Health care

[KenC]

Forgot to address the tort issue.

I'll agree 100% that it needs to happen it's definitely a necessary reform, but I'm not convinced that even with comprehensive reform, that care delivery costs will drastically be reduced. It will reduce the costs of the physician, but that's still only part of the overall cost of care. There's still the nursing staff, technician staff, admin staff, equipment, space (OR/clinic), etc. Tort reform will do a lot, but not a much as people often assume.

[KenC]

As to that first point, we already do via medicare and medicaid. If we could correct the problems that cause the lower income people to "regularly require the most medical care", then we would really be making a difference. I would argue that is the real fix to that problem. Of course saying that and doing that is nearly impossible. Many of the poor are poor for a reason. Either drug addictions, lack of ethics, lack of drive, laziness, or just plain stupidity put a lot of people there. Fixing them would be a real challenge. Yes, I realize that a good percentage of them are not that way and are just a little trapped, but generally just a helping hand for a short while gets those people out of that situation. I'm all for that kind of help.


Your last question there is a good one. It is a moral dilemma. On the one hand, it is not my responsibility to take care of some asshole who got drunk and fell down the stairs. If that is expected of me, then I expect that once that person is healthy again that they are either required to pay me back, or they spend time in jail. A moral person would want to pay me back. An immoral person would consider it their right to free service.

So, I guess what I am saying is that it is not a right. It is something you earn and should be thankful for. That doesn't mean that anybody should be denied care. It just means that you are responsible for you. It doesn't matter if it is before the fact or after. We as a society are responsible for the overall system and for policing it. We are not responsible for the individual.

Insurance pools, whether government run or privately run, are all built off of risk and cost. Reduce one or the other or both and you will have substantial savings.

Reducing insurance costs is also difficult. Tort reform is the place to start.

You'd be very surprised at how much cost reduction a good tort reform package will produce. (eg, 10 years ago, NY doctors were paying on average $250,000 per year for malpractice insurance)

Competition in insurance via removal of the state barriers will most likely not lower quality. There will be a full range of choices.

If you pay for cheap insurance, then expect lousy service in your claim processing. Also expect a lot of hassles about what is and is not covered, much like Geico car insurance. It'll work sometimes, but it is going to be a hassle. Or, go for a slightly more expensive program and get much better service. It's up to you.

Look at the car insurance business for an example. They deal with risk pools and you can find insurance to meet your needs for reasonable amounts of money. Competition drives both cost reductions, often through innovation, and also will drive service up. People will not put up with horrible service if they have a choice (which I will point out that a government plan does not provide).

Those cost reductions do not equal a reduction in cost to provide medical care, it is a reduction in cost for insurance premiums. Combine that with tort reform, and we'll start seeing some major improvements overall.

What really needs to happen is detailed studies into why medical procedures cost so bloody much, and find where we can reduce or remove those costs. I can't tell you what a lot of that is because I'm not an expert, but I'm betting there's a whole lot of government regulation there that is getting in the way. I'm not saying to remove safeguards, I'm saying let the medical community come up with what those safeguards are and work at streamlining them. Then attack each cost the same way and I'll bet you could reduce the cost of common procedures by 50%.

One silly example: Have you ever watched a nurse work? If they are doing their job right, they are washing their hands a lot. Before every procedure involving a patient and after. Sometimes, they wash their hands 25 times per day. That's probably close to an 30 minutes of hand washing time per shift. Now, it's a very good thing because it reduces the transmission of infections from one patient to another and also protects the nurse. However, those procedures take tons of time and it can lead to hand problems for nurses that cause them to miss work. So, if you came up with an efficient system that reduced the time spent washing by 90% and increased the effectiveness, you just saved a bunch of cost. Stick your hands into the machine, 5 seconds later you are sterile and can move on. Fewer nurses can cover the same workload, fewer infections get spread, everybody wins. Yeah, I know it sounds silly, but that's just one goofy idea by a guy who knows little about health care.

Back to the first point. The poor, for whatever reason (I think you alluded to some of them in your post) require the most care. If you could pin-point it and find a solution you would be the most sought after person on the plant. But the fact remains that they do. Even with a great decrease in overall premiums, one can logically assume that there will still be a large population of individuals that will only be able to afford the cheapest of the plans, which offer the smallest amount of coverage. Their medical bills mount and they can't pay them. Now do we cover them through increased premiums for insurance consumers as we do now, or through taxes (Medicaid expansion). I'm not sure which one is cheaper for the populace.

