“I want you to know I care deeply about your views”

May 6, 2009 11:01 PM

Single-payer health care advocates arrested at Senate hearing. On May 5, 2009 advocates of a U.S. national health care program disrupted a Senate Finance Committee event to call for single-payer healthcare to be part of the discussion. The eight protesters were subsequently arrested. The protesters included representatives of Physicians for a National Health Program, which favors the The United States National Health Care Act, H.R. 676. Committee Chair Max Baucus (D - Montana), who has received more money in contributions from health insurance companies than any other member of Congress, favors requiring Americans to purchase private health insurance from those companies. Baucus, who has previously said that single-payer is "off the table," responded to the doctors and their fellow activists with, “I want you to know I care deeply about your views," and then, "we need more police [to eject protesters]."
posted by univac (146 comments total)

I had great hope for health care reform when Obama was elected, but it has become obvious that nothing but more bullshit is on the way. Chuck Schumer has laid out the bullet points for a "compromise" health care bill. It would entail the following:

1) No government or taxpayer subsidy of the public plan. All money is to come from premiums and copays.

2) The plan must pay doctors and hospitals more than Medicare does.

3) Doctors and hospitals are not to be compelled to participate in the plan even if they accept Medicare.

Note that this isn't the Republican starting point for negotiations... this is the supposed compromise blueprint laid out by Democrat Chuck Schumer. Anybody with a brain can see that this is doomed to complete and utter failure. If all of points 1-3 are true, then either the monthly premiums for being part of this plan must be very high (which defeats the purpose of national health care) OR there will be virtually no doctors and hospitals participating (which makes it pointless for patients).

It's all a farcical charade.
posted by Justinian at 11:16 PM on May 6, 2009 [10 favorites]

If by 2009 you don't already have your own blog...
posted by Pope Guilty at 11:16 PM on May 6, 2009 [7 favorites]

Protest is wonderful, but let's not forget that deliberation is supposed to have a role in our politics. If you must disrupt something with your protests, it should not be the deliberations of our elected representatives.
posted by grobstein at 11:39 PM on May 6, 2009 [4 favorites]

(We just had a national election in which health care was arguably the biggest issue. The system is working. You are not being oppressed just because you're not getting what you want.)
posted by grobstein at 11:41 PM on May 6, 2009 [3 favorites]

Eh, a little intrusive rabble will probably do congress good. The Republicans have pushed around the spineless Democrats for years, why not let the electorate have a turn. Wishful thinking, I know.
posted by ryanrs at 11:47 PM on May 6, 2009

Idiots. They set thier cause back with this shit.
posted by LarryC at 12:02 AM on May 7, 2009

1) No government or taxpayer subsidy of the public plan. All money is to come from premiums and copays.

There's a lot of workspace here that is a good for public policy improvement.

That's what insurance is . . . the more people we get in the pool the more we can pay for everyone and move the system from three-tier to universal.

Just throwing money at the problem via single-payer or whatever isn't the full solution.

As a self-employed person I'm paying $200/mo ($230/mo starting next quarter) for a PPO with $1750 annual deductible from BlueShield. I don't see why everyone can't join me via mandates -- ie. forced participation in plans like these.

We need to get costs -- profits -- down, and more people everyone insured.

I think -- and I mention this often online -- that there's a very subtle economics angle here that people don't understand -- mandated costs will largely come of out of rents in the end.

Land value and the rents we pay are the hidden surplus we don't even see, just as fish don't see water and we don't see air. Cut income taxes, land values will go up. Raise taxes, land values will go down. Now, I don't know if this is a 1:1 economic law but I for one don't fear mandates.
posted by mrt at 12:05 AM on May 7, 2009 [1 favorite]

That's what insurance is . . . the more people we get in the pool the more we can pay for everyone and move the system from three-tier to universal.

In theory. Problem is, private insurance firms have an incentive to make a profit. I don't relish paying out the ass for a plan where they can simply refuse to cover me for some bullshit reason like a preexisting condition.
posted by showbiz_liz at 12:09 AM on May 7, 2009 [7 favorites]

We just had a national election in which health care was arguably the biggest issue. The system is working.

Is it, really?

The people of the United States elected Obama and established a major legislative plurality tasked with rebuilding our crumbling national infrastructure, getting our troops out of Iraq, arresting and imprisoning Bush and his cronies for war crimes, and dealing with the disaster the private insurance industry has made out of American healthcare.

100+ days in and we still have telecom CEOs immunized, continued and massive redistribution of taxpayer-generated wealth to oligarchs and bankers, no clear and true end in sight to the Iraq war, no spine on dealing with the criminal chaos Bush and his friends perpetrated on our international reputation and our domestic economy, and we now seem to bear witness to compromise after compromise with health insurance companies on our physical well-being.

If the system is working, it's only working in the most cynical and Machiavellian sense for those already privileged.
posted by Blazecock Pileon at 12:14 AM on May 7, 2009 [52 favorites]

...responded to the doctors and their fellow activists with, “I want you to know I care deeply about your views," and then, "we need more police [to eject protesters].

The takeaway is that eight doctors would rather be arrested than have their view be unrepresented at this hearing. That's classic civil disobedience: break the law when the law needs to be broken, but accept punishment so as to show respect for the rule of law and to shame your jailers. Their protest would have been less meaningful had it been without consequences.

To look at it another way, there have to be consequences. Yes, it's a moral outrage that the US didn't implement single payer years ago, but self selected citizens don't get to interrupt Senate business just because they feel morally outraged. Awful as he is, tens of thousands of voters put Baucus in front of that microphone. Eight people were trying to shout him down.

The funny thing is that “I want you to know I care deeply about your views," and "we need more police" are not contradictory statements. I agree with what they said, but I also think that they ought to be arrested for staging this kind of protest.
posted by justsomebodythatyouusedtoknow at 12:16 AM on May 7, 2009 [7 favorites]

I don't relish paying out the ass for a plan where they can simply refuse to cover me for some bullshit reason like a preexisting condition.

yeah, in return for compulsory programs we really need to cut the hassles, overheads, and balkanization of who takes what coverage.
posted by mrt at 12:26 AM on May 7, 2009

100+ days in

Jesus Christ. Obama's got (we hope) 2800+ days left. I was in Japan at the time but in retrospect I think Clinton's major screw up was too far too fast in 1993-1994.

The shit's been fucked up for decades so a couple of years working towards a fix isn't that big a deal.
posted by mrt at 12:30 AM on May 7, 2009 [4 favorites]

assuming you currently have health insurance...
posted by ryanrs at 12:38 AM on May 7, 2009 [1 favorite]

It mystifies me that a country as wealthy as America doesn't have a national health system. It surely should be the absolutely first service the state provides with taxpayers' money, with all necessary treatment for every citizen given free at the point of need.
posted by imperium at 12:41 AM on May 7, 2009 [8 favorites]

The shit's been fucked up for decades so a couple of years working towards a fix isn't that big a deal.

A couple of years = $10,000 dollars in my health insurance costs. Health insurance, not total health care. Add another thousand or so for things that weren't covered.

Forgive some of us if we feel impatient.
posted by Kutsuwamushi at 12:42 AM on May 7, 2009 [8 favorites]

They did the right thing. Look, huge numbers of Americans support single payer:
CBS poll

Yet, despite the fact that nearly half of Americans support single payer, it is "off the table." So our elected "representatives" can see that almost half of Americans support government provided health care for all problems, yet they're not even going to discuss the option. Seriously WTF? WHAT THE FUCK? When you see those facts together, it makes one think that the insurance companies have bought and paid for the Congress.

It is totally unacceptable that our Congresspeople so clearly represent narrow moneyed interests, whom President Theodore Roosevelt referred to as malefactors of great wealth, over that of those of the American people as a whole. It is disgusting. I saw the CSPAN footage, and I think what those protesters did was in the great American tradition of civil disobedience. It was necessary.

As to "hurting the cause," well, with that logic, African Americans should never have sat at all white lunch counters, or shut down Birmingham. Yeah, they should have just quietly and meekly asked the great white father for their rights. That's ridiculous. You know why middle Americans don't respect liberals? Because for too long liberals just wanted to take the bullshit, oh-no-gosh-what-if-someone-is-offended, Caspar Milquetoast approach to politics. And look what that's gotten us.
posted by wuwei at 12:52 AM on May 7, 2009 [34 favorites]

It mystifies me that a country as wealthy as America

Have you looked at the government's books? We're already indebted far past our ability to pay. It's already inevitable that we'll be reneging on our liabilities, because we're simply unwilling to stop spending far more than take in. We'll try to hide it in any number of different ways, using any number of different catchphrases, and blaming various targets-of-the-month, but renege we will.

Since we can't even keep the promises we've already made, we're in no position to be making extravagant new ones.
posted by Malor at 12:57 AM on May 7, 2009 [3 favorites]

Yet, despite the fact that nearly half of Americans support single payer, it is "off the table." So our elected "representatives" can see that almost half of Americans support government provided health care for all problems, yet they're not even going to discuss the option. Seriously WTF? WHAT THE FUCK? When you see those facts together, it makes one think that the insurance companies have bought and paid for the Congress.

It's the same as in every other instance where the electorate itself is significantly to the left not only of the GOP, but of the Dems. There is a... well, I guess you'd call it a consensus among the professional political class that certain ideas and policies and whatnot are "unserious" or "too far", despite very large amounts of support in the population. Marijuana decriminalization is another such issue where the people favor it but even suggesting it as a national-level politician gets eyes rolled at you.

Denis Kucinich resembles more of the population than the consensus is happy to admit.
posted by Pope Guilty at 1:02 AM on May 7, 2009 [33 favorites]

with all necessary treatment for every citizen given free at the point of need

I was thinking about this recently, how the Fire Department doesn't send you a bill for saving your house.

But there's a lot more demand -- a universal demand -- for health services and since health is our foremost item of personal wealth -- wealth is to be well, after all -- there's plenty of rents to be collected for those involved in the supply of it.

The promised care we provide our seniors via Medicare, when added up, is a lot of money -- Tens of trillions of dollars of so-called future unfunded mandates.

The major drug manufacturers run a profit margin that would make Steve Ballmer and whoever's running Apple now blanche at its raw pricing power over the consumer.

If present trends continue this will be a nation of wage slaves ruled by our medical service provider overlords -- but to a large extent this is already true. Medical professionals are already extracting shedloads of quasi-rents to provide their guild services to us.

Part of the expense of health care is that it is labor-intensive, and the skilled laborers seem to be happiest making a thousand an hour or so.

"Free at the point of need" and these high wages don't go together so well. Something's gotta give. Much of the fortunate portion of the populace -- like me -- with good access to the guild providers don't want the system monkeyed with, they've got theirs so sod off if you can't get in.

We basically need to double the service providers and slash the profit margins, plus of course whatever bugbears our conservative friends on the right point out as fixable inefficiencies, like tort reform (punitive damages going to the state would be a start).

People now think Medicare is an actual viable program, but if my Mom's experience in the Central Valley in Fresno is of any relevance, it's a total crock, one step above being treated as a campesino on charity case.
posted by mrt at 1:09 AM on May 7, 2009 [4 favorites]

Since we can't even keep the promises we've already made, we're in no position to be making extravagant new ones.

Just gotta tax people more. All these billionaires and multimillionaires should get sheared of their taxable surplus since the wealth of america is created by its wage earners and how it got into people like Paris Hilton (I went there) 's hands is an injustice -- anybody making over the FICA limit is a rentier to some extent.

'course, I'd tax land wealth first and capital last but that's a total non-starter unfortunately.
posted by mrt at 1:13 AM on May 7, 2009

Since we can't even keep the promises we've already made, we're in no position to be making extravagant new ones.

