The Insured Poor

[Spiral]

But we already give blood transfusions to drug addicts. We already pay for the birth of anybodys baby. We even pay if you illegally sneak across the border and show up at a hospital. Those are not things we reject now.

Exactly. So why make these the stumbling blocks of health care reform?

Some people will get upset if some 60 year old guy they know who has already had 17 stents, 2 angioplasties and 2 coronary bypass operations continues to eat filet mignon with blue cheese twice a week.

Some other person who lives a healthy lifestyle might say, "My tax dollars are paying for that crap!"

Or, "My daughter's college tuition is outrageously high and it's all because all of our tax money is going to pay for this guy's unhealthy lifestyle and not to pay for my daughter's degree at Perdue University. I'm outraged."

You personally might be willing to donate more of your own money to help pay the health care expenses of that 60 year old guy with bad eating habits.

But others might not be so willing. It's a real issue that always crops up during a health care reform discussion.

[dailycarbs]

You personally might be willing to donate more of your own money to help pay the health care expenses of that 60 year old guy with bad eating habits.

But others might not be so willing. It's a real issue that always crops up during a health care reform discussion.

With reform or without, we as a society must decide these issues together anyway. My take is that this tack is a dangerous slippery slope. Maybe I don't want to pay for anyone getting into a bike accident because I think bike riders are a nuisance and bike riding is dumb (not the case since I ride a bike ). Oh, since I don't have kids, why should I pay for schools? Public transportation sure is stoopid if you live in the suburbs. Nope! Not paying!

Point is, you're debating public policy points that should be debated separately—irrespective of what health care system we select.

[petero]

The function of a public corporation LOOKS like it's to maximize shareholder value, but that simply isn't true. The function is to provide upper level executives with the maximum amount of income and benefits without making it look like they're cheating the shareholders or beating their employees into the ground. Modern major corporations are run by bureaucrats, not entrepreneurs. They get ahead primarily by politics and destroying inter-company rivals.

For small business it's another matter. You incorporate to protect against lawsuits and to have a substantial tax advantage.

That's a good point, there's a "coordinator class" that's in league with the system because of the rewards they receive, and a petty bourgeoisie that's constantly in play, like their capture by the tea party. You can pander to them and get their votes and contributions, but mainly what's needed is votes. The Kock brothers have plenty of money to give, but it's still a formal democracy.

Ad Switzerland arguments aren't really substantial unless we know *why* they rejected a single-payer system. Maybe it was all the propaganda against single-payer systems they've been hearing? Humans aren't exactly known for their rational behavior, unless you're an economist I guess. It is nice to have referendum be a civic right, though. They also passed a guaranteed minimum income in Switzerland, so maybe they don't need single-payer then, though I haven't been keeping track of what happened to that. A Gallup poll showed 52% of people in the United States support heavy taxation on the rich to correct economic inequality. I guess we're not a bastion of democracy after all, maybe Switzerland is.

Why anyone would think that single-payer health coverage has anything to do with the 60 year old eating pizza is beyond me. Ask your employer-supported private coverage provider to put you in a group that only eats McDougall food, I'm sure there's tons of companies doing that. I'm sure Blue Cross is happy to meet your personal needs, like when they tried to kick me out by (literally) lying about my pre-existing conditions. Or just cut to the chase and self-insure then, and give up being part of a risk pool. (I really wish John Galt would get his butt in gear and leave already so we can get on with it.) Otherwise, people who have insurance understand that it's a risk pool, which is its purpose. There might have to be more publically funded programs to get people to eat healthy. So tax the rich and fund the programs. No problem.

[Spiral]

Ad Switzerland arguments aren't really substantial unless we know *why* they rejected a single-payer system. Maybe it was all the propaganda against single-payer systems they've been hearing?

It's true that the people representing 64 percent of the vote in Switzerland could have been snookered into voting against a single payer system. But there are other possible explanations as to why they voted the way they did.

I mentioned Switzerland because we often hear the words single payer used as a synonym of the words universal health care. But the two are not the same. It appears that Switzerland has universal health care (by most peoples' definition of that term) but does not have a single payer system.