As one who is involved in medicine everyday, I can assure you that hospitals and physician groups are constantly and vigerously looking to increase their efficiency. It's a common assumption that through study and trials that efficiency in every process can be found. This is true in nearly every realm, however, the variables that exist within humans are extensive and the risks even greater. My beast analogy is the fully automated plant that VW built for the Phaeton; they had every process and step worked out perfectly and didn't even need a human on the floor. But let's say that every third chassis that rolled down the line had a different size, metal composition, or used different nuts and bolts? All of a sudden your perfectly calculated line is at a standstill. Such is the case in medicine as we all have differences in our genes. I'll agree that there are areas where improvements in efficiency can be made, but only to a certain extent when you have a human on both sides of the equation. The managed healthcare company that I work for opperates within an evidence-based "best-practices" delivery system and is one of the most efficient in the nation, but care delivery is expensive nonetheless. I would consider a drop in the cost of care delivery by 10% to be a great accomplishment.

In reference to your nurse handwashing example, we have automated dispensers of foaming alcohol hand sanitizer which offers 99% sterilization in less than 30 seconds... With lotion for skin :).

[joshh]

The funny thing here is that if (thankfully it will never pass as is) this bill were to pass, you'd find many people going back to the insurance companies because of the huge fucking waits that would be required of the public option.
If the doctors we have are overwhelmed with patients, you'd better believe care will be worse.

[mrsleeve]

Again Hallen you have put much of my thinking much more eloquently than I would have.

[Hallen]

I see this as an issue because as any healthcare administrator, or physician for that matter, will tell you is that it is the lower-income populations that regularly require the most medical care. I think it will be necessary for the public to supplement this population just as they do the uninsured... but I guess that's just something that I feel we, as a society, are obligated to do.

I find it odd that it hasn't been addressed in this thread yet, but there is a underlying question that no one has posed: Is health care a right, or a privilege? It's a moral issue that is essentially impossible to debate upon, yet is still driving the heart of the reform debate.

As to that first point, we already do via medicare and medicaid. If we could correct the problems that cause the lower income people to "regularly require the most medical care", then we would really be making a difference. I would argue that is the real fix to that problem. Of course saying that and doing that is nearly impossible. Many of the poor are poor for a reason. Either drug addictions, lack of ethics, lack of drive, laziness, or just plain stupidity put a lot of people there. Fixing them would be a real challenge. Yes, I realize that a good percentage of them are not that way and are just a little trapped, but generally just a helping hand for a short while gets those people out of that situation. I'm all for that kind of help.


Your last question there is a good one. It is a moral dilemma. On the one hand, it is not my responsibility to take care of some asshole who got drunk and fell down the stairs. If that is expected of me, then I expect that once that person is healthy again that they are either required to pay me back, or they spend time in jail. A moral person would want to pay me back. An immoral person would consider it their right to free service.

So, I guess what I am saying is that it is not a right. It is something you earn and should be thankful for. That doesn't mean that anybody should be denied care. It just means that you are responsible for you. It doesn't matter if it is before the fact or after. We as a society are responsible for the overall system and for policing it. We are not responsible for the individual.

Insurance pools, whether government run or privately run, are all built off of risk and cost. Reduce one or the other or both and you will have substantial savings.

Reducing insurance costs is also difficult. Tort reform is the place to start.

You'd be very surprised at how much cost reduction a good tort reform package will produce. (eg, 10 years ago, NY doctors were paying on average $250,000 per year for malpractice insurance)

Competition in insurance via removal of the state barriers will most likely not lower quality. There will be a full range of choices.

If you pay for cheap insurance, then expect lousy service in your claim processing. Also expect a lot of hassles about what is and is not covered, much like Geico car insurance. It'll work sometimes, but it is going to be a hassle. Or, go for a slightly more expensive program and get much better service. It's up to you.

Look at the car insurance business for an example. They deal with risk pools and you can find insurance to meet your needs for reasonable amounts of money. Competition drives both cost reductions, often through innovation, and also will drive service up. People will not put up with horrible service if they have a choice (which I will point out that a government plan does not provide).

Those cost reductions do not equal a reduction in cost to provide medical care, it is a reduction in cost for insurance premiums. Combine that with tort reform, and we'll start seeing some major improvements overall.

What really needs to happen is detailed studies into why medical procedures cost so bloody much, and find where we can reduce or remove those costs. I can't tell you what a lot of that is because I'm not an expert, but I'm betting there's a whole lot of government regulation there that is getting in the way. I'm not saying to remove safeguards, I'm saying let the medical community come up with what those safeguards are and work at streamlining them. Then attack each cost the same way and I'll bet you could reduce the cost of common procedures by 50%.