It'd be very easy to do - but unfortunately over 50% of the budget is defense and therefore untouchable. Obama supports increased military spending. With that and the bailouts, doing anything useful with our money is out-of-the-question.
posted by lupus_yonderboy at 1:14 AM on May 7, 2009 [2 favorites]

Denis Kucinich resembles more of the population than the consensus is happy to admit.

yeah, well, how many faithful listeners do O'Reilly, Rush, Savage, Hannity, and Dr Laura have?

The problem is that rational, thoughtful people are balanced if not outnumbered by the idiot right, which causes our national politics to triangulate toward them. Reminder, in 2005 a Harris Poll found "A majority of U.S. adults (54%) do not think human beings developed from earlier species, up from 46 percent in 1994."[1]. Whenever I say we our a nation of idiots, I'm thinking of these people.
posted by mrt at 1:19 AM on May 7, 2009 [1 favorite]

Obama supports increased military spending.

I'll be right alongside Pileon on the barricades if we're spending more than $500B per year in FY11.

Outspending the rest of the world on military crap is unsustainable, and worse, is stupid.

But, again, changing shit requires tactics. Obama's got all the slack he needs from me for as long as he needs it. But if the shit doesn't change, then yeah, he'll be a miserable failure to add to the others.

Of course, every $1 billion in military spending is, or should be, ten or twenty thousand jobs. If I were king I'd cut $300B tomorrow but that'd be around four million lost jobs (and if it's not 4 million jobs I want to know where the money is being siphoned off).
posted by mrt at 1:24 AM on May 7, 2009 [1 favorite]

Of course, every $1 billion in military spending is, or should be, ten or twenty thousand jobs. If I were king I'd cut $300B tomorrow but that'd be around four million lost jobs (and if it's not 4 million jobs I want to know where the money is being siphoned off).

The idea is that if we're not spending that money on the military, it will be spent on other economic activity that will also require employing people -- hopefully in ways that don't involve so much killing.
posted by grobstein at 1:39 AM on May 7, 2009 [3 favorites]

That's what insurance is . . . the more people we get in the pool the more we can pay for everyone and move the system from three-tier to universal.

It doesn't work if there's more than one pool.

The fundamental problem of multi-payer for-profit health care. There is a huge disincentive for paying for preventative care.

Why?

You are Payer AA (of many.) You decide you want to lower your payouts, by increasing preventative and early care. You, thusly, offer more coverage on those items. Your insured pool becomes healthier. It's working.

And your competitors, seeing this, sweep in and lowball the insurance premiums on your pool, taking your healthier pool away. Or, in other words, Payer AA just spent money making (now) Payer's BB covered pool healthier.

Most people do not stay with a single payer for any real length of time -- between job changes, and between employers changing coverage to (attempt) to save money, who's actually going to be covering you in five years is a crapshoot. It's likely not to be the person covering you now. So, there's another factor -- why make your currently covered pool healthier, when not doing so is cheaper, and it's likely that when a member of your current pool becomes seriously ill, somebody else is paying for that -- even though early care would have seriously reduced the costs, it doesn't reduce the current payer's costs. So why do early care? You don't make money making your future competitor's insured pool healthier!

Single payer aligns the economic interests of the payer and the insured. There's now a serious interest in preventative care, because the payer knows that they'll be paying for the care down the road. We have a real life demonstration in this, in the VA. They known that they're going to have to cover their patients for life, not until the next year when health care benefits are redone. Thus, they have serious interests in this, since the Clinton Administration decided to fix the VA, they're showing just what single payer -- even in an incredibly unhealthy population -- can do in terms of reducing costs *AND* improving outcomes.

Because the VA will pay for the care regardless, they'll do their best to make sure that you get the $1500 treatment now if there's a decent chance that it will avoid a $150,000 treatment requirement in three years.

Multi-payer means multiple pools, and the competition becomes to force the unhealthy into another pool. And, of course, the simplest way to make a larger pool is to simply merge two existing pools.

But the real magic is that single payer means that the payer *knows* they're going to be paying for the care, no matter if it happens today or ten years from now.
posted by eriko at 1:40 AM on May 7, 2009 [28 favorites]

In other words an ounce of prevention is worth a pound of cure, and anybody who has to buy the pound would rather pay for the ounce.
posted by Pope Guilty at 2:28 AM on May 7, 2009

There will never be national health care in the United States.

The threat of loss of employer-provided health insurance is one of the surest tools available for an employer to keep its employees in line & working hard until the time comes for the employer to lay them off.
posted by Forrest Greene at 2:40 AM on May 7, 2009 [18 favorites]

Don't tase me, HMO!
posted by Rykey at 3:05 AM on May 7, 2009 [3 favorites]

In other words an ounce of prevention is worth a pound of cure, and anybody who has to buy the pound would rather pay for the ounce.

Right. And if you think there's a good chance that someone else will have to buy the pound, why spend for the ounce now?
posted by eriko at 3:17 AM on May 7, 2009

As a self-employed person I'm paying $200/mo ($230/mo starting next quarter) for a PPO with $1750 annual deductible from BlueShield. I don't see why everyone can't join me via mandates -- ie. forced participation in plans like these.

Because a plan like this is useless if you have a chronic illness, or you don't have $1750 sitting around to pay the deductible. Also, as stated above, many of us would be turned down for a plan like this, or, if they took our money, every claim we sent them would be rejected.

The number one reason to get rid of the insurance companies is because of the cost of the paperwork and the staff WE pay to reject our claims so the shareholders can make more money. It is a nonsensical business model to anyone not indoctrinated into our system.
posted by hydropsyche at 3:55 AM on May 7, 2009 [5 favorites]

The threat of loss of employer-provided health insurance is one of the surest tools available for an employer to keep its employees in line & working hard until the time comes for the employer to lay them off.

The cost of employer-provided health insurance is slaughtering companies in the United States. It's the reason why US automakers have so much trouble competing with Japan. We're having this conversation because we've reached the point where private insurance is facing complete and total system dysfunction, and we need a single-payer system. The Democrats, who are major beneficiaries of the current system, are scrabbling for ways to save it. They won't work.
posted by graymouser at 4:10 AM on May 7, 2009 [5 favorites]

The big numbers say it all.

The US, #1 in health spending per person, #45 in life expectancy.

I've lived in Europe, the US and Australia. People here sometimes don't realise it but the US is really richer, the GDP per head figures at PPP are pretty much on. But US health care is down right scary. It is really weird for a foreigner to wonder why the rest of the world is not used as an example for you Americans. The figures are clear, Australia, the UK, Japan have a better system. How can the US polity ignore this?

It's surprising that there isn't a bunch of big industrial employers who are out supporting this. A big part of the problem with the US auto industry is the extraordinary inefficiency of the US health care system. US industry is forced to pay what is almost a tax to scary, dodgy US health care 'providers'.
posted by sien at 4:34 AM on May 7, 2009 [5 favorites]

> Obama supports increased military spending.

This was not the change I was looking for.

> How can the US polity ignore this?

Because, SOSHALIZM!!!!!
posted by Stonewall Jackson at 4:36 AM on May 7, 2009

The Republican Party is at a low ebb but that only means that conservatives and the wealthy just fall back to the second line of defense: media ownership and corporate control of the political process.
posted by DU at 4:36 AM on May 7, 2009 [3 favorites]

As a self-employed person I'm paying $200/mo ($230/mo starting next quarter) for a PPO with $1750 annual deductible from BlueShield. I don't see why everyone can't join me via mandates -- ie. forced participation in plans like these.

Are you sure you'll be able to use that when you need to?
posted by stavrogin at 4:38 AM on May 7, 2009 [1 favorite]

As a self-employed person I'm paying $200/mo ($230/mo starting next quarter) for a PPO with $1750 annual deductible from BlueShield. I don't see why everyone can't join me via mandates -- ie. forced participation in plans like these.

That's pretty reasonable, but only possible in certain areas. I bought single-payer for myself about 3 years ago for six months, and it was $200 a month for a $15,000 deductible. For a 32-year-old. The only reason I had it was to maintain coverage for any preexisting condition crap.

I find it laughable that nobody in Congress ever seems to think about the fact that universal health care coverage would probably spur a boom in entrepreneurship, as all the people who have great ideas finally try to put them into practice once they don't have to worry about health care costs any more.

The United States pays about twice as much per capita for health care, once all costs are accounted for, including those without coverage, than many other countries. Just think of how much more efficiency we could find with universal coverage.

Sure, there would probably be bureaucracy, but at least a significant portion of our population wouldn't be using the ER for primary care.
posted by miss tea at 4:39 AM on May 7, 2009

As a self-employed person I'm paying $200/mo ($230/mo starting next quarter) for a PPO with $1750 annual deductible from BlueShield. I don't see why everyone can't join me via mandates -- ie. forced participation in plans like these.

Well, aren't you a lucky, healthy single person? How long have you had that plan? You're probably due for the cursory 28% rate increase.

Now, add a spouse and a couple of kids to your plan. Let's say one of them has a seasonal allergy problem, just to keep things real. Guess what? Now you're talking $800-1,200/month, with a minimum $2500 individual deductible and a $5000 family deductible (which kicks in only if at least one member of your family actually hits the $2500 individual mark) Oh, and no prescription co-pays. You pay the negotiated price. And, of course, no dental or vision. And this is an "affordable" plan. From one of the Blues.

Congresscritters should be required to live on the US average income during their tenure and shop for/purchase their own family health insurance from the open market. Bet things would change overnight.
posted by Thorzdad at 4:43 AM on May 7, 2009 [16 favorites]

Now, add a spouse and a couple of kids to your plan. Let's say one of them has a seasonal allergy problem, just to keep things real. Guess what? Now you're talking $800-1,200/month, with a minimum $2500 individual deductible and a $5000 family deductible (which kicks in only if at least one member of your family actually hits the $2500 individual mark) Oh, and no prescription co-pays. You pay the negotiated price. And, of course, no dental or vision. And this is an "affordable" plan. From one of the Blues.

As a Godless Canuck I read stuff like this and wonder...what do plans like these actually cover? When health plans are that expensive and cover that little, what's the point?
posted by you just lost the game at 4:53 AM on May 7, 2009 [4 favorites]

As a self-employed person I'm paying $200/mo ($230/mo starting next quarter)

I may be comparing apples and oranges here, but what strikes me about the US private health system is how much you pay for so damn little!

$230 a month is about $300 Australian. I pay $170 a month for Hospital + Extras cover for my whole family. Not that I've ever had to make a claim on it, because every health care need we've ever had has been covered by the public health care system. But it's there incase any of us ever need elective surgery quickly, basically.

And I keep hearing stories about people in the US being denied care by insurance companies (preexisting conditions, all that shit). That seems like a complete scam - insurance companies making arbitrary decisions about people's lives, independent of what doctors say they actually need.

You appear to have the worst of both worlds, with the only people with the ability to change it being completely bought and paid for by the only people who benefit from it. Someone should start a movement to get anyone (Democrat or Republican) who's ever accepted money from the private health industry the hell out of congress.
posted by Jimbob at 4:55 AM on May 7, 2009 [11 favorites]

Now, add a spouse and a couple of kids to your plan. Let's say one of them has a seasonal allergy problem, just to keep things real. Guess what? Now you're talking $800-1,200/month, with a minimum $2500 individual deductible and a $5000 family deductible (which kicks in only if at least one member of your family actually hits the $2500 individual mark) Oh, and no prescription co-pays. You pay the negotiated price. And, of course, no dental or vision. And this is an "affordable" plan. From one of the Blues.

Yep, no exaggeration. We pay more for our insurance than for our mortgage. Think about what that means for a second. I make an average salary and no one in my family is particularly ill, but I have pay for a SECOND HOUSE just to make sure we are covered in case "anything happens".
posted by DU at 4:58 AM on May 7, 2009 [3 favorites]

ie. forced participation in plans like these.

So yet another group gets a protected market by government fiat.

Do I get to write off the money spent? Do the citizens who are now compelled to pay get any say about the level of compensation the Insurance Company staff/CEO gets? How about them fancy looking buildings most insurance firms are in? With this magic mandate - what about the present rejected claims issues - that going to be addressed?

