manage health care since big government provides much of their funding,  Example government unions.   Republicans coffers are filled by the business interest that see a monopoly as a win win situation.  They can never loose money so long as they have politician in their pocket from both parties.  No one can enter the market and everyone has to purchase what the offer.  No choice.  That is why both parties are actually working together and trying to make it seem they are opponents.   A Lie. 
Saint George Added Sep 23, 2017 - 7:38pm
The wait times are grossly over hyped
 
Then, again, you've done no research in this area, have no data to offer except a personal anecdote with no details.
 
Below is just one of hundreds of online articles linked to published studies:
 
Health care wait times hit 20 weeks in 2016: report
 
"A survey by the Fraser Institute found a median wait of 20 weeks [NB: 5 months] for “medically necessary” treatments and procedures in 2016 – the longest-recorded wait time since the think tank began tracking wait times."
 
"The survey looked at total wait times faced by patients starting from the time they received a referral from a general practitioner, to the consultation with a specialist, to “when the patient ultimately receives treatment.
 
"In terms of specialized treatment, national wait times were longest for neurosurgery (46.9 weeks) and shortest for medical oncology (3.7 weeks).

Neurosurgery: 46.9 weeks
Orthopaedic surgery: 38 (NB: ~ 9-1/2 months)
Ophthalmology: 28.5
Plastic Surgery: 25.9
Otolaryngology: 22.7
Gynaecology: 18.8
Urology: 16.2
Internal medicine: 12.9
Radiation oncology: 4.1
General surgery: 12.1
Cardiovascular: 8.4
Medical oncology: 3.7"

 
"Median wait time by province in 2016:

New Brunswick: 38.8 weeks
Nova Scotia: 34. 8
P.E.I: 31.4
Newfoundland and Labrador: 26
British Columbia: 25.2
Alberta: 22.9
Manitoba: 20.6
Quebec: 18.9
Saskatchewan: 16.6
Ontario: 15.6"

 
"In a statement announcing the survey’s results, the institute estimated that Canadians are currently waiting for nearly one million “medically necessary” procedures."
 
“Crucially, physicians report that their patients are waiting more than three weeks longer for treatment (after seeing a specialist) than what they consider to be clinically reasonable,” the statement read."
 
"Prior to 2016, the longest recorded median wait time was in 2011, at 19 weeks."
 
"Michael Decter, chair of the advocacy group Patients Canada, told CTV’s Power Play that simply pouring more money into the system won’t fix it."
 
"His proof, he said, is that the federal government has increased health transfers to provinces by six per cent a year for more than a decade, yet wait times have gotten worse."
 
“'It’s about innovation, it’s about accountability, it’s about focus and it’s about transparency,'” he said. “'It’s not about more money.'”
 
"Dr. Brian Day, a former president of the CMA, agreed that the problem isn’t a lack of funding.
 
“'The studies around the world show that Canada is one of the biggest spenders but down at the bottom in access and quality,' he said."
 
"The real problem, according to Day, is the government monopoly on insuring medically-necessary care, which leads to rationing of doctors and services, and “no accountability.”
 
"Day has frequently pointed out that the only other country with such a monopoly is North Korea."
 
[END EXCERPT]
 
See links below to above-referenced study:
 
https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2016
 
https://www.fraserinstitute.org/sites/default/files/waiting-your-turn-wait-times-for-health-care-in-canada-2016.pdf
Saint George Added Sep 23, 2017 - 7:53pm
Primary Healthcare needs to be free for the population.
 
Healthcare — like food, water, shelter, clothing, communication, education — can never be free, even in principle. Something that has a cost attached to its production of $1.00 doesn't become "free" just because government might redistribute one penny from 100 citizens to pay for it. You're allowing yourself to be fooled by words and Utopian feelings. 
 
Not only from the human decency perspective, but also to protect the population from communicable diseases
 
There's nothing decent about making patients sicker by making them wait a median period of 20 weeks for medically necessary procedures and giving them lowered quality care as well.
 
There's nothing decent about government's breaking a citizen's legs, handing him a publicly-paid-for crutch, and then telling him, "Aren' we kind and decent to you? What you do with our benevolent and free help? Why, you'd have to crawl around in pain . . . or worse: you'd have to pay for crutches out of your own pocket!"
 
