United States Healthcare Reform

[JeffL]

If you want a short argument that painfully and clearly makes the point on the need for changes, go download and listen to the most recent This American Life, entitled "The Fine Print" or something similar. Skip to the piece on the Congressional committee interviewing insurance officials and their victims. In particular, one woman who testified to being diagnosed with advanced breast cancer. The hospital demands a $35,000 deposit before they will do the required surgery, and the insurance company digs to find a reason to deny her claim, and they end up using a dermatologist's report that said she had acne. They claimed it could be interpreted to mean she had some kind of pre-existing cancerous growths. The dermatologist called the insurance company, told them he wrote it, it was acne, that was he said it was, and begged them to pay for her surgery. They refused, and the woman was forced to wait months while this advanced cancer spread through her body.

At the end of the piece, the Congressional committee asked the three insurance CEO's if they would pledge to never again deny claims from someone who they had accepted and had paid their premiums, purely for non-fraudulent mistakes in their application, and all three said they would not make that pledge.

[NoWayJose]

If you want a short argument that painfully and clearly makes the point on the need for changes, go download and listen to the most recent This American Life, entitled "The Fine Print" or something similar.

I'm not sure anyone is arguing there is no need for change. And insurance reform seems like one of the most likely aspects of healthcare reform to end up on the president's desk. It's one of the reasons republicans are suggesting tackling healthcare reform in a series of smaller bills, instead of one 1,300 page omnibus. Being able to pass insurance reform on its own will make them look like winners to their core constituency, who already have insurance and will appreciate making it portable, non-revokable, etc.

[JeffL]

Sounds like Obama heard the same show - he just cited that example in his speech. ;)

[Hawkeye Fierce]

I'm curious why people who object to modeling our system on any of the other government-run or -supported systems do so. If we all agree, as NWJ says, that change is needed (and I'm not sure this is true - among the right-wing I'm sure there are some calling for status quo) why not adopt a proven model?

[TheTrunkDr]

I'm curious why people who object to modeling our system on any of the other government-run or -supported systems do so. If we all agree, as NWJ says, that change is needed (and I'm not sure this is true - among the right-wing I'm sure there are some calling for status quo) why not adopt a proven model?

Because then those insurance company CEOs couldn't afford another ivory back scratcher, do you want to deprive people of their hard earned ivory back scratchers? WON'T SOMEONE PLEASE THINK OF THE CEOs?!

[Brian Seiler]

I'm curious why people who object to modeling our system on any of the other government-run or -supported systems do so. If we all agree, as NWJ says, that change is needed (and I'm not sure this is true - among the right-wing I'm sure there are some calling for status quo) why not adopt a proven model?

In short, because solutions that work for other nations rarely, if ever translate to the United States. In general character, the nation distinguishes itself in being a lot more individualistic and generally conservative about policy than continental Europe, and our population is a lot more spread out, so just taking a model and trying to hammer it to fit the U.S. is arguably a worse solution than designing something from the ground up to be palatable to a broader majority of the population here. After all - those models are only proven to work for a social set with the same characteristics as those foreign nations that have implemented them. If folks in the United States behave differently, there's no reason to expect equivalent levels of success.

[Hawkeye Fierce]

In short, because solutions that work for other nations rarely, if ever translate to the United States.

Can you come up with some examples?

In general character, the nation distinguishes itself in being a lot more individualistic and generally conservative about policy than continental Europe, and our population is a lot more spread out,

What effect do you think these issues will have on the efficacy of other models?

so just taking a model and trying to hammer it to fit the U.S. is arguably a worse solution than designing something from the ground up to be palatable to a broader majority of the population here.

I'm unclear why "people won't like it" translates to "it won't work."

After all - those models are only proven to work for a social set with the same characteristics as those foreign nations that have implemented them. If folks in the United States behave differently, there's no reason to expect equivalent levels of success.

What would "behave differently" mean in this context? It seems awfully vague. Are there specific social behaviors that you can identify as having a potentially negative effect on a government run plan? Is there any particular reason to expect it'll be worse than what's happening now? Honestly, this argument just seems like misplaced nationalism to me. The US is somehow different, and therefore we shouldn't even try anything that has worked for others.