More of taking public money into private hands for private benefit. Combining Government power and the ethics of Corporations - why that should work out really well for the citizens!

Oh and 3 words: American International Group (AIG) - now lets talk about Government then bailing out the Insurance firms.
posted by rough ashlar at 5:08 AM on May 7, 2009

what do plans like these actually cover?

In the documentary series done by Mr. Python - #17 I believe - covers that question:

Vicar: you refuse to pay my claim.
Devious: (rising and crossing to a filing cabinet) Oh well, reverend Morrison...in your policy...in your policy...(he open the drawer of the filing cabinet and takes out a shabby old sports jacket; he feels in the pocket and pulls out a crumbled dog-eared piece of paper then puts the coat back and shuts the filing cabinet)...here we are. It states quite clearly that no claim you make will be paid.
Vicar: Oh dear.
Devious: You see, you unfortunately plumped for our 'Neverpay' policy, which, you know, if you never claim is very worthwhile...but you had to claim, and, well, there it is.
Vicar: Oh dear, oh dear.
Devious: Still, never mind - could be worse.
posted by rough ashlar at 5:12 AM on May 7, 2009

Malor Since we can't even keep the promises we've already made, we're in no position to be making extravagant new ones.

But it's not making an extravagant new promise, it's the very opposite: making drastic savings. You wouldn't be adding single-payer health care to existing spending, you'd be replacing the current grossly inefficient, expensive, and poorly implemented system.

On an individual level it'd be like buying groceries and learning to cook: a non-zero cost, but when you take into account the fact it's replacing buying whatever takeaway crap is available where you are whenever you happen to be hungry (and hoping you never get hungry after midnight), it looks a lot more sensible.
posted by aeschenkarnos at 5:31 AM on May 7, 2009 [4 favorites]

As a Godless Canuck I read stuff like this and wonder...what do plans like these actually cover? When health plans are that expensive and cover that little, what's the point?

Several years ago I spent five days in the Intensive Care Unit, and another two weeks in recovery. The total bill was approximately $25,000. So, to answer your question: because the cost of not having insurance is at least an order of magnitude more scary.
posted by Civil_Disobedient at 5:35 AM on May 7, 2009

There will never be national health care in the United States.

The threat of loss of employer-provided health insurance is one of the surest tools available for an employer to keep its employees in line & working hard until the time comes for the employer to lay them off.

You're wrong. Well, you're right about the corporate greed and need in keeping the status quo. But you're wrong about national health care. It will happen; bit by bit, in increments, side by side with private plans which will continue indefinitely. But at least an option for government health insurance for anyone, not just the poor, will happen. Not like the European model, not yet anyway. More like Japan, where govt. insurance is an option like all the private ones.

Here's why things will change: the current system we have now is unsustainable. (I'll resist the urge to further make my point by putting that last word in allcaps, flashing, scrolling, etc. You get the idea).

Republicans have traditionally been the blockers of this change, but things are genuinely different now because a) The Republican party is shrinking and b) the average Republican voter is just as fucking fed up with insurance bullshit as anyone else. Hell, FOX News gave Michael Moore's Sicko a glowing review.

The problem is exactly what's going on with douchebags mentioned in the story, Congressional douchebags from both parties who are at the beck and call of health insurance lobbies. I'd hate to be the reviled single-issue voter, but there's probably no better reason to become one than over the creation of national health care.
posted by zardoz at 5:48 AM on May 7, 2009 [1 favorite]

This is what pisses me off the most about all of this. We all call this stuff health insurance. It is not insurance. You will need to visit a doctor. You should be visiting a doctor. You should be taking preventative steps to stay healthy. That is not insurance, that is health care.

Insurance is for stuff that may happen. Your roof might get a tree on it. Your car may be involved in a wreck. May, maybe, possibly.

Insurance is a hedge against bad things happening. Health insurance is essentially a selective discount program where what gets discounted is determined by people with an eye on their bottom line and little concern for the big picture of health.

I like to think that if we started talking about paying for health care, it would become a lot clearer to everyone that we're not descending into socialism, but instead cutting out a middleman that is taking a huge chunk for himself and causing other problems as well.

Don't forget that some of the high costs of health care are driven by those very insurers. See, they all demand discount rates from health care providers. For those providers to make their nut, they've got to have sufficiently high base rates to be able to discount to a survivable level. So the end result of that is anyone without insurance (a discount plan) is screwed.
posted by BeReasonable at 5:54 AM on May 7, 2009 [6 favorites]

So the end result of that is anyone without insurance (a discount plan) is screwed.

And that would make for a fun lawsuit. What's your "price" and why am I being "oppressed".

Love to see someone take it court on the basis of unfair trade.
posted by rough ashlar at 6:02 AM on May 7, 2009 [1 favorite]

Rough Ashlar, how is the naked lady?
posted by WinnipegDragon at 6:40 AM on May 7, 2009

Rough Ashlar, how is the naked lady?

More fun than the Bishop I tell you what.
posted by rough ashlar at 6:42 AM on May 7, 2009

Idiots. They set thier cause back with this shit.

Of course. Most rational people would rather go without healthcare just to spite some annoying hippies!

As a self-employed person I'm paying $200/mo ($230/mo starting next quarter) for a PPO with $1750 annual deductible from BlueShield. I don't see why everyone can't join me via mandates -- ie. forced participation in plans like these.

How do you know your insurance company won't just dump your plan if you actually get sick? That happens to a lot of people, you know. I don't see why I should be forced to pay for a product that can and is revoked when it's actually needed. But given then evil that these insurance companies have been engaged in for years, why the hell should I be forced to pay them, and let their shareholders take a chunk of my money in profits and make choices about my healthcare designed to further their bottom line?

I don't think Single payer is necessary, but there should at least be a public plan. If people have to choose between private insurance companies, why shouldn't they be able to opt out? Why should these companies be rewarded for fucking up U.S. healthcare for decades?

The people of the United States elected Obama and established a major legislative plurality tasked with rebuilding our crumbling national infrastructure, getting our troops out of Iraq, arresting and imprisoning Bush and his cronies for war crimes, and dealing with the disaster the private insurance industry has made out of American healthcare.

Obama never said anything about "arresting bush and his cronies for war crimes"
posted by delmoi at 7:02 AM on May 7, 2009 [1 favorite]

"Health Care" in the United States is a for-profit business, selling a product. It must have a good profit margin, like anything else. It has lobbyists who try to influence Congress to make laws to their benefit, and that's why we spend the most, yet are 40th in lige expectancy. Until we do something about healthcare as a for-profit industry, we will continue to spend lots of money, not very effectively.
posted by GreyFoxVT at 7:05 AM on May 7, 2009

This stuff terrifies me. Literally terrifies me.

A couple of years ago I had some major health problems and had to be hospitalized multiple times. I was nineteen and a college student, and I had insurance. When the bills came, the insurance covered the first hospital stay, but some technicality in the coverage plan exempted them from paying for the subsequent ones, and there was nothing I could do. The bills came, for thousands of dollars which I did not have, and then the calls from collection agencies and the threats.

The past several years have involved seemingly endless financial struggle, and exhausting, awful jobs. Plus the worry over my continuing health issues, and how I could possibly pay for health care when I needed it. I eventually lost the health coverage I did have, and am basically unable to find new insurance. Plans like the one mrt mentions would never cover me, with all my pre-existing conditions. Meanwhile I have medication I have to take every day, and it's not generic. Sometimes I can get free samples, sometimes I have to pay through the nose.

Unless something changes, really changes, with our health system, these problems will probably be with me for my whole damn life. My medical issues are not going away. I look forward to a future of worrying about finding insurance, worrying about whether my insurance will cover what I need, worrying about paying the exorbitant prices that insurance would cost me and covering all the left over, non-covered costs. Or else not having insurance at all, and facing a constant barrage of medical bills, and that awful terror and weighing of the possibilities that comes when you're sick but just cannot afford to go to the doctor right now. I don't want to be in debt my whole life.

I had a lot of hope that the Obama administration would usher in a new health care system. Maybe that was naive, my hopes blinding me to the reality of our political processes. Congress is pumped full of health insurance money. Compromises abound. "Singe-payer is off the table"-- How the fuck can single-payer be off the table? There is massive popular support for single-payer.

So yes, protest on, doctors and advocates. Health insurance lobbyists should be arrested for disrupting congress.
posted by bookish at 7:16 AM on May 7, 2009 [18 favorites]

The shit's been fucked up for decades so a couple of years working towards a fix isn't that big a deal.

No, you have to spend the political capital NOW. It gets harder the longer the adminstration is in office and more people have time to complain. This was Clinton's fundamental problem when he took office.

This whole thing is disappointing. I mean, I'm under no illusions about the fact that health insurance companies are going to have a hand in writing reform legislation. But to have single-payer advocates totally shut out of the discussion? Is our system that broken? I don't know if support for single payer is actually 50% of the electorate, but it is certainly sizeable proportion probably the single largest unified and organized group. And PNHP is an impressively reasonable group that has spent years creating an incredibly logical argument for their proposed solution (These are not crazy out of touch hippies, I have been to several local meetings here -- these are mainstream physicians, respected in the medical community who have spent their careers struggling with the inadequacies of the system and researching solutions). And now, after sweeping electoral change (the kind we're not likely to see for again for a long time), they find themselves having to shout their message from the back of committee chambers, getting arrested in the process.

There is enough public support and well researched evidence from experts in the field to push this through. I'm willing to accept that our politicians and media have been somewhat corrupted and that there will be some kind of compromise. But to completely ignore the obvious no-brainer solution? There is something much more fundamentally wrong with the system.
posted by Slarty Bartfast at 7:38 AM on May 7, 2009

As a self-employed person I'm paying $200/mo ($230/mo starting next quarter) for a PPO with $1750 annual deductible from BlueShield. I don't see why everyone can't join me via mandates -- ie. forced participation in plans like these.

We need to get costs -- profits -- down, and more people everyone insured.
posted by mrt at 12:05 AM on May 7 [1 favorite +] [!]

okay mrt, time for a Canadian (me) to explain why you're being ripped off. I pay about $50 3 times a year for my healthcare plan. Because of my low income my plan completely pays for my medication (long term only) and I have to pay only $20 if I need to get physiotherapy or chiro. I can have this expense written off completely with a doctors note and I can get 100% of this money back via tax return.

I acknowledge that our systems not perfect. Whenever I visit a hospital after a seizure the whole thing takes pretty long (2 hours Prince George, 4 hours Royal Colombian [Vancouver]).

I know that your guys' healthcare reform is none of my buisness but if you think this is a good deal or than every person can afford a $200/mo regressive fee then you're sadly mistaken.
posted by Pseudology at 7:43 AM on May 7, 2009

Bookish, if I were in your position, I would probably choose to leave the country. Thank you for sharing your story.
posted by Slarty Bartfast at 7:43 AM on May 7, 2009

This: Health insurance lobbyists should be arrested for disrupting congress.
posted by nax at 7:46 AM on May 7, 2009 [2 favorites]

The system will not change for one simple reason: you're all gonna pay anyway.

Oh sure, you're gonna mewl and whine while you're paying, but you're still gonna pay and slink away quietly in the end to meet your fates.

As long as that's true, there's no reason for anything to change. There's no penalty for continuing to operate as-is. None.
posted by aramaic at 7:46 AM on May 7, 2009 [1 favorite]

Yep, no exaggeration. We pay more for our insurance than for our mortgage. Think about what that means for a second. I make an average salary and no one in my family is particularly ill, but I have pay for a SECOND HOUSE just to make sure we are covered in case "anything happens".

This is not a bad thing. As long as health care is expensive someone's going to have to pay it. Why not you? What are the chances one of your family is going to run into a $100,000 bill in the next 10 years? Are you saving for this eventuality?