As for protecting people from "communicable diseases", I have no idea what you're talking about and I suspect, neither do you. Anything that's not an autoimmune condition (arthritis, ALS, Crohn's disease, etc.) is communicable, whether it's bacterial or viral. The level of communicable disease per million people in Canada is no lower than it is in the United States. And in any case, you guys did a really bang-up job protecting your own population from the SARS epidemic a few years ago. Good work.
Saint George Added Sep 23, 2017 - 7:56pm
I tend to think some kind of payment makes people value it.
 
You don't pay for the air you breathe. You're claiming you don't value air?
John Minehan Added Sep 24, 2017 - 11:27am
"You don't pay for the air you breathe. You're claiming you don't value air?"
 
As a Scot, I grew up with the precept: "Breathe deep, the air is free." 
Katharine Otto Added Sep 24, 2017 - 2:33pm
St. George,
Air used to be free, but with the ACA, you're mandated to pay if you're breathing.
Katharine Otto Added Sep 24, 2017 - 2:38pm
Thomas,
I was actually agreeing with you, too.  You present a more detailed history of the politics behind the ACA, but few people are aware or remember that the Republican Chief Justice Roberts was the tie-breaking vote on the personal mandate, the most significant and egregious personal violation (in my opinion) about the whole shebang.
 
It is not a Republican-Democrat split.  It's a government vs. the people split.  Are our bodies owned by the federal government, then?  We used to call that "slavery."
Katharine Otto Added Sep 24, 2017 - 2:44pm
St. George,
Public Health Departments are charged with protecting community health, including communicable diseases. Epidemics affect everyone, the health departments deliver services directly to the community and they don't rely on insurance.  That's the kind of health care that, as a taxpayer, I support.
 
Never mind that the health departments' original purpose has been diverted to selling vaccines, like flu vaccines, in recent years.  Rather than drain boggy marsh, like Walter Reed and William Gorgas did to control malaria and yellow fever in the Panama Canal zone, we now dump malathion on the entire ecosystem to kill mosquitoes. Then we promote the $1.6 billion flu vaccine industry for SmithKlineGlaxco and Sandofi.
Katharine Otto Added Sep 24, 2017 - 2:58pm
Everyone,
The entire health care/snare racket is over-rated, and the costs and profits go up if you can scare everyone into thinking "health care" is some magic solution to every problem and pretend problem imaginable.
 
The system is in chaos, and all the economic/legislative ballyhoo only wastes time and resources to increase profits on Wall Street.  People need to understand that health and health care is a personal issue, first and foremost.  The one-size-fits-all policy wonks only get in the way, while extracting as much as possible from the people they presume to help. 
John G Added Sep 24, 2017 - 3:26pm
So you are against Medicare for All, KO?
John Minehan Added Sep 24, 2017 - 4:08pm
"The entire health care/snare racket is over-rated, and the costs and profits go up if you can scare everyone into thinking "health care" is some magic solution to every problem and pretend problem imaginable."
 
In other words, "over-medicalization" and the "sick-role."
 
Those cultural phenomena are a major part of figuring out how to pay for healthcare in the US.
 
If we think Medicine can cure anything, there ain't enough money in the world to pay for that. 
 
Getting doctors and patients back in the position to make treatment decisions might be a good start to dealing with this.  
  
John G Added Sep 24, 2017 - 5:54pm
If we think Medicine can cure anything, there ain't enough money in the world to pay for that. 
Hmmmm, considering that money is infinite and virtual and that it comes from nothing and returns to nothing, that's not a statement of fact.
John Minehan Added Sep 24, 2017 - 6:06pm
Yeah and perpetual motion machines work.
John G Added Sep 24, 2017 - 6:28pm
Mine was a statement of fact.
As always, you've deployed a tactic to avoid the issue.
Fiat currency is created from nothing and returns to nothing. It is virtual and infinite.
So your statement is bollocks.
Saint George Added Sep 24, 2017 - 6:58pm
Air used to be free, but with the ACA, you're mandated to pay if you're breathing.
 