[Jon Rowe]

I would like to believe that the poster behind her head says "HURR!!!"

Sarah Palin chimes in, still believes in "Death Panels"

My favorite part

"Is it any wonder that many of the sick and elderly are concerned that the Democrats' proposals will ultimately lead to rationing of their health care by -- dare I say it -- death panels?" she writes. "Establishment voices dismissed that phrase, but it rang true for many Americans."

People believed my lie! Some people said my lie was untrue, but look at how many senior citizens I tricked into believing something that is untrue! That's gotta be worth something right?

[Brian Seiler]

Can you come up with some examples?

Most environmental proposals, as an example, fail to consider the breadth and scope of the United States economy. Mass transit proposals have routinely failed to take into account the general American preference for being in total control of your own movement.

What effect do you think these issues will have on the efficacy of other models?

I can't speak with absolute certainty with respect to health care, since I wouldn't consider myself any kind of a scholar on the subject (my exposure to this sort of thing comes from watching ten years of light rail debacle in Austin and Houston and the renewable energy topic my junior year of high school debate), but I'm just guessing that the demographic differences between your average European state and the United States are going to have some implications. Our nation probably has different endemic health risks than Sweden or Great Britain as well. While I wouldn't reject a plan that has been implemented elsewhere offhand just because it's foreign, I also wouldn't assign it a lot of merit at the outset just because it worked for a group of people who are demographically distinct from the population for whom you're trying to craft a plan - I would prefer to examine how well the model fits what it's going to be trying to do in the United States. You also have the problem of entrenched industries in the United States that you can't go disturbing if you don't want to risk major economic upset. Europe has, for a long while now, evidenced a more controlled economy than the United States. Some of the assumptions that that situation allows you to make don't necessarily hold across the pond.

I'm unclear why "people won't like it" translates to "it won't work."

A plan can only work for as long as it exists, and a plan can only exist for as long as people like it. Let's say that a controversial plan gets rammed through with a big....ramming device or whatever would make the analogy sensical. Now you've got maybe forty percent of the United States cheesed off and actively rooting for the plan to fail. They're not going to be treating it charitably, and you better damn well hope that the whole thing goes off without a hitch (this never happens; not ever - I may not have the longest history of project management, but every single thing that I've seen in the history I do have indicates to me that the only common thread you can be guaranteed to find between projects is unanticipated hardships and unexpected failures) or you'll be out of a job and your new entitlement program will be shitcanned before you can say "midterm election." Public buy-in to a program is incredibly important in that regard. The difference between a modern democracy and a dictatorship is that you can do that sort of thing in a dictatorship, but not a democracy. It's also the reason why Aristotle eventually concluded that an enlightened dictatorship was the most superior form of government, but that's not what you're dealing with here, so you have to consider how accepting the population will be of the intervention you're proposing when you try to figure out how effective a plan can possibly be. The United States is, in general, a lot more suspicious of government intrusion into any subject than any European state, which implies that selling any solution that worked over there may be simply impossible here.

[Hawkeye Fierce]

Most environmental proposals, as an example, fail to consider the breadth and scope of the United States economy.

What environmental proposals have we adopted from foreign countries? It seems to me that our track record is mostly filled with examples of rejecting foreign-led environmental proposals.

Mass transit proposals have routinely failed to take into account the general American preference for being in total control of your own movement.

Huh? Mass transit can and does work in this country - I take it every day. I'm not sure what this objection means. I also don't think we've adopted foreign models here. The Boston T does fine, but I compare it to say, Madrid's system and there's no contest.

The rest of your objections I understand, but I again have to point out that they are very vague. I'm not sure why general demographic differences are going to have a significant effect on the nature of health care. Can we point out issues in our current health care system based on demographics? If so, we can probably make reasonable speculations about what would happen in a different system. If not, why are they going to make a difference in a different system if they don't make a difference now?