The problem with subsidized health care is that someone will take those savings and go buy that SECOND HOUSE, essentially transferring wealth from taxpayers to speculators.

This is not to say that health care needs massive cost and profit slicing, and insurance needs to be single pay or equivalent. The question is how do we get there from here.
posted by mrt at 7:47 AM on May 7, 2009

I wish I could get one of those 200-dollar-a-month plans. Even if it had a big deductible, since I have a savings account for that sort of emergency. Oh, wait, no I don't, we had to spend that on my father-in-law's Alzheimer's care, which costs ten grand a month and isn't covered by his VA insurance, Medicare, his AARP insurance, or any other gap-filling insurance he has. Of course his retirement plans are all cleaned out and any savings he had. Bye bye nest egg, for two different households, and now we have to try to sell his house in this shit market.

God help us if something happens to my husband or me. No insurance, no safety net. I had a scary thing happen yesterday; turned out to just be an optical migraine but I didn't know that at the time. Think I "called my doctor" or went to the hospital? Hell no! I don't have a doctor! And I know an ambulance ride is a four-digit splurge even if nothing's wrong, and I don't have that kind of cash.

The system is broken. Eight protesters is nothing; we need pitchforks and torches and mobs.
posted by bink at 7:51 AM on May 7, 2009 [4 favorites]

The problem with subsidized health care is that someone will take those savings and go buy that SECOND HOUSE, essentially transferring wealth from taxpayers to speculators.

What a bizarre argument.
posted by Slarty Bartfast at 7:54 AM on May 7, 2009 [1 favorite]

but if you think this is a good deal

Yes, yes I do. Canada has the population of California. It can afford to be more socialist.

But as Prop 8 showed, California really isn't the Moonbeam left state. We've got Orange County and San Diego rivieras where all the stupendously wealthy live, plus the central valley which looks a lot like Alberta in politics still.

but if you think this is a good deal or than every person can afford a $200/mo regressive fee then you're sadly mistaken.or than every person can afford a $200/mo regressive fee then you're sadly mistaken.

How much is your rent? My argument is that rents will fall (up to) $200/mo eventually. $200/mo for $6 million coverage of future care seems fair to me!
posted by mrt at 7:55 AM on May 7, 2009

mrt: "The problem with subsidized health care is that someone will take those savings and go buy that SECOND HOUSE, essentially transferring wealth from taxpayers to speculators.

What the fuck are you going on about? Making shit up whole-cloth now?
posted by notsnot at 7:57 AM on May 7, 2009

The system will not change for one simple reason: you're all gonna pay anyway.

Oh sure, you're gonna mewl and whine while you're paying, but you're still gonna pay and slink away quietly in the end to meet your fates.

As long as that's true, there's no reason for anything to change. There's no penalty for continuing to operate as-is. None.

That's what has been true up to this point. Being without access to health care is pretty scary and insurance companies prey on that. But there is a point for everyone where the equation shifts. In my family, with a lot of hardship, we probably could weather a single $100,000 catastrophe. I'm not sure we could weather a $3000 a month premium.
posted by Slarty Bartfast at 7:59 AM on May 7, 2009

What a bizarre argument.

It's a subtle argument. Similar to the mortgage interest deduction serving to just raise home prices by the amount of the cost savings.

When you give a $X00 monthly subsidy to everyone in the end it's going to end up in land prices and rents. This is the law of the "All-Devouring Rent". Churchill made a speech on this 100 years ago:

"And a friend of mine was telling me the other day that in the parish of Southwark about £350 a year, roughly speaking, was given away in doles of bread by charitable people in connection with one of the churches, and as a consequence of this the competition for small houses, but more particularly for single-roomed tenements, is, we are told, so great that rents are considerably higher than in the neighbouring district. All goes back to the land, and the landowner, who in many cases, in most cases, is a worthy person utterly unconscious of the character of the methods by which he is enriched, is enabled with resistless strength to absorb to himself a share of almost every public and every private benefit, however important or however pitiful those benefits may be."
posted by mrt at 8:00 AM on May 7, 2009

> Several years ago I spent five days in the Intensive Care Unit, and another two weeks in recovery. The total bill was approximately $25,000. So, to answer your question: because the cost of not having insurance is at least an order of magnitude more scary.

This and several additional comments have left me wondering: Are Americans the battered spouse of their healthcare system?
posted by Decimask at 8:03 AM on May 7, 2009 [1 favorite]

How much is your rent? My argument is that rents will fall (up to) $200/mo eventually. $200/mo for $6 million coverage of future care seems fair to me!
posted by mrt at 7:55 AM on May 7 [+] [!]

Okay, BC Liberals spending 2 Billion a year on healthcare and they've actually dropped taxes. It's possible to be capitalist AND have a government healthcare system.

My rent is disproportionally high because I live in Whistler, home of the high demand housing, and it's already dropped $200/mo anyway thanks to the recession.

Face it, your country is run by politicians from the short yellow bus.
posted by Pseudology at 8:04 AM on May 7, 2009 [1 favorite]

How much is your rent? My argument is that rents will fall (up to) $200/mo eventually. $200/mo for $6 million coverage of future care seems fair to me!
posted by mrt at 7:55 AM on May 7 [+] [!]

We pay higher consumer costs (light bulbs, food, cars, etc.) in exchange for all this nice free healthcare and other functioning government services, not land prices. BTW, its worth it.
posted by Pseudology at 8:09 AM on May 7, 2009 [1 favorite]

There is enough public support and well researched evidence from experts in the field to push this through. I'm willing to accept that our politicians and media have been somewhat corrupted and that there will be some kind of compromise. But to completely ignore the obvious no-brainer solution?

I don't think that single-payer is being ignored at all, in fact. The single most controversial issue right now is whether the legislation that comes out of Baucus's committee is going to include a government-run plan as one of the options that people can select as their plan, even if they don't qualify for Medicare now.

Everyone, and I mean everyone, who is close to this debate in DC understands what a government-run option is: that's single-payer in sheep's clothing. Not right now--it's totally politically unfeasible to switch immediately to single-payer, not least because it would involve such a wrenching change to the 85% of the insured who currently receive insurance through their employer--but the understanding of everyone in the game is that a government-run plan represents a real incremental avenue to eventually getting to single-payer. That option would presumably be lower-cost, it'd be the 'default' plan for everyone who didn't select one, and over time (if it's well run) enough people pile in that one day, everyone--or nearly everyone--is in it. That's how you get to single payer from here. That's why everyone is watching which Senators are saying 'no way' to a government option (I'm looking at you, Specter) and which ones are pushing for it, because they understand that including that option means a high likelihood we'll evolve into a single-payer system within a decade or two.

While I'm sure lobbyists are a piece of why no one serious about health care reform is proposing single-payer right off of the bat, a MUCH bigger issue is that it's literally impossible for anyone with any experience running government health programs to believe that single-payer could be implemented in any way but incrementally. I mean, when Medicare Part D rolled out, a tiny fraction of the population (the elderly and disabled below the poverty line) saw just their insurance for prescription drugs change from one government program (run by the state) to another (run by the federal government). It was, not to put too fine a point on it, a total clusterfuck. Doesn't anyone else remember the pictures on the front pages of newspapers of 80-year-olds sitting on the curb in front of pharmacies, crying? The quotes from people about how they couldn't get the medications that kept their blood pressure from skyrocketing or their diabetes from spiraling out of control, because the computer couldn't find their name on any list? People experienced serious, serious disruptions in their care; I would be totally unsurprised if a number of people died because of disruptions in their medications. The major take-away for CMS (the organization that runs Medicare) was that they made a huge error in trying to switch over the 6 million people from Medicaid to Medicare in one day, rather than rolling it out slowly in waves across the country. And single payer advocates are proposing that we do something much more major (changing all medical insurance, not just prescription drug insurance) for 200 million people all at once. It's not surprising in the least to me that Senators and Representatives and the President and everyone else serious about this isn't listening to that proposal at all, because it's so far outside the realm of possibility that it's hard to take seriously.

I'm left wondering why the Physicians for a National Health Program are doing something so disruptive and counter-productive rather than working their asses off to build enough support for including a government-run plan in whatever passes. If you truly want to see single payer, you should be writing letters to your Representatives and Senators telling them that you demand the option of a government-run plan in the eventual health reform bill, then going out and getting all your neighbors to write the same letter. That's productive and stands a snowball's chance in hell of actually accomplishing single-payer. What PNHP did? Not so much.
posted by iminurmefi at 8:16 AM on May 7, 2009 [12 favorites]

And I keep hearing stories about people in the US being denied care by insurance companies (preexisting conditions, all that shit). That seems like a complete scam - insurance companies making arbitrary decisions about people's lives, independent of what doctors say they actually need.

The central problem is that the US has a population 10X the size of Canada, and 15X the size of Australia. We can't cover everyone's medical bills for $170 per family per month! Well we could, but income taxes would have to double.
posted by mrt at 8:58 AM on May 7, 2009

Serious question:

To those who expressed moral outrage that we don't have a gov't run care, how much do you expect us to save in switching?

To those who are in the industry and have actually studied the question, where can we actually effect savings? What happens to testing? What happens to pharma?
posted by FuManchu at 8:59 AM on May 7, 2009

Single payer systems would be an extraordinary asset for the management of chronic diseases that cost little if kept stable through periodic access and management by a physician. Things like diabetes, dementia, heart disease, hypertension. Real bread and butter stuff. Where it costs us dearly is in the "work-up" and care of the worried well. The phantom pain that your kid gets or you get, that we are now conditioned to expect a raft of bloodwork and a CT to diagnose or exclude something life-threatening, would have to go away, either all at once or in stages, and would require recalibrating the expectations of an entire one or two generations of the population as to what constitutes good care. A lot of patients in the Kaiser Perm system loathe their approach as it incorporates evidenced-based medicine, as opposed to "how can we make you happy/how can I stay out of malpractice court" medicine.

I suspect we will also have to adapt to the fact that a lot of the care will also be delivered by people with far less training than MD's - there simply aren't enough altruists out their willing to work decades with the sick for a salary they could exceed in a dozen other industries with similar or less training and far less risk and stress. If you pay a doctor working 70 hours a week 80-100K a year after training you will see either a total slowdown of care delivery, burnout, or a depletion of new graduates in favor of poorly trained midlevels, FMG's, or worse.

If some sort of universal minimum is not instituted we have assured our place in the world as a second or third-rate power.
posted by docpops at 9:07 AM on May 7, 2009

Face it, your country is run by politicians from the short yellow bus.

no, 54% populated by people riding the short bus.

It'd be nice if California could secede from our idiot Red State friends and become another BC. We've already lost most of the defense spending we had in the 80s.

But note that California itself has the population of Canada! While we have 150% of your national GDP, we also have a lot more income disparity -- ie. high-crime urban blight -- and a sizable powerbloc of conservatards that outmatch what you have in Alberta.
posted by mrt at 9:08 AM on May 7, 2009

mrt: "
The central problem is that the US has a population 10X the size of Canada, and 15X the size of Australia. We can't cover everyone's medical bills for $170 per family per month! Well we could, but income taxes would have to double."

Do you not understand teh concept of per capita?

I can cut approximately 45% out of health care costs right now: 31% of current private health insurance costs goes to figuring out what gets covered for each individual, and figuring out what to deny. In other words, actuarial overhead. Have an acorss-the board coverage for everyone, and there goes that. Then if you take the 10-20% profit ("shareholder value"!!!) Bam! there's the savings.

As for the millions of claims deniers (er, "adjusters"), they can finally get out of that job they hate and actually become what they wanted to be, i.e. health care providers. God knows we need primary care physicians. There's not enough PCPs to go around because it's one of the least profitable specialties. I know a coupld doctors that would love to be PCPs but are ER docs instead because of the headaches of claim forms, compliance issues, etc. Plus, there's an artificial demand for ER docs because of all the folks who have no insurance and use the ER as their PCP.
posted by notsnot at 9:11 AM on May 7, 2009 [6 favorites]

When you give a $X00 monthly subsidy to everyone in the end it's going to end up in land prices and rents.

