<p>Bclintonk, do you want to cut medicaid?</p>
<p><a href=“http://www.medicaidwebsites.com/whoiscoveredbmedicaid.php[/url]”>http://www.medicaidwebsites.com/whoiscoveredbmedicaid.php</a></p>
<p>Unnecessary visits which could be hundreds of thousands of patient visits every year could be very costly.</p>
<p>bclin - the thread is about health care spending (not just medicaid OR medicare). I agree with those above who argue that there are limited resources, whatever the bucket. And, in my state, the federal gov’t is woefully behind on the supplements owed the schools, so my non-federal taxes are now higher to fill in the gap. I think of my taxes in their entirety (federal, state, and local) which pay for expenses in their entirety (medicaid, medicare, schools, etc.) </p>
<p>I would say that 12.6% of the federal budget is a huge number. I don’t begrudge reasonable heath care to our seniors (I hope to be a senior, my parent is a senior), but there are valuable discussions to have regarding reasonableness of one expenditure versus the opportunity cost of the expense. </p>
<p>Would you rather immunize thousands of children against polio or extend anyone’s (old or young) poor quality of life (Terri Schiavo or mnmom’s dad) for a day or a week?</p>
<p>It’s a question based on a factoidal. Because they don’t come from the same budget, or some pot of funds, we never get to ask that question (even if it was a real one). And wouldn’t be until we have Medicare for all. </p>
<p>British Columbia wrestles with this “question” rather well (and can afford both). As to whether we should help extend someone’s poor quality of life, that’s really a different question.</p>
<p>Can’t really have a rational discussion about the reasonableness of one expenditure until one has a rational discussion about the reasonableness of an entire system of payment/care.</p>
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<p>Note, however, that the US government spends a percentage of US GDP on medical care (primarily Medicare and Medicaid) is similar to what the Canada government spends as a percentage of Canada GDP on medical care (i.e. 6% to 7% of GDP in both countries). However, the US government covers about 25% of the population (granted, mostly the sickest 25%) while the Canada government covers all of the population.</p>
<p>Of course, private medical spending in the US is about 9% to 10% of GDP*, but only 2% to 3% of GDP in Canada (for total spending of about 16% of GDP in the US versus 10% of GDP in Canada). Even if the private medical spending were replaced by Medicare for all (which is probably preferable to the current mess, though hardly ideal if Medicare remains the way it is, providing incentives for doctors to give more care, rather than better care), with a 20% bureaucratic savings on the private spending converted to government spending, that would still leave the US spending much more than Canada on medical care, as a percentage of GDP (i.e. still about 14% of GDP).</p>
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<li>One can argue, with employer tax deduction of medical insurance for employees, that the US government share is higher (perhaps 8% to 10%) while the private share is lower (perhaps 6% to 8%).</li>
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<p>“However, the US government covers about 25% of the population (granted, mostly the sickest 25%) while the Canada government covers all of the population.”</p>
<p>And out of the number, Canada also funds public health, prevention, quality of care initiatives. They also control pharmaceutical costs.</p>
<p>Medicare for all is just the start. (I know the problems with current Medicare, much of it caused by their inability to regulate quality of care effectively.) Once you’ve got the entire system in one bucket, then there are possibilities to make major improvements in quality of care. But not before. The incentives in our current system just don’t pan out.</p>
<p>A Canadian system that spent as much per capita as we currently do would be an extraordinarily rich health care system indeed. I’ve seen what they can do with roughly 40% less, and I’d chose that today.</p>
<p>bclintonk, I’m not “blaming” any program. Dancing around which dollar spent comes from which tax is pointless. There are a finite number of tax dollars available from the American public. It doesn’t really matter if they come from a “dedicated payroll tax” or state, or local, or federal taxes. It’s public - i.e. tax - dollars and its allocation should be made rationally. There’s no free lunch. Spend more here and you either have to raise taxes or spend less elsewhere - zero sum. ** </p>
<p>We’ve seen a variety of anecdotes here - recommended hip replacement for a non-ambulatory Alzheimer’s patient, my MIL’s chemotherapy for an incurable cancer, the vascular surgery urged on my FIL (at age 85), etc. My son who is an EMT and is called upon to transport patients to and from various facilities could fill a book - and it wouldn’t be pleasant reading.</p>
<p>Lots of very old, very infirm people receive lots of expensive medical care that’s not going to actually improve the quality of their lives, just because that is the default decision, and it’s paid for by “other people.” That’s something that needs to be faced and addressed.</p>
<p>** I agree with mini about the merits of a single-payer alternative. The underlying question, however, will still not disappear.</p>
<p>Medicare reforms to improve effectiveness and lower cost need not depend on Medicare-for-all, and vice-versa. Each can be pursued independently of the other (of course, politics of entrenched interests are big problems for either, but the entrenched interests are not necessarily the same in each situation).</p>