In terms of the political issue - yeah, it could be unpopular. Unpopular proposals have been carried out to fruition before. I again don't see that "people won't like it, and the opposition will fight it" is a reason to not do anything. Democrats have tried that. It doesn't work. I'm frankly of the opinion that the current GOP returning to power is going to be disastrous regardless of what happens in the meantime, so I say let's attempt to make some progress anyway.

[WarrenM]

Let's say that a controversial plan gets rammed through with a big....ramming device or whatever would make the analogy sensical.

Obama's got a big ramming device for you.

[unbongwah]

Mass transit proposals have routinely failed to take into account the general American preference for being in total control of your own movement.

If by that you mean that as long as gas is cheap people prefer to drive, I agree with you. People's preferences can be changed by economic factors, though. Like, say, raising the gas tax? But that's a tangent for another thread.

Perhaps rather than hand-waving dismissals, you could cite some specific examples of why you think, say, the British or Japanese health-care models wouldn't work in the U.S.? You know, presuming your objections rise about the level of the philosophical into the sphere of the practical.

Here, I'll help you get started: how does the U.S.'s lower population density and much higher rates of obesity (and its associated health risks) pose unique problems which other universal health care systems would be unable to adequately address?

[wahoo]

I
Perhaps rather than hand-waving dismissals, you could cite some specific examples of why you think, say, the British or Japanese health-care models wouldn't work in the U.S.?

Japanese health care has big problems. They have extremely low physician payment leading to braindrain and a docs that aren't just as good, in part b/c overwork means less time to integrate new technology and techniques. Emergency medicine is poor compared to the US. The average American is much less healthy compared to his Japanese counterpart, as witnessed by the much higher heart attack rate in the US. But you're twice as likely to survive a heart attack in the US b/c docs are able to have more training and specialization in life saving techniques.

Japan also has a big problem with over utilization of health care services, especially hospital stays. And like just about every other country, long-term costs is a huge factor. So on the face of it, I'd say that the US mortality rate would increase unless a conversion to Japanese medicine was accompanied by a change to the Japanese lifestyle. BTW, the WaPo had an excellent article on Japanese health care earlier this week.


As for GBR, things that work in Britain are unlikely to work here. GBR has a long takeup rate for new medicines and new techs. The medicines also have to be approved by NICE. I doubt that US politicians will be able to resist public pressure like NICE can/does.

For example, NICE determined a certain Alzheimer's drug wasn't cost effective enough. While this met with a huge citizen's protest, NICE was able to uphold its decision. In the US, this decision would be met with a huge attack by the AARP and I find it unlikely Congress would decide not to offer the drug.

[unbongwah]

Here's the WaPo article on Japan's health-care system.

The good:

The Japanese visit a doctor nearly 14 times a year, more than four times as often as Americans. They can choose any primary care physician or specialist they want, and surveys show they are almost always seen on the day they want. All that medical care helps keep the Japanese alive longer than any other people on Earth while fostering one of the world's lowest infant mortality rates.

Health care in Japan -- a hybrid system funded by job-based insurance premiums and taxes -- is universal and mandatory, and consumes about 8 percent of the nation's gross domestic product, half as much as in the United States. Unlike in the U.S. system, no one is denied coverage because of a preexisting condition or goes bankrupt because a family member gets sick.

The bad: costs are projected to double due to their rapidly aging population. A declining birth rate means a shortage of young workers to pay into the system. Hospital doctors are underpaid and overworked compared to those in private practice, so the most skilled doctors tend to leave the former for the latter, which negatively impacts the quality of hospital care.

[Tortilla]

Japanese health care has big problems. They have extremely low physician payment leading to braindrain and a docs that aren't just as good, in part b/c overwork means less time to integrate new technology and techniques. Emergency medicine is poor compared to the US. The average American is much less healthy compared to his Japanese counterpart, as witnessed by the much higher heart attack rate in the US. But you're twice as likely to survive a heart attack in the US b/c docs are able to have more training and specialization in life saving techniques.

Japan also has a big problem with over utilization of health care services, especially hospital stays. And like just about every other country, long-term costs is a huge factor. So on the face of it, I'd say that the US mortality rate would increase unless a conversion to Japanese medicine was accompanied by a change to the Japanese lifestyle. BTW, the WaPo had an excellent article on Japanese health care earlier this week.