Let's put aside the problem that rabid proponents of this kind of economic theory always get into by ignoring tertiary costs.

Instead let's look at one simple fact: Housing has a very hard limit with regards to supply and a fairly hard limit with regards to demand. Health care does not, and it makes this kind of comparison pretty flimsy.

Supply is a stark difference: They're not making any more land (except in small quantities in Dubai). Making actual units to sell is pretty costly and not very flexible. If you build a unit in DC you can't just up and move it to Boston.

Health care, on the other hand, is much more portable. Most doctors can relocate, as can much of the rest of the staff. Even an MRI can be had in a portable but limited unit. Training new doctors and staff does have a longer ramp-up time than building a single-family house, but our existing system is facing a shortage of RNs so we're not without problems there already.

Demand is the biggest (potential) area of difference here. Everyone, to some extent or another, needs a place to live. There's some quantity of people who want/have 2nd or Nth homes, but as a percentage they're irrelevant. They don't have an appreciable impact on the purchase price of homes for the 99.9% of the population who just want one place to lay their head at night.

Health care, on the other hand, has a capacity for HUGE variation in demand. Eriko very eloquently discussed the problem we have now with insurance companies looking to play the "someone else's problem" game. You can barely swing a cat without hitting a story talking about how if we just spend $1 on X we'd avoid $100 in Y health care costs. It's not a mental challenge at all to think of things that cost little to prevent but a lot to ignore.

Unmanaged diabetes - insulin vs amputations and blindness. Heart disease - statins vs bypass surgery. STDs - condoms vs penicillin/the-AZT-of-today.

The demand for health care can be varied in a way that housing demand never can. Trying to draw that parallel with regards to subsidies is impossible.
posted by phearlez at 9:22 AM on May 7, 2009 [1 favorite]

Do you not understand teh concept of per capita?

Per capita works both ways. Both Australia and Canada are continent-spanning countries with immense natural wealth to support their tiny populations.

The US is a nation of 300 millions, 100 million households. Half of this country faces rather dire economic conditions -- just look at our $800B/yr workfare defense budget and one trillion dollar 2010 deficit! Can you imagine what unemployment would be now if this were $100B like it should be?

I agree that there is a lot of administrative overhead and rack-rent profit that can and should be eliminated from the US present system, but the present system took decades to get screwed up and a quick pricing fix isn't going to be sufficient.
posted by mrt at 9:23 AM on May 7, 2009

notsnot, I think your numbers are off. Be sure that you're using premium-to-medical cost ratios, and not total revenues. A good chunk of insurance revenues come from investments, and shouldn't be used to calculate possible savings. Most MBRs are near 90% nowadays.
posted by FuManchu at 9:30 AM on May 7, 2009

I don't know about Australia, but I can assure that Canada does not have "immense natural wealth". Alberta has immense natural wealth. And it keeps cutting back on funding for education and social welfare programs. But that's because it's the Texas of Canada.

Ontario, where I live, has got very serious economic problems right now, since much of our economy is centred around manufacturing, especially automotive. So we just went from contributing to the federally managed program that equalizes funding for certain programs, to taking money from the feds to prop up our services. For the first time since the transfer payments program was introduced.
posted by djfiander at 9:36 AM on May 7, 2009

There's some quantity of people who want/have 2nd or Nth homes, but as a percentage they're irrelevant. They don't have an appreciable impact on the purchase price of homes for the 99.9% of the population who just want one place to lay their head at night.

25% of purchases in 2005-2006 in California were second homes. Most of the homes being bought now are for investment purposes at auctions. Land values in any desirable (ie crowded) area will ratchet up to suck every last disposable dollar from the middle class who live there, either via rents or mortgage payments. I fail to see what's controversial about this given recent history.

Everyone, to some extent or another, needs a place to live.

Everyone also wants to live somewhere nicer in their area. New move-up buyers also fed the real estate bubble 2003-2007, until the subprime crisis slaughtered that part of the dynamic.

Health care does not, and it makes this kind of comparison pretty flimsy.

It's my argument that the dominant components of any household's budget are government taxes and either the mortgage or rents, and that the latter will expand to fill any (incremental) gaps left by the former, since housing is incredibly responsive to consumer purchasing power.

Let's say we get sweeping systemic reforms, and health care costs the median J6P family $800 per month on average; if we subsidize this down to $200 per month in insurance payments then we either have to tax the family the other $600 or it will end up in increased rents (+$600/mo) and/or land values ($600/mo can support $150,000 in land value).

Or we could just soak the rich for that $600/mo, but I don't see what's wrong with having people pay for their government services.
posted by mrt at 9:42 AM on May 7, 2009

To those who expressed moral outrage that we don't have a gov't run care, how much do you expect us to save in switching?

The secondary impact is almost incalculable. Eriko discussed the "someone else's problem" issue with preventative care, but we have a similar issue with our workforce. Not all jobs offer health care, particularly lower paying ones, because why bother? Low skill labor is highly fungible - if Skippy gets too sick to work you just hire Slappy to take over his job stacking cans at the Wal-Mart. But there's an impact to the economy to have workers laid up.

For employers who offer benefits there's potentially crippling costs as well. The legacy health coverage costs to the auto industry are part of what's strangling them. It's debatable whether they made bad decisions by entering into these contracts with labor that saddle them with these costs, but it's beyond argument that they're having an impact on their ability to stay in business.

Thankfully we've more or less ended any argument in our society about whether it's in our interest to have an educated workforce and we've got a persistent public education system. Personally I think it's just as incontrovertible that it's in our interest to have a healthy workforce, and I think that's the debate we're going to have going forward.
posted by phearlez at 9:45 AM on May 7, 2009 [4 favorites]

In response to the "serious question"

If you believe it is morally outrageous that the US does not provide universal health care, it does not necessarily follow that you believe it will be cheaper. Sometimes doing the right thing costs money. It is still the right thing to do.

There are some areas where we might see cost savings

Administrative Costs:
Hospitals and doctors' offices have to comply with the arcane billing rules of up to dozens of payers. Then they have to fight with denials, send additional information, endlessly follow up. This adds cost to your health care encounters.

Chronic Care Costs:
People with chronic illness and poor or no health insurance often wait until they are in a crisis to receive medical care. Foot amputation or heart attack care for a patient with poorly controlled diabetes is expensive. Helping the patient control their diabetes with education, support groups, appropriate equipment, etc. is less expensive. For reasons outlined by others here, the voluntary private insurance system is incentivized to ignore this. This is probably the area where we could see the biggest savings. Happily, it would also provide the greatest increase in quality of life for patients.
posted by jeoc at 9:46 AM on May 7, 2009

Idiots. They set thier cause back with this shit.

Really? So health care is going to live or die by the actions of a few protesters? Our democracy must be very fragile and ready to collapse if that's true, but I don't believe it.
posted by krinklyfig at 9:51 AM on May 7, 2009 [1 favorite]

I am surely not the only one who suspects we need deep, fundamental changes toward significantly more progressiveness - WITH A BIG FUCKIN' SPINE - before change is going to come when it needs to.

I have completely stopped trusting politicians. Except, maybe, for Russ Feingold, who is the only non-wimp liberal politician I'm aware of. I'm proud that he's a congressman from my state.
posted by kldickson at 9:52 AM on May 7, 2009 [1 favorite]

Yes, yes I do. Canada has the population of California. It can afford to be more socialist.

There may be good arguments against single-payer (although I've never seen one), but this certainly ain't one of them. Maybe you can research "economies-of-scale", in your spare time. It's the main reason corporations (including insurance corporations), desire to get bigger and bigger.

Economic arguments against keeping the population healthy are all horseshit, anyway. Keeping insurance companies healthy at the expense of citizens is morally repugnant.

I am 48 years old, have Type-1 diabetes (which is the equivalent of leprosy or bubonic plague to insurance companies willing to cover me), have a family, a house, and no current job. I, too, pay more for insurance than my mortgage.

The problem is I get NOTHING at all guaranteed for those premiums. The insurance company is still free to, and never misses an opportunity to, make the rules up as they go along. They can dispute any little thing they want to. They can make any backroom deal they want to with the providers. They can refuse to pay their due, and I can't do shit about it; after paying EXTRA to get them to recognize that I exist in the first place.

This system is BROKEN. Anyone defending it, in any way,shape or form, is insane. Or bought. Or both.
posted by Benny Andajetz at 9:55 AM on May 7, 2009 [11 favorites]

iminurmefi,

Thank you once again for bringing your reasoned perspective to this debate. Things look a lot different out here and the arguments are emotional because the details of health care reform are complicated and easily grasped by the rest of us. I usually expect PNHP to represent my interests because they traditionally haven't resorted to tactics like this so reading this yesterday dismayed me. I agree with you when you say change will have to be incremental, but is it possible to get there without the health insurance companies stacking the deck against us?
posted by Slarty Bartfast at 9:56 AM on May 7, 2009

I acknowledge that our systems not perfect. Whenever I visit a hospital after a seizure the whole thing takes pretty long (2 hours Prince George, 4 hours Royal Colombian [Vancouver]).

The persistent idea that wait times in countries with socialized medicine are so much more onerous than in the US for-profit system is laughable to me.

Just a couple of months ago, my wife and I had to take our 2 and a half year old son to the emergency room late in the evening because he woke up coughing, vomiting and choking in his sleep, with a high fever. When we got to the ER he was still suffering from severe breathing problems. We arrived at the hospital around 9:00 PM and didn't even get in to see the triage nurse until around 3:00 AM! Instead we were left in the waiting room, acutely aware that our son would probably have to literally stop breathing and turn blue before we could get anyone's attention.

It's bullshit, is what it is. Absolutely every argument against fully publicly-funded health care is utter bullshit, and the only motivating factor for the politicians defending the status quo is to look out for the interests of what they see as their true constituency--which isn't people like you and me, not the citizens they're elected to represent, but the health care industry and other corporate interests that pay their way and guarantee plentiful new business opportunities for them when these so-called "public servants" leave office.

But what bears pointing out in this discussion is that the responsibility for making sensible and meaningful health-care reform happen lies squarely with the legislature. The only powers President Obama has to influence policy in this area are the veto (which, obviously, can't be used to directly pass anything new into law, though it can be used, to some extent, to exert pressure on the legislature) and the persuasive powers of the bully-pulpit. IMO, President Obama has done a lot to influence public opinion toward support for a public health care system. But while in our nation's past, significant popular pressure to enact particular reforms may have been enough to prompt meaningful legislative action, we don't live in that world anymore.

Public political pressure no longer meaningfully influences the legislative process because, while getting votes may be a prerequisite to getting elected, without sizable sums of money for campaigning, you literally can't get a major party nomination. And in a country where 1% of the population accounts for 22% of the total annual income earned (the largest income inequality gap in the developed world), it isn't hard to see who's got the home field advantage. In effect, our system currently gives wealthy interests the power to veto potential elected officials before they can even mount bids for office. Granted, it's disappointing that Obama hasn't taken more of a lead in addressing campaign finance reform (and declined public funding for his own campaign). But ultimately, it's up to us to really turn on the heat on our legislators if we want to see progress on most of these issues. Maybe it's getting to the point where that doesn't just mean letters and polite phone call, but sit-ins and human barricades.
posted by saulgoodman at 9:58 AM on May 7, 2009 [6 favorites]

25% of purchases in 2005-2006 in California were second homes. Most of the homes being bought now are for investment purposes at auctions.

You're conflating investment properties with second homes. The quantity of people who purchase another house with the intention of maintaining an ongoing alternate second location to live is statistically irrelevant. It also is another area where your analogy breaks down, as it's not possible to go out and get yourself MRIed so you can sell it to someone else 6 months down the road.