One silly example: Have you ever watched a nurse work? If they are doing their job right, they are washing their hands a lot. Before every procedure involving a patient and after. Sometimes, they wash their hands 25 times per day. That's probably close to an 30 minutes of hand washing time per shift. Now, it's a very good thing because it reduces the transmission of infections from one patient to another and also protects the nurse. However, those procedures take tons of time and it can lead to hand problems for nurses that cause them to miss work. So, if you came up with an efficient system that reduced the time spent washing by 90% and increased the effectiveness, you just saved a bunch of cost. Stick your hands into the machine, 5 seconds later you are sterile and can move on. Fewer nurses can cover the same workload, fewer infections get spread, everybody wins. Yeah, I know it sounds silly, but that's just one goofy idea by a guy who knows little about health care.

[kishg]

Well sort of, Hospitals are only required to stabilize a patient regardless of insurance coverage or money, once they are stable it is entirely up to hospital to determine if they keep treating the patient. This is also the reason why people will get turned away after being stabilized even though they weren't fully treated.



I agree with you, The US Government has been subsidizing almost 40% of the entire healthcare industry for the past 20 years or more.



Well that's actually the question, is it about expanding coverage or reforming the way hospitals deal with the red tape of private insurance companies (which is why I state there is a difference between health CARE reform and health INSURANCE reform.) In my opinion, which is why I disagree with the bill, we need to get rid of the red tape from insurance companies, and return the power back to the doctors, then we open up policies across state lines, this will drastically lower the cost of insurance as well as improve healthcare. Thus making it far more affordable to purchase insurance and expand coverage. I'll give a better explanation and analogy below.



One of the easiest ways to lower premiums and expand coverage is by opening up coverage across state lines. Auto Insurance works on the exact same principle as Health insurance with two HUGE Exceptions, 1) it is required by both the state and federal government and 2) it is universal across state lines, whether I purchase my insurance in Texas and get into an accident in Maryland is irrelevant, Either way I'm covered. Nobody seems to be overly complaining about HAVING to buy auto insurance! Why is that?? National Coverage allows major companies to compete across the board, sure there are only about 5 major companies and 20 or so local companies per state (guesstimating) but the competition between those few has significantly driven down costs, which is why I have no complaints about paying $40 a month for liability for my e30. If we opened up Health Insurance coverage across state lines there would be 300+ companies available overnight, more than half will go out of business and leave us with 10 or so major players but premiums would drop drastically because of the competition, thus wildly expanding coverage. Combine that with thinning the red tape between Insurance and Pharmaceutical companies, doctors and their patients and you will boost revenue, immensely reduce wasteful spending and boost the overall care of patients. We also need to do far more to protect doctors from ridiculous malpractice lawsuits (ie TORT Reform) that way they can concentrate on taking care of a patient and not worry about their license and practice.

I'm only about 400 pages into the new 1990 page House Bill, but what I have learned from a few friends (judges, doctors and lawyers) this bill still does little to none of what I have mentioned. On the other hand the Republican bill that I have read (which is also the only one I can get my hands on) pushes directly in this direction and significantly reduces the deficit and creates real reform.



Well I think there were far more pressing issues like two wars and Social Security Reform (sadly failed) at the time.

once again, a reasoned discussion, i agree with most of your points.

[KenC]

I think we need to have the conservative fortitude(tm) to do what it takes to reduce costs (opening the market on insurance, tort reform, doing away with the anti-trust exemption, etc), however, I believe our society needs to be compassionate enough to subsidize care for those without acccess to it.

That is, I'm all for reducing costs where we can, but I'm not convinced it will be enough to reduce them enough to make adequate coverage universally affordable, which is where the public needs to step in.

[mrsleeve]

^^^^^^^^^^^^^^^^^^

You bring up very valid questions and while I am a big supporter, of freeing up the markets. I really feel its one 1 part of a lager system and right now would have been a better option to go than to spend trillions on this folly we are being choked with.

[KenC]

I was also thinking about this on my drive home. I'm not convinced an increase in competition between insurance companies will lower premiums significantly. In order to pass savings along to consumers, they'll either need to GREATLY increase internal efficiency within the actual insurance company itself, decrease coverage to its customers, or reduce profits. Administrative costs are only a small fraction of healthcare costs, and I'm not convinced that physicians are overly inefficient in their practices. I work with many of them and there isn't one that's willing to subject a patient to unnecessary tests (especially expensive imaging, but mostly due to radiation exposure). The fact is that it's expensive to provide care. Equiment, and especially qualified staff aren't cheap. Tort reform is probably th best way to reduce costs on the provider side of care, but even that isn't going to drastically reduce costs (although it's necessary and will definitely help).

