<p>Mercymom, I missed this until I tried to figure out what you and Thumper where talking about.</p>
<p>"Shrinkrap, why do you think it is the non-urgent care that makes health care so ominous in the US? When one of our Ds had an appendectomy (emergency) the total cost came to about $42k. "</p>
<p>I think things like that are going to happen and be paid for, no matter what. Rarely an argument there. I think the devil is in the details. Should a provider provide after hours care, because it is convenient, even if it is inefficient? Should you see a PA, an NP, a GP, FP or a “specialist” for acne? Should you get name brand vs generic because you say you have “allergies”? What about the costs to the system when people habitually miss appointments, smoke cigarettes or abuse drugs? An issue near and dear to my heart; Will the system pay for therapy if medication is cheaper and faster? Will you have a choice? And what about the latest drug advertisements, with the admonition to “ask your doctor” if the drug is right for you" or “call your doctor” if one of these complications happen. OK, sorry… turning into a rant…</p>
<p>Three steps necessary to provide quality health care to everyone without one penny more in outlay than we do today: 1) universal coverage (so that we don’t end up with some folks using the emergency room for primary care); 2) No private insurance companies (save 25-30% right there in underwriting, marketing, paperwork and denial of care; and 3) regulate pharmaceutical companies like the public utilities they are. The rest is just details.</p>
<p>The only thing difficult about the prescription is the politics.</p>
<p>I wonder, though, if everyone could be covered by the same aggregate amount, then is the issue who pays what portion of that amount? I just don’t think you can look at this problem as from an aggregate perspective except on a theoretical level. Isn’t it true that some Americans would bear additional costs for universal health insurance and some Americans would simply reap the rewards of universal health insurance?</p>
<p>If someone is unemployed and, as a result, has no health insurance, then that person isn’t paying taxes to fund universal health insurance coverage.</p>
<p>If someone is chronically ill and, as a result, is unemployed, and, as a result, has no health insurance, then that person isn’t paying taxes to fund universal health insurance coverage. </p>
<p>So who is going to pay the additional taxes to fund the universal health coverage for these uninsured folks? Unfortunately, I’m willing to bet that it will be the working folks who, in many cases, already have health care coverage. Why should Americans who took jobs specifically because those jobs offered health care insurance be penalized with higher taxes?</p>
<p>As for the proposition that we get rid of insurance companies, I can’t argue that they are an inefficient middle man. However, do you really think that our federal government would do a better, more efficient, job? I am concerned that this new national health service would turn out like social security has – almost bankrupt.</p>
<p>As for regulating pharma companies, if you regulate them (Do you have them cease to be public companies first? What agency would provide ovesight for the new regulation? Who would pay to fund this new agency and its employees?), do you also then take away all incentives to put money into research and development? If these companies can’t patent their meds and sell them at a profit for some period of time in order to recoup their costs, why would they bother developing new drugs? Would we better off if all research and development was a government function? Again, then who would pay for that research and development?</p>
<p>I am concerned that no one is proposing a solution that actually pays for universal health insurance. Until someone finds an answer that doesn’t include working people with health care insurance paying additional taxes to fund health care insurance for everyone else, I will continue to think that universal health insurance is a wonderful idea in theory but difficult, if not impossible, to install as a practical matter.</p>
<p>“However, do you really think that our federal government would do a better, more efficient, job? I am concerned that this new national health service would turn out like social security has – almost bankrupt.”</p>
<p>As noted, we have experience with this one. It could be handled by the feds, or by the states. In my single-payor plan in my state, it is administered by a board of consumers and health practitioners, with costs 30% lower than that provided by the insurance companies. Even Medicare, which has been systematically starved for funding, has overhead of less than 3%.</p>
<p>“Isn’t it true that some Americans would bear additional costs for universal health insurance and some Americans would simply reap the rewards of universal health insurance?”</p>
<p>It’s politics - there are always winners and losers. But right now, those with insurance subsidize high-cost emergency room admits for those without insurance. Every one of those emergency admits costs $2k, just in the door, for what could be done for $70. It mounts up fast. And when you can consider that lots of those admits are for conditions which, if taken care of earlier, would never have been at the emergency room at all, those with insurance, in aggregate, and when coupled with savings in underwriting costs, marketing, and profit, would likely see their costs go DOWN, not up. I know from experience that mine actually have.</p>
<p>Let me give you an actual example from my work. I help administer a $10 million program that takes individuals gravely disabled as a result of severe mental health and/or substance abuse problems and diverts them from jails and emergency rooms to a secure detoxification facility that both evaluates their physical and mental health, and moves them toward treatment. Most of these individuals, left untreated, end up multiple times a year in emergency rooms or in jails, at tremendous cost to the taxpayers. Through the diversion, we are able to prove savings - in medical care alone - of $285 per patient per month ($3,420 per year) for at least two years. Almost all of this savings is a result of savings in emergency room admits and psychiatric hospitalization.</p>