Universal coverage <> single payer.

But here's the interesting part.

Take a woman who lives in Switzerland. She purchases a health insurance policy. That insurance policy has a deductible and a co-pay built into the policy. So, this woman has health insurance, but still pays some money out of pocket for health care. If this woman is, for whatever reason, unable to pay her deductible and/or co-pay, can she be denied health care? If so, maybe Switzerland does not really have universal health care coverage.

Okay. Maybe it should be:

Universal coverage = single payer.

But what if the government gives everyone health care roughly equivalent to that provided by the Veterans Administration? This isn't what we are after either, is it?

If the federal government gave everyone a free bottle of aspirin each year, that would not comport with most peoples' idea of universal health care coverage, even if each bottle had the same number of aspirin tablets in it.

Why anyone would think that single-payer health coverage has anything to do with the 60 year old eating pizza is beyond me. Ask your employer-granted private coverage provider to put you in a group that only eats McDougall food, I'm sure there's tons of companies doing that. Just self-insure then and give up being a risk pool. Otherwise, people who have insurance understand that it's a risk pool, which is its purpose. There might have to be more publically funded programs to get people to eat healthy. So tax the rich and fund the programs. No problem.

This gets to the questions of how a health insurance corporation should be allowed to deal with two different people:

Type A The 30 year old who lives a very healthy lifestyle (trim, non-smoker, physically active, lots of fruits and vegetables, little or no junk food and limited animal based foods and vegetable oils).

Type B The 60 year old who lives a very unhealthy lifestyle (obese, smoker, sedentary, few fruits and vegetables, lots of junk food, lots of fried food and lots of animal based food).

One school of thought is that the health insurance corporation should charge Type A and Type B people the same premium even though one is likely to cost them very little and one is likely to cost them a bundle of money. But if the premiums are made uniform, the Type A people say, "No thanks. I don't think I will purchase health insurance." That's where the government has to enact some form of punishment to people who don't purchase health insurance.

This is one of the more unpopular features of the ACA. It's known as the Individual Mandate. There's also the employer mandate, which requires businesses to purchase health insurance for their employees.

The alternative is to let the health insurance corporation charge Type A a low premium in order to seduce the healthy person into the insurance pool and to charge Type B a high premium so that the health insurance company will have enough dough to pay the doctors and hospitals for all of the pills and procedures Type B is inevitably going to need.

Neither policy is 100 percent satisfactory, is it?

[dailycarbs]

Why Did Swiss Voters Reject Single-Payer Health Care?
http://portside.org/2015-01-05/why-did- ... ealth-care

[f1jim]

Not the most objective perspective on the Swiss vote but interesting to speculate.
f1jim

[petero]

Universal coverage <> single payer.

I think it should be like in Britain, where nobody ever sees a bill and every medically useful procedure is covered. I'm not handing over the sheep to the wolves (insurance companies) if I have a choice. Have doctors or impartial "death panels" decide but anything is better than a private system where the payer decides what to pay for. That obviously makes the least sense to anyone except the rich.

Neither policy is 100 percent satisfactory, is it?

No. Just tax the rich and pay for it all in a single-payer system. Health is its own incentive. The savings on profit and administrative costs alone will justify it, as they do in Canada. (Not that the social cost has anything to do with a private healthcare system, so I don't understand why it's a concern at all to market fetishists except to justify cuts in social spending.) You are implying that the person who eats poorly doesn't deserve medical care, which isn't that obvious at all, but what you really have to justify is that the poor person doesn't deserve it, whether they eat richly or not, because that's how it's rationed in a private system. The rich steak eater gets all the medical care he or she likes. In a public system you might have a leg to stand on, as long as you could ethically justify your position, which is doubtful I suppose.

[dailycarbs]

Not the most objective perspective on the Swiss vote but interesting to speculate.
f1jim

In fact, Switzerland is irrelevant to this conversarion and I've said so before on this thread. It's Spiral that brough up a WSJ opinion piece about it several times. I simply posted the link for balance.

[Spiral]

In fact, Switzerland is irrelevant to this conversarion and I've said so before on this thread. It's Spiral that brough up a WSJ opinion piece about it several times. I simply posted the link for balance.