[KenC]

If we opened up Health Insurance coverage across state lines there would be 300+ companies available overnight, more than half will go out of business and leave us with 10 or so major players but premiums would drop drastically because of the competition, thus wildly expanding coverage. Combine that with thinning the red tape between Insurance and Pharmaceutical companies, doctors and their patients and you will boost revenue, immensely reduce wasteful spending and boost the overall care of patients.

Can't we also assume that in an effort to drive down premium prices between these competing insurance companies that coverage to individuals will be reduced to drive down the bottom line of opperation to have a competative ROI to shareholders? Although, I work within a not-for-profit managed care health system (Kaiser Perm. NW), the private practice providers I've spoken with are at wits end with the cumbersome task of justifying procedures to insurance companies (no matter how hard you try, you can't stremline medicine like a manufacturing plant, the variables are too great and the risks even higher)... which often takes as long to deal with as seeing multiple patients in clinic. I guess this necessary within our system, as the providers chief concern is that of his or her patient, while the insurance company answers to a board and investors.

You're making a huge assumption that decreasing costs will lead to an increase in the quality of care delivered. The US has the best doctors in the world, it's access to them that's the issue here.

I think it's going to be a combination of a lot of things that will make our system not only effective, but also efficient. Included within the current bill that went through the house is a repeal of the anti-trust exemption, which I'm happy about. I would also like to see an aggressive, yet realistic tort cap (Google "OHSU Tort Cap" if you want to see an atrocious example). I would agree that we also need to open up health insurance accross state lines as you pointed out auto insurance is currently.

However, even with all of the potential cost reductions and assumed premium reductions, I don't see how we can rely on the private sector to adequately provide our entire nation with health care/insurance. If all of the above mentioned were to happen and premiums reduced to "affordable" levels, I would be curious to see what the plans associated with the cheaper premiums cover, as the often overlooked population of the "underinsured" is a huge issue as well. I see this as an issue because as any healthcare administrator, or physician for that matter, will tell you is that it is the lower-income populations that regularly require the most medical care. I think it will be necessary for the public to supplement this population just as they do the uninsured... but I guess that's just something that I feel we, as a society, are obligated to do. If it's a subsidised public option that's made available to them, I'm all for it, however, it doesn't look like the one in the bill has it quite right yet.

I find it odd that it hasn't been addressed in this thread yet, but there is a underlying question that no one has posed: Is health care a right, or a privilege? It's a moral issue that is essentially impossible to debate upon, yet is still driving the heart of the reform debate.

[Vedubin01]

welp,
were fucked.

Not so fast, its still got to get through the Senate.

[xwill112x]

welp,




were fucked.

[mrsleeve]

Oh I see you dismiss something because of a known fact that the Health Insurance industry is exempt from the Anti trust laws, that allow them to hold monopolies or near monopolies of entire populations of states. Allowing them to charge what ever they want to those residents. :rolleyes

Yes it would bring down the costs across the board, along with current Govt, programs, would have the desired effect, to get coverage available to those that want it but cant afford it.

yeah i read that and dismissed it because it was some hype about anti-trust and not any concrete proposals to alow more entrants into the health insurance market. this maybe one market where the pure free market model isn't the most efficient simply because we've already decided that we won't let people die. real free market would be that. i'm not saying i'm for that, im just pointing out that the problem isn't as simplistic as what you imagine.

All that said here is a letter confirming that if you dont comply with all this, you could face prison time and fines up too $250,000 (yes a 1/4 mill)

PELOSI: Buy a $15,000 Policy or Go to Jail
JCT Confirms Failure to Comply with Democrats’ Mandate Can Lead to 5 Years in Jail
Friday, November 06, 2009

Today, Ranking Member of the House Ways and Means Committee Dave Camp (R-MI) released a letter from the non-partisan Joint Committee on Taxation (JCT) confirming that the failure to comply with the individual mandate to buy health insurance contained in the Pelosi health care bill (H.R. 3962, as amended) could land people in jail. The JCT letter makes clear that Americans who do not maintain “acceptable health insurance coverage” and who choose not to pay the bill’s new individual mandate tax (generally 2.5% of income), are subject to numerous civil and criminal penalties, including criminal fines of up to $250,000 and imprisonment of up to five years.

In response to the JCT letter, Camp said: “This is the ultimate example of the Democrats’ command-and-control style of governing – buy what we tell you or go to jail. It is outrageous and it should be stopped immediately.”