I'm sorry but all of that is completely unconvincing. The bottom line is still better overall outcomes for less money in these other countries. I'm sure they have their issues, perfection being such an elusive goal, but overall I find it very difficult to be convinced that these systems shouldn't be held up as examples for us to copy and hopefully improve upon.

[TheTrunkDr]

Most environmental proposals, as an example, fail to consider the breadth and scope of the United States economy. Mass transit proposals have routinely failed to take into account the general American preference for being in total control of your own movement.
...

The infrastructure is there and services the population as is and any health care change isn't going to result in moving hospitals or such activities.

How would a single payer option similar to the Canadian system, for example, radically change the way Americans go about getting their care? Rather than showing a card issued by their insurance company they'd show a card issued by a governmental agency?

Ultimately the reform we're talking about is in coverage and billing. The act of going out and getting treatment for people will be mostly unchanged. I fail to see how the peculiarities of the geography and demographics of the US is going to be a significant factor in this.

[Jon Rowe]

The bad: costs are projected to double due to their rapidly aging population. A declining birth rate means a shortage of young workers to pay into the system. Hospital doctors are underpaid and overworked compared to those in private practice, so the most skilled doctors tend to leave the former for the latter, which negatively impacts the quality of hospital care.

Japan's healthcare system isn't good at all. It is going to really run into some big problems soon.

[JeffL]

On Japan's healthcare - I've spent time in Japan, as I'm sure others here have, and they do have some serious problems as outlined above, and within Japan it is a pretty big issue. The example was a good one - they have less heart attacks, but the cause has nothing to do with their health care system, it is due to their diet and eating habits relative to Americans. But when they do have a heart attack, the health care system is tested and has problems, as noted above you have a much better chance of staying alive after a heart attack in the U.S. system vs. the Japanese system.

In terms of why we don't just copy another country's model, I think it is indeed an issue of the enormity of completely dismantling our system and starting over, from a practical point of view. Obama himself stated that the system in Canada was a good one, but would not work in the U.S.

[TheTrunkDr]

In terms of why we don't just copy another country's model, I think it is indeed an issue of the enormity of completely dismantling our system and starting over, from a practical point of view. Obama himself stated that the system in Canada was a good one, but would not work in the U.S.

I'm fairly certain that bit about not working isn't a logistical issue. There's no reason hospitals and clinics couldn't send bills to a government body to be paid. I think the reason it wouldn't work is because it would involve dismantling a rather large health insurance industry to the point where it would be a small fraction of what it was.

[Hugin]

But you're twice as likely to survive a heart attack in the US b/c docs are able to have more training and specialization in life saving techniques.

This is slightly misleading. One of the reasons the American healthcare system does so well with heart attack victims is because we have so many of the damned things, our physicians have a lot of practice dealing with it and there's a robust market for training and innovating in the specialty. It's the system following the malady (and the money), not so much inherently being better at dealing with it structurally. We're also better at dealing with gunshot wounds than a lot of other countries.

[jeffd]

I'm curious why people who object to modeling our system on any of the other government-run or -supported systems do so. If we all agree, as NWJ says, that change is needed (and I'm not sure this is true - among the right-wing I'm sure there are some calling for status quo) why not adopt a proven model?

The short version is that moving to any other model means someone (probably lots of someones) will make less money. And it's not just insurance company executives - doctors, pharmacists, pharmaceutical companies, etc.

[unbongwah]

I'm sure they have their issues, perfection being such an elusive goal, but overall I find it very difficult to be convinced that these systems shouldn't be held up as examples for us to copy and hopefully improve upon.

That's kind of a key point. Japan's health care system has some serious issues looming on the horizon. It would be unwise to copy them wholesale if we inherited the same problems as well. There's also other factors at work: population density, demographics (Japan's elderly-to-young ratio is even more skewed than ours), lifestyle choices (e.g., Japan has a 3% obesity rate vs our 30+%), etc.

I support universal health care, but it's overly simplistic to say, "If we just did what Nation X does, we'd be fine!" Unless you literally mean being exactly like Nation X.