The reason why I think Switzerland's rejection of single payer in that referendum is relevant to this conversation is because we often hear that the United States is the only economically advanced nation that does not have universal health care. This is true. But many people think that this means that all economically advanced nations (except for the US) have single payer. But Switzerland has achieved universal health coverage without adopting a single payer system.

I think it should be like in Britain, where nobody ever sees a bill and every medically useful procedure is covered. I'm not handing over the sheep to the wolves (insurance companies) if I have a choice. Have doctors or impartial "death panels" decide but anything is better than a private system where the payer decides what to pay for. That obviously makes the least sense to anyone except the rich.

The disadvantage of the British system is that we could end up with Veterans Administration style health care. The government pays a bundle of money to a government agency (in the British case it's the National Health Service [NHS]) to provide health care to all.

But if the government does a bad job of delivering health care, if the hospitals are filthy, if the doctors are rude and incompetent, the person needing health care is in a vulnerable situation because the government has created for itself a monopoly over health care.

That's the irony, I think, of single payer.

If a private corporation had a 100 percent monopoly over the delivery of health care, you would have consumer advocates demanding that this private corporation be busted up, broken up into smaller corporations that would have to compete against each other for business.

But a single payer system would give a National Health Service a 100 percent monopoly over the delivery of health care. At least with McDonald's, if I think their food is unhealthy, I can take my myself and my money elsewhere. If I think the National Health Service is running a filthy hospital staffed with incompetent doctors and uncaring hospital administrators, I have no recourse because the government has a monopoly.

Hey, at least the Canadians have the option of travelling 50 miles to the United States for health care if they find their own health care is lacking.

And some Canadians have gone to court, some cases making it all the way to the Canadian Supreme Court, saying that they are not getting the health care that they have been promised.

No. Just tax the rich and pay for it all in a single-payer system. Health is its own incentive.

Somehow, I think that If it were as simple as taxing the rich, California would have enacted single payer by now. Heck, back during the Truman and Eisenhower administrations we had a top marginal income tax rate of 91 percent on the super-rich. This was before President John Kennedy reduced that top income tax rate from 91 percent to 70 percent. But did that 91 percent tax rate fund single payer health care? No. In fact, back then we didn't even have Medicare or Medicaid.

But my sense is that a significant percentage of liberals, in additional to most conservatives, do not want to have a National Health Service (or a California Health Service) as their only option for health care.

Me, personally? I would like to see California adopt a single payer health care system.

I think it would be a failure and I think the other 49 states could learn valuable lessons from that failure. But of course, the alternative is true. People could visit California and say, "You know they have a great new single payer health care system there." And other states would want to copy it.

[dailycarbs]

The reason why I think Switzerland's rejection of single payer in that referendum is relevant to this conversation is because we often hear that the United States is the only economically advanced nation that does not have universal health care. This is true. But many people think that this means that all economically advanced nations (except for the US) have single payer. But Switzerland has achieved universal health coverage without adopting a single payer system.

I'm really confused. Are you against single payer and pro Obamacare?

[Spiral]

The reason why I think Switzerland's rejection of single payer in that referendum is relevant to this conversation is because we often hear that the United States is the only economically advanced nation that does not have universal health care. This is true. But many people think that this means that all economically advanced nations (except for the US) have single payer. But Switzerland has achieved universal health coverage without adopting a single payer system.

I'm really confused. Are you against single payer and pro Obamacare?

I am in favor of gradual transition towards a mostly free market health care system. Given how many non-market features have crept into our health care system over the last 80 years, there are lots of policy changes that I would support.

One feature in Obamacare that I do support is what is known as the Cadillac tax. It treats part of the money paid by an employer for a high cost health care plan as taxable income. Prior to Obamacare, all employer paid health care plans, no matter how expensive, were considered non-taxable fringe benefits. I might want to expand on this idea. Taxing more employer paid health plans while providing everyone, including the self-employed and people who work for employers that don't offer health coverage, a tax deduction and/or tax credit to purchase a high-deductible health insurance plan.