Key excerpts from the JCT letter appear below:

“H.R. 3962 provides that an individual (or a husband and wife in the case of a joint return) who does not, at any time during the taxable year, maintain acceptable health insurance coverage for himself or herself and each of his or her qualifying children is subject to an additional tax.” [page 1]

- - - - - - - - - -

“If the government determines that the taxpayer’s unpaid tax liability results from willful behavior, the following penalties could apply…” [page 2]

- - - - - - - - - -


“Criminal penalties

Prosecution is authorized under the Code for a variety of offenses. Depending on the level of the noncompliance, the following penalties could apply to an individual:

• Section 7203 – misdemeanor willful failure to pay is punishable by a fine of up to $25,000 and/or imprisonment of up to one year.

• Section 7201 – felony willful evasion is punishable by a fine of up to $250,000 and/or imprisonment of up to five years.” [page 3]

When confronted with this same issue during its consideration of a similar individual mandate tax, the Senate Finance Committee worked on a bipartisan basis to include language in its bill that shielded Americans from civil and criminal penalties. The Pelosi bill, however, contains no similar language protecting American citizens from civil and criminal tax penalties that could include a $250,000 fine and five years in jail.

“The Senate Finance Committee had the good sense to eliminate the extreme penalty of incarceration. Speaker Pelosi’s decision to leave in the jail time provision is a threat to every family who cannot afford the $15,000 premium her plan creates. Fortunately, Republicans have an alternative that will lower health insurance costs without raising taxes or cutting Medicare,” said Camp.

According to the Congressional Budget Office the lowest cost family non-group plan under the Speaker’s bill would cost $15,000 in 2016.

http://republicans.waysandmeans.house.gov/News/DocumentSingle.aspx?DocumentID=153583

[Vedubin01]

^^^^^ well put!

[TexasTerp]

As it stands right now you cant be denied treatment, based on your ability to pay. You will be treated and will be taken care of regardless!!!

Well sort of, Hospitals are only required to stabilize a patient regardless of insurance coverage or money, once they are stable it is entirely up to hospital to determine if they keep treating the patient. This is also the reason why people will get turned away after being stabilized even though they weren't fully treated.

exactly. guess who is paying that 98k?

I agree with you, The US Government has been subsidizing almost 40% of the entire healthcare industry for the past 20 years or more.

yeah but it does little to expand coverage, isn't that the entire point of this exercise?

Well that's actually the question, is it about expanding coverage or reforming the way hospitals deal with the red tape of private insurance companies (which is why I state there is a difference between health CARE reform and health INSURANCE reform.) In my opinion, which is why I disagree with the bill, we need to get rid of the red tape from insurance companies, and return the power back to the doctors, then we open up policies across state lines, this will drastically lower the cost of insurance as well as improve healthcare. Thus making it far more affordable to purchase insurance and expand coverage. I'll give a better explanation and analogy below.

and how do you propose to expand competition?

One of the easiest ways to lower premiums and expand coverage is by opening up coverage across state lines. Auto Insurance works on the exact same principle as Health insurance with two HUGE Exceptions, 1) it is required by both the state and federal government and 2) it is universal across state lines, whether I purchase my insurance in Texas and get into an accident in Maryland is irrelevant, Either way I'm covered. Nobody seems to be overly complaining about HAVING to buy auto insurance! Why is that?? National Coverage allows major companies to compete across the board, sure there are only about 5 major companies and 20 or so local companies per state (guesstimating) but the competition between those few has significantly driven down costs, which is why I have no complaints about paying $40 a month for liability for my e30. If we opened up Health Insurance coverage across state lines there would be 300+ companies available overnight, more than half will go out of business and leave us with 10 or so major players but premiums would drop drastically because of the competition, thus wildly expanding coverage. Combine that with thinning the red tape between Insurance and Pharmaceutical companies, doctors and their patients and you will boost revenue, immensely reduce wasteful spending and boost the overall care of patients. We also need to do far more to protect doctors from ridiculous malpractice lawsuits (ie TORT Reform) that way they can concentrate on taking care of a patient and not worry about their license and practice.

I'm only about 400 pages into the new 1990 page House Bill, but what I have learned from a few friends (judges, doctors and lawyers) this bill still does little to none of what I have mentioned. On the other hand the Republican bill that I have read (which is also the only one I can get my hands on) pushes directly in this direction and significantly reduces the deficit and creates real reform.

Where were all these great ideas when Bush was in office and they could have made these changes. The Dem's have had control for three years. Bush and the Reps had 5 years to make it happen.

Well I think there were far more pressing issues like two wars and Social Security Reform (sadly failed) at the time.