Right. And under "ObamaAir," if you choose to hold your breath, you pay a special mandate, er, uh, I mean "tax". (Whatever. We'll agree to call it whatever John Roberts arbitrarily decides to call it, OK?)
Saint George Added Sep 24, 2017 - 6:59pm
money is infinite
 
But real goods are not. So unless you want hyperinflation, dumbshit Moslem-arse-wipe, you'll have to limit money-printing to some finite number.
Saint George Added Sep 24, 2017 - 7:02pm
Bin-Arse-Wipin' confuses fantasies with statements of fact. Pity.
John Minehan Added Sep 24, 2017 - 7:11pm
This is interesting from Harvard School of Public Health.
Katharine Otto Added Sep 24, 2017 - 7:39pm
John G,
I just turned 65 and refused Medicare, OK?  When I was a private practice "provider," I opted out of Medicare, because it doesn't allow patients to do their own billing. It basically closes patients out of the decision-making loop.  It is a horrendous system that bleeds everyone's time and money for substandard care.  It forces rationing of health care, over-use of the system, and the mistaken notion that the health scare/snare racket deserves the respect it gets.
 
Your attempt to reduce everything to monetary terms trivializes the discussion.  Quality care and quality of life are not factored into the equation.  In fact, the pressure to be "productive" creates a patient-and-paperwork-churning frenzy that short-changes everyone.
Katharine Otto Added Sep 24, 2017 - 7:49pm
John M., 
Agreed.  I would add that most patients are adults and should be treated as adults, including open access to all their medical records and negotiations with the third-party payers.  
 
As far as over-medicalization and the sick role go, I've noticed that big-time in psychiatry.  Not only that, many people seem to identify with their diagnoses, as though it gives them special status. There's a lot of gratification in the sick role, as in the victim role, so they can be difficult to give up.
Thomas Sutrina Added Sep 24, 2017 - 7:50pm
Saint G.  this is reality and the best of reality, "Primary Healthcare needs to be free for the population,"  In Cito health care study of the top 11 ranking but only 5 had data on GDP cost and out of pocket cost.  GDP went to health care  Government 9.14% that paid 80% and patients our of pocket 18.2%.   U K is 18th  Canada is 30th and USA is 37th with 15% not receiving health care and 15.5% of GDP paying 45%  with out of pocket 13%.  
Saint George Added Sep 24, 2017 - 7:53pm
Interesting link from Minehan. The author of the article writes:
 
"It’s great if you can have timely cardiac surgery and pay little or nothing out of pocket. But if you die unnecessarily from a preventable error, you didn’t get what you needed from the health care system."
 
Ya think? In other words, "free" is bullshit if it kills you. Glad we got that one cleared up. 
 
The author continues:
 
"Finally, we want a health care system that creates new knowledge so that we get better at caring for sick people . . . A system that generates new therapies that save lives is critical, and its importance is often overlooked when assessing health system performance."
 
The two most important aspects of a healthcare system — positive healthcare outcomes for patients, and innovation — he mentions last, almost as an afterthought. Additionally, the fundamental importance of innovation is only overlooked by left-leaning biased articles that concentrate only on low-cost/free "access". It has certainly never been overlooked by any writer aware of the connection between innovation and progress.
 
The author is also enthusiastic about Obamacare, writing how great it is that about 91% of people are insured. The truth is that "getting insurance coverage" and "getting medical care" are two different things, and the former in no way guarantees the latter.
 
Much better is this article by Scott Atlas, M.D., of Stanford University:
 
https://www.the-american-interest.com/2017/08/02/fact-based-health-care-reform/
Fact-Based Health Care Reform
 
"The two major elements of the [ACA] —a significant Medicaid expansion for non-disabled adults and subsidies for exchange-based private insurance—will each be funded with almost $1 trillion of taxpayer money over a decade, according to January 2017 CBO analysis. Just as the ACA’s supporters passed it despite the widely anticipated failures of the law, advocates of a single payer system today ignore the well-documented half century of failures of nationalized health care.
 
The harmful impacts of this ill-conceived approach are now well documented:
 
Insurance premiums have skyrocketed; many insurers have withdrawn from the state marketplaces; and for those with coverage, doctor and hospital choices have narrowed dramatically. The ACA will also undoubtedly accelerate the development of the kind of two-tiered health care system characteristic of other nationalized systems, where people with money or power are able to circumvent the substandard government systems that the lower classes must endure. The result will be an end to the superior access, broad freedom of choice, and exceptional quality of care that distinguishes American health care from the centralized systems that are failing the world over.
 