<p>Believe me, medications given in a medical setting do not cost that much—to the hospital–only to the patient. It’s called “mark up” and is perfectly legal, although I don’t agree with the amount of mark up that is permitted. A $800 injection will cost the patient $3800—this is true–I have seen the mark up that was passed along to the patient. Absurd!</p>
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<p>No, sorry, you’re just wrong about this. It’s NOT “zero sum,” and it’s not just all one big pot of money. It’s a question of how much we want to tax ourselves, for what services. Taxes have become toxic in this country; we actually pay rather low taxes by global standards, way at the bottom of the list of industrialized nations in total tax burden as a percentage of GDP, for example. We could pay more for public sector services that we think are underfunded, but we elect not to. So, OK, that’s our democratic choice, and it reflects our values as a society. But then let’s not turn on seniors and say it’s all their fault, because it’s not. </p>
<p>Notwithstanding the view of an earlier poster, I’m not convinced our schools in the aggregate are underfunded, though there may be distributional mismatches and we may be making some poor choices about how we spend in that area. But if they are underfunded, it’s because we elect not to provide more. It’s really just about as simple as that. And with regard to K-12 education, that’s a decision that’s made almost entirely at the state and local levels. But it turns out the answer to proposals to spend more on schools isn’t always “No.” How much we spend on schools is highly variable by state, and in some states, highly variable by locality. You can’t just say if we cut Medicare more money would be available for schools, because it wouldn’t. You could eliminate Medicare entirely, and schools in some states and school districts would get not a dime more. In other places school spending is going up even as Medicate costs increase, because people are making different choices. The two just don’t have much to do with each other—not unless you think there’s some kind of iron law that aggregate taxes at all levels can’t be higher than X and we’re already at X. But that, I think, is just plainly wrong. Canadians tax themselves more than we do (Canada 35.8% of GDP, U.S. 29.6% of GDP), and they seem to be doing just fine. They’re just making different choices about these things, that’s all. And possibly wiser choices.</p>
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<p>Canadians also seem to have more efficient government and medical spending. Both governments spend about 6% or 7% of GDP on medical care, but Canada covers all its population while the US covers about a quarter of its population. The difference is that, in the US, private spending on medical care is much higher, at 9% or 10% compared to 2% or 3%. That erases the advantage of being taxed less in the US.</p>
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<p>Unfortunately, those markup are necessary in order to cover the cost of the uninsured as well as the cost of new technology. I can assure you profit margins at most hospitals these days are slim to none (3% is considered quite high). I work for one of the largest healthcare systems in the southeast. We get inquires all the time from smaller hospitals in our state and the neighboring states asking if we will buy them or otherwise financially support them. There are many small hospitals that can no longer afford to stay open because Medicare, Medicaid and Managed Care have ratcheted so far down on their reimbursement as to make it difficult to break-even.</p>
<p>I believe most of us will end up in the 5% if we live long enough and don’t die unexpectedly. Older people have more health problems. That’s just a fact of life. The question isn’t whether an 80 year old deserves a hip replacement. The question is whether a particular 80 year individual needs a hip replacement. Not all 80 year old have the same level of mobility, cognition and overall health. A 80 year with moderate dementia probably doesn’t need a hip replacement. A 80 year who still travels and gardens and lives on their own probably does. The problem (as I see it after working in healthcare administration for 25 years) is there is not enough evidence based medicine being practiced. Many treatments, tests and medications simply do not work or are unnecessary.</p>
<p>“The difference is that, in the US, private spending on medical care is much higher, at 9% or 10% compared to 2% or 3%. That erases the advantage of being taxed less in the US.”</p>
<p>People don’t understand that. It is a little frustrating to hear people advocate for less taxes…when they end up with higher costs…</p>
<p>People should look at the costs…whether they are taxes or insurance premiums, or higher drug prices, etc…</p>
<p>This idea…of don’t raise my taxes no matter what…even if I end up with less with lower taxes… is too prevalent in our society and society is a big
loser.</p>
<p>If the choices are my health care costs are 25,000 a year…or my health care costs are 15,000 a year but the 15,000 a year comes out of taxes…i would rather pay the 15,000 and have an additional 10,000 in my pocket. I guess others would rather pay the 25,000.</p>
<p>Just got back from THE signup for Medicare Supplemental " F" , premium plan for DW.</p>
<p>bclintonk, I agree with much you say. I am aware that the US is a low tax country by developed nation standards. But that doesn’t change the fact that education - not just K-12 but post-secondary as well - is seeing lowered public funding while a greater share of the total tax dollars available for public services goes to providing unquestioned and expensive medical care for people over 80 who will be dead in less than a year. </p>
<p>“Turn on the seniors”? “It’s not their fault?” Pretty loaded language for a rational discussion of funding priorities.</p>