My problem was with what I read as your stating that a subsidy in health care will have a similar impact to mortgage subsidies. "Similar to the mortgage interest deduction serving to just raise home prices by the amount of the cost savings." I don't think putting $x into health care will raise total health care expenditures by $x, and I stated my problem with that idea.

It's my argument that the dominant components of any household's budget are government taxes and either the mortgage or rents, and that the latter will expand to fill any (incremental) gaps left by the former

Okay. I'm uninterested in that topic and, even if it's stipulated as a fact, don't think it's a good reason not to address the problems with health care availability in the US. So if that's the crux of your position then I've got nothing to say about it.
posted by phearlez at 9:58 AM on May 7, 2009

did i mention "meaningful'? /self-criticism
posted by saulgoodman at 10:00 AM on May 7, 2009

Part of the expense of health care is that it is labor-intensive, and the skilled laborers seem to be happiest making a thousand an hour or so.

IANAD--I hire them. Just want to push back a bit on the out-dated fantasy of physicians being the richest people in town. No doubt, physicians continue to make a comfortable living in most communities (except New York City, where laws of supply and demand keep salaries suppressed). However, it isn't what it used to be: primary care is grossly undercompensated compared to specialty care, and reimbursements (from both Medicare/Medicaid AND private insurance sometimes decrease , and at the very least do not increase at the same rate as direct costs (in a physician practice, human resources and pharmaceuticals are usually two of the most expensive). So a physician finds him or herself working harder (ie seeing more patients in a day) for progressively less take-home. Who would sign up for that? Which leads to...

We basically need to double the service providers

At the very least. Unfortunately, training a new doc takes 10 years, so even if more med schools were opened TODAY, we wouldn't see relief for a long time. And that physician will come out of med school with an average of $140,000 in student loan debt. The shortage, of course, is driving salaries up, which will also contribute to improved supply in the future, but for right now just adds to the healthcare systems cost.
posted by njbradburn at 10:01 AM on May 7, 2009 [2 favorites]

It's my argument that the dominant components of any household's budget are government taxes and either the mortgage or rents, and that the latter will expand to fill any (incremental) gaps left by the former

Then your argument's wrong. In my household, we don't even notice our tax liabilities, overall. Our biggest expenses apart from our mortgage tend to be food, daycare, gas, and, yep, health care.

Meanwhile, our state government is on the verge of collapse, failing to meet basic constitutionally-mandated public service obligations with teacher layoffs and deep service cuts everywhere you look because the only issue our legislature can be bothered to take any action on for the last ten years or so has been what the Republican leadership here touts as the "Property Tax Crisis," advancing a radical agenda of property tax rollbacks that even went so far as to subvert the long-established sovereign revenue generating authority of local (county and municipal) governments by setting limits on millage rate adjustments.

I'm so sick to death of hearing people whine about taxes that I think it's time for a pro-tax lobby: Americans for Responsible Taxation (ART) or something like that. Who's with me?

What do we want? More taxes! When do we want them? Now!

No. I'm not kidding. Fuck you, Norquist.
posted by saulgoodman at 10:15 AM on May 7, 2009 [13 favorites]

we don't even notice our tax liabilities, overall. Our biggest expenses apart from our mortgage

these two statements may be related. If you've got the standard $350,000 middle-class mortgage you're seeing $5000 or so in tax benefits if you live in my state.
posted by mrt at 10:35 AM on May 7, 2009

Per capita spending

Look at the first chart and tell me that there are not savings to be found in a more efficient health care system.

Look at the fourth chart, which expresses health care expenditures as a percentage of GDP.

We spend way too much for health care.

Partially because people who do not have insurance don't go for preventative care, or even if they are having severe symptoms, because they don't have the money. So they wait and let a common UTI turn into a kidney infection. They also don't learn about their high blood pressure, high cholesterol, etc. until it's much more difficult to treat. They go to the emergency room, where costs are significantly higher.

Partially because as noted above, we're paying a significant amount for claims 'adjusting' and insurance company profits. (Obviously some of these savings would be plowed back into pay of government employees in a single payer system.)

Obviously there are other issues. But those who argue we can't afford a new system when the system we have is costing us 15% of our GDP, and rising, are clearly not paying attention.

I totally second the story about the ER as well. I, unfortunately, have spent a fair amount of time in ERs over the past few years, with my mom who has cancer. Once out of those times we were seen within half an hour. Otherwise, it's been waits of 2-8 hours. 8 hours. For a cancer patient who can't breathe, and is sometimes screaming in pain.

The system is broken, and to refuse to even put a single payer option on the table is absurd.
posted by miss tea at 10:43 AM on May 7, 2009 [1 favorite]

To those who expressed moral outrage that we don't have a gov't run care, how much do you expect us to save in switching?

I really don't give a damn if we save anything. I take home less than 70% of what I "earn," stripped away in this tax and that tax and the other tax, and half of what I spend gets hit for another 7% for sales tax, and I am eager to make even less money if it means that people can get treated for getting sick. I have a friend who's now thousands of dollars in debt because of a medical emergency. I see stories like the one bookish just told us. I do not give a flying fuck if we save a single dollar. I just refuse, absolutely screamingly no-compromise no-exceptions refuse to accept for a single moment that a country as wealthy, as powerful, as the United States, can allow its citizens to experience health problems and have them keep being sick because they're unable to afford treatment, or aren't fortunate to have the right kind of job to provide non-evil coverage.

It's expensive. So the fuck what. Human beings get sick. Their wealth, or profession, should have zero bearing on whether they get to be treated.
posted by Tomorrowful at 10:44 AM on May 7, 2009 [18 favorites]

If you've got the standard $350,000 middle-class mortgage

FWIW, ours mortgage is for less than half that--in fact, it would be just under six-figures if we hadn't cashed out some equity a while back for home improvements and to buy musical gear.
posted by saulgoodman at 10:48 AM on May 7, 2009

The central problem is that the US has a population 10X the size of Canada, and 15X the size of Australia. We can't cover everyone's medical bills for $170 per family per month! Well we could, but income taxes would have to double.

I really don't understand this argument. Later you speak about an enormous wealth of natural resources and conclude that with a small population and this enormous wealth, public health care is made affordable.

I've lived in Canada most of my life and I can assure you that every Canadian has it drilled into them that Canada has a lower per capita GDP than the U.S.

Perhaps I have missed something in your argument?
posted by girlpublisher at 11:04 AM on May 7, 2009

jeoc, You're right about the moral / cost savings conflation. I just saw a couple comments above that could be interpreted as "it's awful we're not single-payer, and those who oppose it are STUPID too, because it's cheaper." I just don't see where there's that much to save. Claims that there should be a minimum level of universal care are fine, but they get lost in other 'savings' arguments.

Any estimate on how much savings that will actually give? Maybe a couple percent?

I just get annoyed at the 'we pay MORE and get LESS' stuff trotted out in every healthcare discussion, implying that it's all because of our non-single-payer system. Like the comments that there will somehow be savings if we untie insurance from employment. No. There won't. The money will still come from somewhere. Libertarians have been pushing for this reform on principle for years, but understand that the costs will come in the form of higher taxes or wages. Not savings.

American healthcare can be pretty awesome. For crazy diseases, or for new treatments, there are few other places in the world that have its resources. It's goddam awful for the poor. It simultaneously creates a market where people should use judgement when getting services, while largely removing their ability to decide. Living in China, I've seen people from the US come here as medical tourists for common procedures, and have seen expats return to the US because they could only get the treatment or medicine they needed there.

America's toe in the single-payer water, Medicare, has been a goddamn disaster. And it's not financially viable. I doubt people would actually vote to put themselves onto Medicare as-is from their current provider. And even now, either its benefits are going to be reduced, or its taxes are going to grow much higher.

Maybe you can claim that 'it only really works when you go all the way, not this half-assed style.' I'm inclined to think so. But then I'm also inclined to think that deregulation usually works, and that it has never really been done fully.
posted by FuManchu at 11:04 AM on May 7, 2009 [1 favorite]

Its not the politicians its the voters. People are selfish and for the 50%+ of americans who benefit from our current system (or perceive they benefit is probably a better way to put it) - why do they want change? If you are lucky enough to be enrolled in employment subsidized healthcare then you have the highest level of medical care of any cohort of people in the world. Ask friends who are/were doctors in multiple countries and are positioned to have an opinion and most of them will support this (my experience is with people who were comparing the UK/US).

No the problem is that those of us who benefit from our current system need to recognize how inherently f'ed up it is that we let people less fortunate then us actually have a lower quality of care/lack of care - which of course has the knock on effect of making it even more difficult for them "catch up"

The reality is that the majority of us need to say "I'm willing to accept a lower quality of care so that all us can have care" But people just aren't altruistic enough generally.

The only way it gets done is if a politician who cannot stand for re-election, or is indifferent towards re-election leads the way. So yeah - not something to expect in the first term from Obama.
posted by JPD at 11:12 AM on May 7, 2009 [4 favorites]

It's my argument that the dominant components of any household's budget are government taxes and either the mortgage or rents,

And when food goes from the 5 to 10% its now at to a historic norm of 30% of the budget?
posted by rough ashlar at 11:20 AM on May 7, 2009

Yea, Tomorrowful, I wasn't trying to address that argument. I totally respect it. But the argument that it's also cheaper is pervasive in the comments above you.
posted by FuManchu at 11:22 AM on May 7, 2009

There are some areas where we might see cost savings

You forgot the millions the insurance firms make.
posted by rough ashlar at 11:23 AM on May 7, 2009

I agree with you when you say change will have to be incremental, but is it possible to get there without the health insurance companies stacking the deck against us?

I dunno. I believe in the power of well-conceived and well-crafted legislation to get us there--I wouldn't be choosing to work in DC if I didn't believe that were true--but I think at this point it can go either way.

Personally, I think the best way forward is to pass a plan that allows competition between a public plan and any private plans that want to stick around to compete; to me that route has the fewest dangers (big wrenching legislative changes often have unintended consequences and I think that possibility should engender serious pause among those who propose such changes) and best possibility for getting true public buy-in to the idea of single-payer. I mean, I think everyone needs to be honest about the fact that there are trade-offs with any system, and our health care system is currently enormously wasteful--but one person's waste is someone else's profit. And also, importantly, one person's waste is another patient's peace-of-mind: lots of people confuse preventative care with lots and lots of screening tests (the "worried well" as docpops puts it) and in general people seem to like the big expensive technologies when they're sick like state-of-the-art cardiac imaging and laser surgery for prostate cancer (none of which has really been shown to be more effective than the old ways of doing things but is a hell of a lot more expensive), and some of that is going to have to get rationed out of existence if single-payer becomes a reality. I worry about the political backlash if we try to sell single-payer as this panacea where you can get the same volume of care as today but for one-third of the price. The electorate in general seems to want single payer because the costs of our current system are becoming untenable, but the electorate as a rule also wants lower taxes and more services, and we've seen how well that works out over the past decade. I think the beauty of a mechanism that makes people one-by-one *choose* single-payer, by signing up for a government plan--explicitly making that choice for themselves that lower costs are worth the fact that not everything will be covered--makes it more likely that single-payer will have the popular support to endure beyond one administration.

The major dangers I current see are: (1) in the near term, Baucus and other Dems using the threat of the public option as a bargaining chip with the Republicans over healthcare reform, and being willing to jettison it in exchange for enough votes to pass the bill; and (2) in the medium-term private insurance companies dumping enough lobbying money into the process to set up a dynamic that allows them to "cream skim" the healthy people into their plans and dump the chronically ill and other expensive people into the public option, making it relatively expensive and dooming it to never get enough enrollees to approach a single-payer type of system. I honestly have no idea how you stop any of this other than what you do for any legislation: pay attention, and mobilize support around the progressive option.
posted by iminurmefi at 11:29 AM on May 7, 2009 [2 favorites]

Oh and by the way: congrats on your new baby Slarty Bartfast!
posted by iminurmefi at 11:32 AM on May 7, 2009

I've lived in Canada most of my life and I can assure you that every Canadian has it drilled into them that Canada has a lower per capita GDP than the U.S.