Shouldn’t we also examine the actual data from nationalized systems with universal insurance? In those countries with the longest experience of guaranteed insurance, epitomized by the UK’s National Health Service, their "fully insured" patients have far worse access to care and worse outcomes than did Americans before the ACA. Published data demonstrates massive waiting lists and unconscionable delays in the NHS that are unheard of in the United States, including for even the sickest patients, like those referred by doctors for "urgent treatment" for already diagnosed cancer (18 percent wait more than two months) and recommended brain surgery (17 percent wait more than four months).
U.S. media outrage was widespread when 2009 data showed that time-to-appointment for Americans averaged 20.5 days for five specialties. That selective reporting failed to note that those waits were for healthy check-ups in almost all cases, by definition the lowest medical priority, and were actually significantly shorter than for seriously ill patients in universal insurance systems, including Brits needing heart surgery (57 days), or
Saint George Added Sep 24, 2017 - 8:12pm
The way the NHS rationing system works is like this:
 
Government establishes what it considers a "reasonable" waiting period (which may or may not have anything to do with what an individual patient with individual needs might regard as "reasonable"). These "reasonable" waiting periods are referred to by government and NHS officials as "BENCHMARKS."
 
So, for example, if government states that the benchmark for neurosurgery is 26 weeks, and every patient who requires neurosurgery receives it within a 26-week waiting period between the time he sees a specialist and the time he receives treatment, then government proudly publishes statements claiming things like, "Excessive Waiting Times? What Excessive Waiting Times? We Have No Excessive Waiting Times! 100% of patients needing neurusurgery received it within the NHS Benchmark!" or perhaps "NHS hits 100% of its neurosurgery benchmark!" Hurray! That's very nice, but I suppose one has to be an outsider to ask, "OK, but what, exactly, is the benchmark measured in weeks?" That tells a different story. If everyone who needed neurosurgery received it after waiting 25.9 weeks, government can still claim how wonderfully efficient the NHS is because everyone received treatment "within the 26-week benchmark."
 
For more on "benchmarks" and actual waiting times, see:
 
http://qmr.kingsfund.org.uk/2017/23/data
NHS Performance
John G Added Sep 24, 2017 - 8:23pm
KO. Your attempt to reduce everything to monetary terms trivializes the discussion.
Your monetary fantasies blind you to the options available. I do not see everything in monetary terms. Quite the opposite.
 
Saint George Added Sep 24, 2017 - 8:27pm
MMT-zombies' ignorance of basic economics blinds them to the essential point that hyperinflation is not an option.
 
Explain Zimbabwe!
John Minehan Added Sep 24, 2017 - 8:55pm
"Explain Zimbabwe!"
 
Zimbabwe and Weimar Germany are extreme outliers (and somewhat intentionally self-inflicted wounds in each case). 
 
The Great Inflation of the 1970s, however, is a good example of how easy it is to let things get out of control and how hard it is to get it back under control.
 
Fiat currency has as much . . . or as little . . . value as other people are willing to afford it.  
Saint George Added Sep 24, 2017 - 9:51pm
Zimbabwe and Weimar Germany are extreme outliers
 
Nice description. Now we want an explanation.
Saint George Added Sep 24, 2017 - 9:53pm
Fiat currency has as much . . . or as little . . . value as other people are willing to afford it. 
 
Um, that's also true of water, diamonds, oil, leather, iron, tin, beef, Stradivarius violins, etc., ad infinitum.
John G Added Sep 24, 2017 - 9:55pm
The inflation of the 70s was largely cost push from OPEC oil prices and war spending.
Currency has no intrinsic value. Confidence has bought to do with it.
John G Added Sep 24, 2017 - 9:56pm
Nought not bought.
Saint George Added Sep 24, 2017 - 11:58pm
Wrong.
 
Neither "cost-push" nor "demand-pull" is capable of explaining a sustained, overall increase in aggregate prices without an increase in the quantity of money.
 
The quantity of money is a necessary (though not sufficient) cause of inflation.
John G Added Sep 25, 2017 - 12:02am
Godwins Law - economic collary
 
It looks to me that there is a economic collary to Godwin's Law arising:

"As an online economic discussion grows longer, the probability of a comparison involving Zimbabwe or the Weimar Republic approaches one."

There are good posts that explain the situation, if you want to know more about Zimbabwe or Weimar.

Otherwise, I'm afraid you just lost the debate.
Saint George Added Sep 25, 2017 - 2:01am
Neither "cost-push" nor "demand-pull" is capable of explaining a sustained, overall increase in aggregate prices without an increase in the quantity of money.
 
The quantity of money is a necessary (though not sufficient) cause of inflation.