Another change I would make would to be raise the deductible for Medicare beneficiaries in exchange for a "Medi-check." So, if you are a healthy 65 year old (or older) you would get some cash. If you are an unhealthy 65 year old (or older) you would also get some cash, but you would likely end up spending your Medi-check on your prescription drugs and doctor's visits as you meet your higher annual deductible.

I would block grant Medicaid to the states and give the states maximum flexibility in terms of how to spend the Medicaid money. They could spend it on just about anything. But it would be a fixed amount of money. It would reduce the federal government's involvement in health care significantly.

At the state level, I like the idea of Medical liability reform. Some people would like to purchase health care, but don't want to pay for the right to sue the be-jesus out of their doctor and/or hospital. Perhaps they would be satisfied with lower medical costs, but a right to sue for a limited amount of punitive damages should things go wrong. Allow for medical providers to choose which legal category they want to be in. Do they want to offer their patients an unlimited opportunity to sue for unlimited amounts of money? Or do they want to limit their liability in some way? I think both Texas and California have some form of medical liability limitations.

With the Veterans Administration, I'd like to see giving our Veterans money to spend on health care at the heath care location of their choice and not necessarily a VA hospital.

My main idea is to get the average consumer into the game of cost control and quality control. This can't happen if the government and health insurance companies are paying the overwhelming majority of the bills. Of course, indirectly, we are all paying for what the government and health insurance companies spend. Thus, my ideas about ending the favorable tax treatment of employer provided health insurance and "Medi-check."

[openmind]

The reason why I think Switzerland's rejection of single payer in that referendum is relevant to this conversation is because we often hear that the United States is the only economically advanced nation that does not have universal health care. This is true. But many people think that this means that all economically advanced nations (except for the US) have single payer. But Switzerland has achieved universal health coverage without adopting a single payer system.

I'm really confused. Are you against single payer and pro Obamacare?

I am in favor of gradual transition towards a mostly free market health care system. Given how many non-market features have crept into our health care system over the last 80 years, there are lots of policy changes that I would support.

One feature in Obamacare that I do support is what is known as the Cadillac tax. It treats part of the money paid by an employer for a high cost health care plan as taxable income. Prior to Obamacare, all employer paid health care plans, no matter how expensive, were considered non-taxable fringe benefits. I might want to expand on this idea. Taxing more employer paid health plans while providing everyone, including the self-employed and people who work for employers that don't offer health coverage, a tax deduction and/or tax credit to purchase a high-deductible health insurance plan.

Another change I would make would to be raise the deductible for Medicare beneficiaries in exchange for a "Medi-check." So, if you are a healthy 65 year old (or older) you would get some cash. If you are an unhealthy 65 year old (or older) you would also get some cash, but you would likely end up spending your Medi-check on your prescription drugs and doctor's visits as you meet your higher annual deductible.

I would block grant Medicaid to the states and give the states maximum flexibility in terms of how to spend the Medicaid money. They could spend it on just about anything. But it would be a fixed amount of money. It would reduce the federal government's involvement in health care significantly.

At the state level, I like the idea of Medical liability reform. Some people would like to purchase health care, but don't want to pay for the right to sue the be-jesus out of their doctor and/or hospital. Perhaps they would be satisfied with lower medical costs, but a right to sue for a limited amount of punitive damages should things go wrong. Allow for medical providers to choose which legal category they want to be in. Do they want to offer their patients an unlimited opportunity to sue for unlimited amounts of money? Or do they want to limit their liability in some way? I think both Texas and California have some form of medical liability limitations.

With the Veterans Administration, I'd like to see giving our Veterans money to spend on health care at the heath care location of their choice and not necessarily a VA hospital.

My main idea is to get the average consumer into the game of cost control and quality control. This can't happen if the government and health insurance companies are paying the overwhelming majority of the bills. Of course, indirectly, we are all paying for what the government and health insurance companies spend. Thus, my ideas about ending the favorable tax treatment of employer provided health insurance and "Medi-check."

There is a big obstacle to getting the the average consumer into the game of cost control and quality control. It is very difficult if not impossible to figure out what hospitals and other health care providers (radiology centers, for example) are charging for particular services. And hospitals charge insane prices to the average consumer (vs. what they charge health insurance companies, which can negotiate discounts). Thus, it appears we will all always be dependent on having some form of insurance (govt. or otherwise).