I think less of Canada's GDP is concerned with frou-frou financial gimmickry and actual production of wealth, which is basically stuff you dig out of the ground or cut down, plus IP like books, movies, games, pharmaceuticals, teaching materials, medical procedures, etc.

Last I checked about a trillion of the US GDP -- over half of Canada's entire GDP -- is booked as "owner equivalent rent" -- rent a homeowner is paying himself to live in his own house. IIRC 40% of the S&P 500's profits came from financial services during the boom times this decade.

The US has been living off of fake GDP and massive debt for 20 of the past 25 years (and the profits of successful neocolonialism for 100 years).

China and India are largely poor because they have 2.5 billion people trying to make a living on the space that Canada and the US inhabits.

Japan was also rather overpopulated and poor until it was able to establish itself as a low-cost manufacturer of high-margin high-tech goodies in the latter half of the 20th century, but that boom died ca 1990 and that nation is turning into a zombie economy from which I don't really see a recovery coming.

While the Physiocrats may have gotten a lot wrong, chances are the more productive land you have per capita the wealthier you're going to be. (Hong Kong and Singapore are interesting exceptions but analyzing the nature of their economies is even more of a divergence from the topic, LOL.)
posted by mrt at 11:35 AM on May 7, 2009

Dear America,

Take the money you pay to kill people in dusty countries "over there" and use it to improve the lives of people "over here" and to keep them alive. The world will love you, and you will love yourself.

Your friend,
Canada.
posted by blue_beetle at 11:43 AM on May 7, 2009 [2 favorites]

There are some areas where we might see cost savings

. . . .

You forgot the millions the insurance firms make.

This is precisely the crux of it. Can't remember where it was, but an article I read recently really put the whole thing in perspective for me (or maybe it was a comment on the blue somewhere).

The health industry is unlike any other market because it's dominated by health insurance companies who aren't themselves actually end service providers of health care. The vast majority of what we spend on health care isn't spent on medical services but on administration costs resulting from the clusterfuck of middlemen in the mix.

We all know that the health care industry is a for-profit enterprise. These companies, despite their egalitarian sounding mission statements and marketing slogans, do not exist to provide quality health care. Only doctors are bound by any sort of professional creed to do that.

No, health insurance providers are answerable only to their shareholders, whose prevailing interest is increasing profits. It should be obvious to anyone that the only way those companies can show rapid revenue growth year after year is to soak all parties involved as much as possible. And that's exactly what motivates their relentless pursuit of regulatory capture through lobbying year after year.

But single-payer isn't the only option. A public plan alternative could work to chip away at the industry if it could genuinely offer a better alternative--meaning, it has to be cheaper, better, and open to everyone, so no one will have an incentive to stay with their private plans over the long run. So it has to be well subsidized.
posted by saulgoodman at 11:46 AM on May 7, 2009

And when food goes from the 5 to 10% its now at to a historic norm of 30% of the budget?

The median household income is $50K, say $30K after taxes. $10K per year is $30 per day, every day. Seems a bit high but let's go with it.

When the cost of living increases, wages will have to go up (as they did in the 1970s in response to rising food prices) or rents will have to go down as our personal budgets rebalance to this new economic reality. What that does to home prices I leave as an exercise to the reader.

The way I see it, each of our budgets is a zero-sum game: household gross income vs. {income taxes, payroll taxes, transportation costs to get to work, housing costs, basic food costs, kids costs, insurance costs, additional retirement savings, and then disposable income for the luxuries of life}.

In an ideal world we'd be able to cleanly negotiate down housing costs to make room for everything else since so much of this component is just paying for space on this planet, which was once free if you think about it. Rents and home values are unfortunately stickier but both the Great Depression and Japan's long recession are demonstrations of this dynamic of falling land values in response to loss of consumer household income and buying power.

My argument is that this repricing dynamic can work to our long-term benefit WRT mandated health insurance plans -- the original complaint above that the current plans before Congress are just private mandates like the Massachusetts plan aren't necessarily a bad thing IMV, just like mandated car insurance isn't a bad thing, since mandated costs are economically supportable -- assuming competent oversight of the process to keep rent-seeking out of the system.
posted by mrt at 11:56 AM on May 7, 2009

in the near term, Baucus and other Dems using the threat of the public option as a bargaining chip with the Republicans over healthcare reform, and being willing to jettison it in exchange for enough votes to pass the bill;

See, if they knew a damn thing about playing hardball and really wanted this, they'd at least make a public show of seriously considering a single-payer system and use that threat as the bargaining chip. That's how you get the concessions you want.

Like the legislature in my state recently. One Department of Education office I work with that focuses on early education requested $1.4 million in operating budget, essentially maintaining previous year funding levels. Well, the senate's final version of the budget included $1.3 million. The house's included $0.

The "compromise" reached in budget reconciliation was for $400,000.

The outcome of that process makes me sick, but that's how to properly use bargaining leverage. Don't come out with a compromise version first, and then compromise even more from that starting point. The blue dog dems have got to go.
posted by saulgoodman at 11:57 AM on May 7, 2009

The shit's been fucked up for decades so a couple of years working towards a fix isn't that big a deal.

I'm perfectly willing to grant President Obama time to fix our country. I think my problem is that he has actually been working hard and has been successful in his first 100 days at giving powerful interests whatever they want, at our expense. I think fixing the mess that right-wing criminals have made of our country would be great, but it just seems we're moving steadfastly in the wrong direction to reach that end.
posted by Blazecock Pileon at 12:04 PM on May 7, 2009

The vast majority of what we spend on health care isn't spent on medical services but on administration costs resulting from the clusterfuck of middlemen in the mix.

saulgoodman, could you cite that? As I wrote above, I don't think that's correct. Aetna has a Medical Care Ratio (Health Costs / Premiums) of 89%. Wellpoint's is 85%.

That's still a good 10-15% difference between premiums and expenditures, but far from 'most'. And to me, that sounds about right for administration of funds that also takes time to review individual procedures. Those costs would not be zero in a single-payer system.
posted by FuManchu at 12:06 PM on May 7, 2009 [1 favorite]

^ there's also the billing overhead on the doctor's side
posted by mrt at 12:20 PM on May 7, 2009

Aetna has a Medical Care Ratio (Health Costs / Premiums) of 89%. Wellpoint's is 85%.

Those numbers look really low, unless they've managed to bring them down a lot. An independent study in 2003 placed them at about 30% in reality. In contrast, the Canadian system spends about half that.
posted by bonehead at 12:22 PM on May 7, 2009

FuManchu: Yes, but doctors offices have to fill out forms to make claims and jump through all sorts of other administrative hurdles to work with health care service providers. It's the medical service provider's who get saddled with burdensome administrative costs.

Or what mrt said.
posted by saulgoodman at 12:24 PM on May 7, 2009 [1 favorite]

Canada has the population of California. It can afford to be more socialist.

What? Have you not heard of economies of scale? We can afford to be more socialist.
posted by oaf at 12:27 PM on May 7, 2009

Thanks, bonehead. That's all administration costs, though. So insurance is still getting a good chunk of that expense.

mrt, does a 15% hospital administration expense sound about right? If that's what Canada's is, and the difference (~15% of health expenditures) is the insurance costs, that sounds about right.

Strange though. That study says that Medicare expenses are only 3.6%?? According to the Medicare board of trustees report, Medicare has administration expenses of 10-13%. Somethin' ain't right.

Anyone have data on this for other countries?
posted by FuManchu at 12:29 PM on May 7, 2009

China and India are largely poor because they have 2.5 billion people trying to make a living on the space that Canada and the US inhabits.

Next you're going to explain why New York is poorer than Montana, right?

China and India are poor because they are enduring the effects of a couple centuries of technological and political backwardness relative to the West.
posted by grobstein at 12:29 PM on May 7, 2009 [2 favorites]

saulgoodman, could you cite that? As I wrote above, I don't think that's correct. Aetna has a Medical Care Ratio (Health Costs / Premiums) of 89%. Wellpoint's is 85%.

These numbers are skewed because there are a lot of inefficiencies that are borne by the medical providers: coding and billing, resubmission of claims that were mistakenly denied, prescriptions written then rewritten when formularies change. All of these costs are included in the insurance companies' payout ("Health Costs") but don't go towards actual health care. When I was in primary care private practice, we had 2.1 administrative support staff per provider who spent a great deal of their time dealing with claims and non-medical related paperwork. I'm not saying that goes away with single payer but the place I work now, where the main payer is the federal and state government, gets by with far fewer support staff.
posted by Slarty Bartfast at 12:41 PM on May 7, 2009

Sorry, we both misread the study I linked to FuManchu. The killer line is this:

Between 1969 and 1999, the share of the U.S. health care labor force accounted for by administrative workers grew from 18.2 percent to 27.3 percent. In Canada, it grew from 16.0 percent in 1971 to 19.1 percent in 1996. (Both nations' figures exclude insurance-industry personnel.)

So that means the Aetna 11% and Wellpoint 15% insurance admin cost is in addition to that 27.3% admin cost of the US healthcare provision system.
posted by bonehead at 12:46 PM on May 7, 2009

Slarty Bartfast, yea, I suppose that makes sense. So how does the government billing deal with approved versus unapproved procedures? Are the providers able to give what they deem resonable within a budget? Are there standard processes before a procedure can be billed? How would that work in the US system?

And if the administration costs in the Medicare report above are correct, the only savings in a US system will be on the provider side.
posted by FuManchu at 12:47 PM on May 7, 2009

It's pretty obvious that insurance companies hold our health-care system by the short hairs.

But we keep dancing around the basic question: What, exactly is their purpose; and, more importantly, why are they allowed to play both sides of the issue? They get to both create and control the market. Maybe that's not a big issue when widgets are at stake, but it's a different ball game when lives are at stake.

They run the gate and own the band and the venue.

When you get down to the meat of this issue, however, one thing is clear. The only way insurance companies can make ever-growing profits is to deny service. Premiums received but not paid out in benefits are their bottom line.

We need to recognize them for the parasites they are. Either we need stronger medicine, as in insurance regulators with teeth and fortitude; or we need to kill the parasites before they kill the host.
posted by Benny Andajetz at 12:48 PM on May 7, 2009 [1 favorite]

If you take the time to take apart the financials of a health insurance company its really two different businesses.

Business 1) = underwriting and administering their own risk pools - this is what you think health insurance companies do. This is not a very good business. Probably a 10% ROE or less

Business 2) Administering third party risk pools - an insanely good business because you are just pushing scale through the fixed cost base you have set up for business 1. How much money you make in business 2 is a function of your ability to provide cheap administrative services relative to your competitors.

To really figure out if a health insurer is making too much money is very difficult. You would need to know how the third party risk pools perform and what their administrative costs are relative to the marginal player in the market. Its pretty opaque.
posted by JPD at 12:50 PM on May 7, 2009 [1 favorite]

insurance admin cost is in addition to that 27.3% admin cost

Yea, you may be right. I need to read through that report in detail. I can't figure exactly what they're comparing.
posted by FuManchu at 12:52 PM on May 7, 2009

until someone in the u.s. has the balls to start actually regulating insurance companies, pharmacies, and medical equipment providers, nothing will ever, ever change. ever. which is why a national system is doomed. you can get the government to pay for everything, but as long as the costs are going to cover obscenely inflated profit margins, the only thing that a national system will accomplish is bankrupting the government.

hell. you could probably cover the entire population of several sizeable states if you just combined the annual incomes of insurance company lobbyists.
posted by msconduct at 12:53 PM on May 7, 2009 [1 favorite]

When you get down to the meat of this issue, however, one thing is clear. The only way insurance companies can make ever-growing profits is to deny service. Premiums received but not paid out in benefits are their bottom line.