Ultimately the reform we're talking about is in coverage and billing.

If those are the only two areas which health-care reform addresses, then it's a failure. There's a lot more which needs overhaul than those two.

[Jason McCullough]

Most environmental proposals, as an example, fail to consider the breadth and scope of the United States economy. Mass transit proposals have routinely failed to take into account the general American preference for being in total control of your own movement.

I think you're wildly overstating your case.

A while back I noted that the kind of libertarians who one would expect to go into conniptions if Fairfax County, Virginia were to propose a stringent rent control law seem surprisingly blasé about the vast array of land use restrictions that infringe economic liberty in that county and most other American jurisdictions. Indeed, some libertarian economists at George Mason University go so far as to laud America’s large houses and plentiful parking specifically as evidence of the superiority of America’s free market economic policy, blissfully unaware that in the United States pervasive regulation requires the construction of bigger houses and more parking spaces than the market would provide.

To this, Bryan Caplan responded with a piece that I think basically proves my point as he grapples with the cognitive dissonance involved by tossing off the (admittedly accurate) fact that some elements of federal policy—for example, large-scale federal ownership of desolate land in the Western United States—place some curbs on sprawl. To this I mostly say what Ryan Avent said, but it’s worth emphasizing the extent to which Caplan is simply missing the point. The point is not about whether policy favors “suburbs” or “cities” but about the fact that the actually existing built environment in the United States—and especially those aspects of it constructed over the past thirty years—overwhelmingly reflect the influence of central planning.

[TheTrunkDr]

If those are the only two areas which health-care reform addresses, then it's a failure. There's a lot more which needs overhaul than those two.

Admittedly I haven't been keeping up on this since I left the US, so what else is this reform intending or hoping to change?

I'm not aware of anyone talking about how care is actually administered to patients and everyone is saying they want the relationships between doctors and patients to remain the same. So other than making sure everyone has coverage (to me this includes eliminating the ridiculous ways insurance companies weasel out of paying the bills they're supposed to), where the bills go and how it's funded seems to be about all that's on the table. So how is that not just coverage and who's writing the cheques?

I realize some of the proposed changes could have huge effects for insurance and pharmaceutical companies but that's more a by-product of the bill rather than the intention. Those issues need to be addressed but as far as the purely health care aspect goes I'm not seeing any other changes proposed.

[unbongwah]

Costs need to come down. There are lots of ways in which we waste money in our current health-care system which need to be addressed. "Coverage & billing" only covers one part of the cost equation.

[ceolstan]

We don't need health care reform. After all, we're number 37.

[Damien Neil]

Here, I'll help you get started: how does the U.S.'s lower population density and much higher rates of obesity (and its associated health risks) pose unique problems which other universal health care systems would be unable to adequately address?

Australia.

[Midnight Son]

No Public Option or Single payer means it's all a bunch of horseshit.

[Lux]

No Public Option or Single payer means it's all a bunch of horseshit.

That may be a tad extreme, but it is trying to compromise our way out of a problem that needs swift and decisive action. This is how we handle environmental concerns and budgetary concerns. The bottom line is probably the same with heathcare in that the current wave of politicians in Washington won't be around when the time comes to pay the tab. We'll get stopgap measures that keep us going a little longer until they retire.

It's only the same horseshit that goes on with every other attempt at change in the USA.

[Jon Rowe]

What do we all think of the "trigger" option?

Basically, it means that there will be no public option in the initial bill, and if certain goals and provisions aren't met, costs being lowered, affordable care, the public option will be instilled.

I think it is a best of both worlds situation here. If the regulation of insurance doesn't work out, blam! Public healthcare. This provides a good compromise from both sides. The repubs say that their idea of co-ops and non public healthcare will work, and if it doesn't, we will go the other direction.

This is perfect because it catches those congressmen in the pockets of insurance companies red handed. They have to support this bill, because it will have popular support, but it will still mean less money for insurance companies. This will also screw over those repubs that were just stalling so that no bill would pass. I really like the trigger idea. Partially because it will force the repubs to swallow the bitter pill of reform, and partially because Obama will be holding the "trigger"... badass.