[petero]

The disadvantage of the British system is that we could end up with Veterans Administration style health care. The government pays a bundle of money to a government agency (in the British case it's the National Health Service [NHS]) to provide health care to all.

An alien species could invade earth and enslave us all, Spiral, so why don't you quit your job and start planting beans and digging a bunker? In the meantime, I would like to focus on making resources available for universal single-payer coverage for the health care of all people in the society. If anyone can get more care than anyone else, then the system is unjust. If the system is inadequate, we need to either devote more resources to it or pressure it to be more efficient and adequate. It's very simple once you get to the root of it. We just have to agree to disagree on that point. If had a British person here to help me argue against your counterfactuals, I would still choose not to.

But if the government does a bad job of delivering health care, if the hospitals are filthy, if the doctors are rude and incompetent, the person needing health care is in a vulnerable situation because the government has created for itself a monopoly over health care.

First of all, you're begging the question again and resorting to sophistic counterfactuals. The fact is, that the government is the only institution that you can even hope to influence in this society. "Voting with your dollar" is a worthless substitute for real democracy and influence and in fact an exercise in futility. If you think something is wrong, you should be yelling at your elected representatives or out in the street fighting to change it, or trying to bring in some form of direct democracy or proportional representation.

Try changing McDonalds and Blue Cross, and call us from your jail cell to let us know how its going. (I'm assuming a stern letter and a demanding phone call won't turn McDonald's into McDougall's, or convince Blue Cross to cover people or whatever, but you can start with that if you feel otherwise.) What makes you think you can affect private power but not your government? It's a genius of a system that can make you believe that, while simultaneously claiming to be a democracy, isn't it?

But like at Burger King, you can have it your way. Go tell the poor person with cancer or something that you don't think they should have health care because their doctor might be rude. It's hard to argue with that kind of logic. However, Cuba has plenty of competent doctors, so I'm sure they could send some here to help us out if our society is too poor to produce them. They could help us staff our impoverished medical schools so we could produce more competent doctors, too.

As my avatar would say, "to make soap, first you have to render fat." All of this is just a facade for the real problem, that the rich(er) Homo economicus don't have any sense of solidarity with, or understanding of, those who aren't as rich, and consequently don't feel they owe them a dime. Nicely asking them to pay more to meet the needs of a society they are not a part of, that they correctly understand as not existing, and that they no longer feel they need to support the facade of, isn't going to get us anywhere. It's sad that people are willing to believe the propaganda used to justify this, though, just to save a few bucks on their taxes. Unlike me, I'm sure historical materialists aren't surprised, so maybe I need to suck up my wishful thinking and learn a few things once and for all... Thanks for the lesson, Sprial.

[petero]

Allow for medical providers to choose which legal category they want to be in.

Fine, as long as I can be in the legal category that can drive with a 0.25% blood alcohol level and negligently burn down my neighbors house and just say "Sorry, Fred" with an awkward grin on my face.

[Spiral]

There is a big obstacle to getting the the average consumer into the game of cost control and quality control. It is very difficult if not impossible to figure out what hospitals and other health care providers (radiology centers, for example) are charging for particular services. And hospitals charge insane prices to the average consumer (vs. what they charge health insurance companies, which can negotiate discounts). Thus, it appears we will all always be dependent on having some form of insurance (govt. or otherwise).

I think the main reason why the American consumer is so dependent on insurance and why the pricing system at hospitals is so non-transparent is because our current policies make it that way.

The federal government spends hundreds of billions of dollars on Medicare, which pays doctors and hospitals. This leaves consumers on the sidelines. The federal government does not tax employer provided health insurance, so health insurance companies pay a larger percentage of health care costs. This, again, leaves consumers on the sidelines.

In order to get American consumers to play are larger and more constructive role in our health care economy, we have to change our policies. That's why I like a Medi-check idea and that's why I like the idea of taxing employer provided health insurance as taxable income and giving the tax savings to people for use in the medical market place.