<p>Let me respond in kind: When non-ambulatory, senile octogenarians are offered “free” hip replacements but undergraduate tuition for bright kids at a state university is over $10K per year - and for professional schools over $40K per year - our priorities as a society are seriously screwed up. I’m happy to let that senile, bedridden old man get a hip replacement if he wants to pay for it with his own money - have at it! I just don’t want to see it come at the expense of poor and middle class 20 year olds starting their lives. </p>
<p>And unless you can figure out a way to convince the voting public to agree to raise taxes there’s still only one pot to get that money from and it’s at the mercy of the taxpaying American voter.</p>
<p>Without having done the research, and having merely skimmed the thread, I am surprised that noone has raised the issue of extremely expensive premature babies. Premature babies in neo-natal intensive care can cost millions of dollars very quickly. According to this article ([Million-Dollar</a> Babies](<a href=“Bloomberg - Are you a robot?”>Bloomberg - Are you a robot?)) preemies cost $26 billion last year for 550,000 babies (that works out to about $48K/baby).</p>
<p>People with chronic illnesses–specifically asthma and diabetes–account for quite a lot of health care costs as well.</p>
<p>agree with kluge</p>
<p>At what point do we start deciding who is “worthy” of saving? </p>
<p>My medical expenses fall into that top 1% ($90k+/yr) on an ongoing basis. If I’m out making $250,000/yr, have I earned the right to stay on chemo? If I stay home and spend the time I have with my kids, am I productive enough to be worth the expense? At what point do we say, OK, you’ve had ten years of $100k medical bills, time to give someone else those resources?</p>
<p>I mentally wrestle with the expense of my treatment all the time. I know good and darned well that the cost of my treatment would pay for a lot of primary care and that my care has far outstripped the premiums and OOP expenses we’ve paid. I have family members who have to seriously budget before going to a doctor. My dad (retired surgical nurse) does home nursing for my mom (and did nursing for my grandmother and aunt before they passed away) because getting outside care is too darned expensive.</p>
<p>But criminy, I’m 51 and I’m not ready to hop on an ice floe just yet.</p>
<p>Dmd77 makes a good point about the increase in babies that end up in the NiCU. I was talking to the Perinatal Director for our region of the state recently and she told me the huge increase in the number of babies ending up with problems and in the NICU is in large part because women are delaying childbearing and ending up either having to go through infertility treatments and that’s the reason we now have so many twins and/or because they are older mothers they tend to have more ‘problem’ pregnancies. She also added that we now have the ability to usurp mother nature and allow women to have babies when many times there was a good physiological reason they shouldn’t have gotten pregnant in the first place.</p>
<p>Our VP of human resources told me that hands down the top three reasons our medical costs for our employees are so high is 1) babies in the NICU with catostrophic illnesses 2) cancer and 3) major trauma cases. Of course, these are by and large uncontrollable and unpredictable so we have no choice but to try to address more chronic conditions like obesity, diabetes, congestive heart failure and the like in order to reduce costs.</p>
<p>Both my siblings underwent infertility treatments (because of advanced age), both siblings ended up with twins. One set had no problems, in the other set, one twin was born with a serious heart defect and they managed to keep him alive (doctors advised against it but my brother and wife insisted) for 8 months to the tune of over $1 million, I have to wonder if delaying childbirth is not as bad as some other the other more controllable risk factors like obesity and smoking. It’s a personal choice, although one that raises all of our premiums. Just food for thought.</p>
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<p>That is one of the ugly problems for which there is no perfect solution.</p>
<p>In a truly free market (not a very distorted one that exists now in medical services<em>) where people are self-pay, personal habits are more likely to be rewarded and punished by medical care, although there is still a significant element of chance. Also, any rationing</em>* decisions are made between the patient and provider without third party involvement.</p>
<p>But costs for medical problems of non-trivial probability even if your have healthy personal habits are so expensive that 99.9% of the population will want insurance against catastrophic medical costs. But then when costs are borne by third party insurance, the incentive to keep costs down is lessened, but the third party then gets a say in rationing** decisions.</p>
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<li>In medical services, it seems that the least distorted markets are optional services like cosmetic surgery, LASIK, and fertility assistance – although the latter, as noted above, may increase costs elsewhere due to causing higher risk pregnancies. In more typical medical care situations, even a self-pay patient will often find a lack of price transparency that can make “shopping around” rather difficult.</li>
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<p>** Yes, the political hot-button word “rationing”. Rationing already occurs, but in a haphazard and inconsistent manner. Only in the self-pay case would the rationing decision by internalized to the patient and provider, rather than the patient and provider being cost-insensitive with the third party payer fighting against higher costs.</p>