They don't actually make any money this way. Everyone is using the same formulas to underwrite risk at every level of healtiness.

The argument should be that one huge administrator should have greater economies of scale then 10 big ones, and if that is mutually owned (rather then profit maximizing) you could get cheaper healthcare. The problem is keeping it an incentivized utility rather then a bureaucracy.
posted by JPD at 12:54 PM on May 7, 2009

Slarty, those numbers are pretty amazing for administrative support.

The PCP that I go to has four senior physicians supervising a staff of 10-12 residents, who are the ones who do most of the "primary care". There are also 2 or 4 nurses.

There are three clerical staff: a ration of 0.125, roughly. That's what a single payer system can do for you.
posted by djfiander at 12:58 PM on May 7, 2009

So how does the government billing deal with approved versus unapproved procedures?

Everyone knows the rules, everyone knows when the rules change, and there's a standardized pathway to get something approved when it is beyond the usual, approved care. And the government doesn't pore through someone's medical chart after the fact to deny coverage based on some arbitrarily enforced rules.

The insurance companies change what medicines and procedures they cover at arbitrary intervals that aren't well publicized and even if they were, trying to keep up with 10 different plans that each represent 10% of your patient base is a losing exercise. So you do what you think is medically prudent instead and fight for payment later after the claim has been denied, realizing that some of these battles you are going to lose.
posted by Slarty Bartfast at 1:02 PM on May 7, 2009

Next you're going to explain why New York is poorer than Montana, right?

My overall point was that the more land you economically control, the richer you tend to be, since, until we're living 24/7 in vats of goo, land is the ultimate source of (physical) wealth. New York City is a case in point, I would think; where owners of capital congregate you will find great opulence, yes. But the actual wealth is largely created elsewhere, like in Montana, or Costa Rica, or, more recently, via the mortgages than middle America is paying to the fatcat bankers that were formerly based in NYC.

While trading states have historically sucked a lot of wealth out of their economic hinterlands, (thanks an abundance of low-wage skilled workers) Hong Kong, Singapore and NYC all also have a history of industrial capability that e.g. Montana lacks, so it's not entirely a one-way economic raping. Like Tokyo, NYC is also a global center of big media, which is also a viable and valid economic role of wealth-creation that is not land-intensive.
posted by mrt at 1:16 PM on May 7, 2009

If the system is working, it's only working in the most cynical and Machiavellian sense for those already privileged.

I'm not ready to say that. But it's clear that Obama is straddling established norms of moneyed interests and the public interest. Problem is, that's not an equitable compromise for the public interest when the problems we're dealing with stem from the power the moneyed interests have. He's doing this in order to get things done, and I can understand the wisdom of not letting the perfect being the enemy of the good, but there are things which must be done right to accomplish anything, and heath care is one of them. We can compromise to a certain degree on the amount of care, but if we rely on the market to dictate the outcome, it will mostly benefit those who stand to make a profit above those who receive the care. We're not doing this for the sake of the insurance industry, and I hope Obama (and the rest of the Democrats) remembers that, no matter who contributed money to whom.
posted by krinklyfig at 1:19 PM on May 7, 2009

What? Have you not heard of economies of scale? We can afford to be more socialist.

Economies scale in some ways but not in others. We have a lot of obesity, a lot of motor vehicle accidents, and a lot more gun violence than Canada.

Canada is mostly closing their national budget deficit, while we are running ours wide open. Now, I think this can be relatively easily fixed by jacking up taxes on the top 5% of taxpayers until the deficit is closed, but a health system that can cover all 300 million americans well is going to be a LOT bigger than it is now.
posted by mrt at 1:23 PM on May 7, 2009

I just want to point out again, Max Baucus has a lot more power on this issue than Obama does right now.
posted by saulgoodman at 1:24 PM on May 7, 2009

a health system that can cover all 300 million americans well is going to be a LOT bigger than it is now

As a percentage of GDP, it will likely shrink a bit. If you're cutting costs by 40%, there's no problem increasing the ranks of the insured by 15%. Especially when those newly insured will be more productive than if they were uninsured.

The insurance companies are so incredibly inefficient because they prioritize extracting wealth from the masses and delivering it into the hands of a select few over actually providing the best available care for the population.
posted by oaf at 2:15 PM on May 7, 2009 [1 favorite]

The insurance companies are so incredibly inefficient because they prioritize extracting wealth from the masses and delivering it into the hands of a select few over actually providing the best available care for the population.

That's exactly right. Priorities for insurance companies are different than priorities based on the best possible outcome for the patient with available resources.
posted by krinklyfig at 2:41 PM on May 7, 2009

If you're cutting costs by 40%, there's no problem increasing the ranks of the insured by 15%. Especially when those newly insured will be more productive than if they were uninsured.

Well, there's Pareto Principle to worry about here.

But yes, I agree that socialized medicine that increases our productivity is a really good thing, so good if we "can't afford it" we can start slashing Defense Department spending, which is largely a gross misallocation of the national weal.
posted by mrt at 2:43 PM on May 7, 2009

That's still a good 10-15% difference between premiums and expenditures, but far from 'most'.

Hard to know, since that's their costs and don't include the administrative costs of the providers and other agents between them and the providers. Bill Clinton famously said that in the healthcare system we have 1M people working to get paid and another 1M people working to keep from paying the first 1M. That's a lotta administrative overhead.
posted by Mental Wimp at 3:14 PM on May 7, 2009

a health system that can cover all 300 million americans well is going to be a LOT bigger than it is now.

That assumes that we're not paying more to cover those uninsured now through indirect costs such as subsidizing deadbeats and the increased costs of care for those without preventive services. There are a lot of invisible costs of caring for the uninsured.
posted by Mental Wimp at 3:15 PM on May 7, 2009

According to the Medicare board of trustees report, Medicare has administration expenses of 10-13%.

Well, I couldn't quickly locate a statement like that in the linked report, but I did find several tables. For example, in Table V.F2, the total benefit expenditures (in billions) in 2005 for HI were HI 181.3 with administrative expenditures of 2.9; in Table III.C1, for SMI the figures are 150.3 and 3.2, respectively. I didn't go through all of them, but the administrative costs look a lot less than 10% for those two parts.
posted by Mental Wimp at 3:37 PM on May 7, 2009

Wow. America. UR DOIN IT WRONG!

Holy shit. You guys actually believe that a government insurance plan is going to help? Here's what will happen.

The insurance companies will lowball the government on the employer plans. The government will be legally mandated to insure everyone with an expensive/preexisting condition. You'll go broke trying to do it and everyone against socialized healthcare will have the world's biggest "I TOLD YOU SO!" ready for you.

You've got to do it incrementally, no question, but not like that. So here's what you do.

Firstly, levy a 0.5 or 1% public health levy on all employers. Don't worry they won't be out of pocket.

Secondly, give every American a health care card or whatever. When they go see the doctor they present it. Or tell the nice lady at the desk their name, DOB and SSN or whatever and the nice lady can do without the card.

Thirdly, doctors get a government mandated amount for every patient they see for 15 minutes. Make it reasonable enough to run a practice off but not too high. Please note this doesn't mean a doctor can't charge above the going rate. They can charge whatever they want.

Finally, use the market clout of the entire US population to force reductions in drug prices and subsidize them. Almost all of them. US$20 a course for normal folks, US$5 for the unemployed and those below the poverty line. Allow drug substitutions (i.e. it says Prozac but you get just plain old Fluoxetine) but do it at the pharmacy level not at the doctor level. If someone wants a brand name drug they pay a price adjusted for the retail price over the generic brand's price for it.

There. Congratulations. You've just introduced public PCPs and prescription drugs. Employers go demand reductions in premiums now that PCPs and prescription drugs aren't under the thumb of insurance companies, PCPs can now compete in an open market rather than being trapped in by insurance companies, PCPs don't have to fight the system anymore.

Some finer points:

While doctors can charge whatever they want (and the federally mandated amount gets deducted from the final price) you'll find that open competition between doctors will typically see prices remain stable and fair. New entrants can be attracted by higher rates driven by demand while a glut in doctors will see health care pricing fall somewhat.

Not only that, it becomes a doctor's discretion on whether they charge the full amount. People with state unemployment cards? Discount them if you want. Make it free and only accept the government amount if you want.

Don't like the pricing as a consumer? Go find another PCP. It's your choice now.
posted by Talez at 4:15 PM on May 7, 2009 [2 favorites]

Then you can get to work on hospitals, ancillaries and other parts of the system. Like I said, incrementally.
posted by Talez at 4:16 PM on May 7, 2009

Mental Wimp, you're right. The costs are well less than 3%. My godawful arithmetic ruins another set of my comments.
posted by FuManchu at 4:26 PM on May 7, 2009

"If the system is working, it's only working in the most cynical and Machiavellian sense for those already privileged."
While I wouldn't go that far just yet, I will say, as a philosophical conservative who is deeply cautious about change, especially radical change that could affect long standing institutions, I'm looking at my watch shouting "C'mon, let's GO. TODAY already!"

It's been time, for a long time. But the time is most certainly now. Like the African-American Civil Rights Movement, there are debates to be had concerning moving too swiftly and attendant problems and errors that can be made. But it's got to happen already. What we have now isn't working.
If it ain't broke, don't fix it, but if it is broke, you got to get off your ass and make it work. It's not like it's going to fix itself or get any better.
posted by Smedleyman at 4:32 PM on May 7, 2009

Talez speaks the truth (sidenote: Doctors in the US have to authorize generic substitution of drugs? What the flaming fuck?).

The system he describes for doctors fees works well, I can attest. Out of pocket expenses for myself or my wife, when we visit the doctor, are about $20 a consult. Our 3-year old son gets in for free. I'm friends with and work with a GP, and I can tell you she's not going broke.

The mix of universal health care and private insurance for those who want it seems to work quite well, too. The presence of a private system means people who can afford it don't take up precious beds in public hospitals. The presence of a public system means private health insurance companies don't have to get involved in every doctor visit or drug purchase.
posted by Jimbob at 4:34 PM on May 7, 2009

(sidenote: Doctors in the US have to authorize generic substitution of drugs? What the flaming fuck?).

No. I think you took the wrong thing out of my statement.

In the US the insurance company will come over the top of you and say they'll cover you for a different (read: cheaper) drug that they think will do the same thing which means back to the doctor to make sure the insurance company isn't about to kill you or engaging a fight with the insurance company.

Now a pharmacist who does drug substitution will give you the same drug but a cheaper generic version of it (if available).
posted by Talez at 4:50 PM on May 7, 2009 [1 favorite]

Aaah, okay. That makes more sense. The way I read it seemed like a perfect way for doctors to make good on all the free lunches drug companies give them.
posted by Jimbob at 4:59 PM on May 7, 2009

Obama supports increased military spending.

Did Obama Just Boost the Pentagon Budget, or Cut It? Depends on Which Document You Read.
posted by homunculus at 7:20 PM on May 7, 2009

Deconstructing Frank Luntz’s Health Care Reform Memo

GOP Wastes No Time In Embracing Frank Luntz’s ‘Patient-Doctor’ Health Care Rhetoric
posted by homunculus at 2:00 PM on May 8, 2009

health insurance providers more like health care preventers am i rite
posted by tehloki at 3:55 PM on May 8, 2009

Baucus strikes again.
posted by saulgoodman at 9:22 AM on May 12, 2009

Two of the protesters are on Democracy Now today: Advocates of single-payer universal healthcare—the system favored by most Americans—continue to protest their exclusion from discussions on healthcare reform. On Tuesday, five doctors, nurses and single-payer advocates were arrested at a Senate Finance Committee hearing, bringing the total number of arrests in less than a week to thirteen. We speak with two of those arrested: Single Payer Action founder Russell Mokhiber and Dr. Margaret Flowers of Physicians for a National Health Program.
posted by homunculus at 9:19 AM on May 13, 2009