<p>But there is more. Their health and mental health care needs are being taken care of. And, as a result of the diversion, YOUR emergency room wait times are lowered, in many cases resulting in lower emergency room/medical costs for YOU. And police are now freer to do their jobs.</p>
<p>The problem? Someone has to cough up the $10 million. Even though it saves the average person with health insurance bucks, and improves their quality of care, without a single budgetary process, there is no way to capture the $10 million. So what in fact happens is that the taxpayer foots the $10 mil, and much of goes to the profit margins of the insurance companies.</p>
<p>But let me be clear: you pay for it either way. You can pay for the emergency room costs (and the jail costs) without individuals getting the medical/psychiatric treatment they need in an unending cycle - which you do now - or you can pay the costs for making possible for at least a few folks to get well, divert them from emergency rooms, so that you can get the care you need more readily. You pay in either way.</p>
<p>First off, Mini is right that under the current system you guys with jobs and insurance are subsidizing the cost of care to the uninsured, not through taxes but through hidden costs buried in the file cabinets of hospital emergency rooms and physicians offices. There are times when doctors and hospitals cannot turn people away and the cost is passed along somehow someway and you pay it. A more orderly system would lower the cost to you and provide better care to everyone, much in the way Mini describes his substance abuse program. And yes, the devil is in the details.</p>
<p>Shrinkrap, I see where you are perhaps seeing the ominous from the providers point of view and I am seeing it from the sick person’s point of view. At my house it’s not the generic vs name brand issue that might bankrupt me, it’s the $42k emergency surgery or the $50k surgery that will keep me from being paralysed that is ominous. For my atty friend it’s the $1,000 a month of meds for MS that mean the difference, not just between working or being unemployed, but the difference between being able to leave the house and being a shut in.</p>
<p>As for your question earlier about how some of this works in other countries, I don’t know about everywhere (others here seem to), but a good friend of mine lived in Italy for 5 years, and he said that for minor ailments like the flu, and ear infection or a throat infection, etc. you went to the pharmacy and the pharmacist diagnosed you and gave you the antibiotics right there in the drug store. For example, take Zyrtec. When my D was in hs, she got this as a prescription for her allergies; now it is otc at the supermarket. Well, in Rome when my friend was there, something like this would be behind the counter at the pharmacy and the pharmacist would give it to you. You go in, say you’re sick with your allergies, you get your Zyrtec (when it was prescription). But no doctor visit. I’m not saying my friend thought health care in Italy was outstanding in all respects, but he did think being able to handle minor illnesses w/o going to the doctor eliminated a lot of hassle and expense.</p>
<p>Because you have no assurance that you or yours will not end up being one of the “someones”. And becaue there’s another “someone” category you’ve not mentioned: someone who is employed but is only offered minimal health care coverage.</p>
<p>^^^ Then there are the people who are employed and get NO health insurance from their jobs and are either trying to pay for an individual policy at enormous expense or priced out of health care altogether. Of the 47 million or so uninsured people in the US about 1/2 of them have jobs.</p>
<p>And yes, it could be YOU with no health insurance in the blink of eye, when you least expect it. A very close relative of mine is in this fix right now, so it is uppermost in my mind at the moment. His business went belly up due to the (cough) recession we’re not supposed to be in, and he lives in a city wracked by the subprime mtge mess, so jobs are hard to find, much less ones that offer health insurance, and he has no COBRA benefits, either cause there is no more company (his employer doesn’t exist anymore) or cause he has no money to pay for COBRA, and he is stuck good and proper. Most people worried about their taxes on this issue do not realize how close the abyss actually is.</p>
<p>And, remember, over the course of a year, it is over 80 million, not 47 million (which is a point-in-time count).</p>
<p>Appropo SlitheyTove’s comment and something to think about: in his “Theory of Justice”, John Rawls suggests that inequality within a society can be justified only to the degree to which 1) one would be satisfied occupying the position of its weakest member; and 2) inequality aided the condition of its weakest member. For those who would justify capitalist inequality, national health care is a good way to go.</p>
<p>Here’s an NPR piece on the Taiwan health care system. It points out that whereas spending in Taiwan is 6% of GDP, health spending in the US is 16% of GDP and not everyone is covered. </p>
<p>Taiwan also uses a “smartcard”. Your health insurance card has that little magnetic stripe that keys you in to a system of electronic record keeping. I think it allows doctors to easily access your overall health records (better diagnosing etc). It also allows the administrators to check if you are abusing the system with too many doctor visits.</p>
<p>Another article about the Taiwan system in The Guardian (UK):</p>
<p>This is my personal experience: Last year I moved from US to Canada. I just finished a batch of tests - whole blood profile, mamo in addition to ultrasound for better diagnosis (apparently standard) , ekg, bone density, eye tests with my physical, abd ultrasounds . It took 3 days to get in for the tests, results will be back in 1 week to 10 days. The only money I had to pay was $35 for a CA125 not covered. I could go to any lab I want for my convenience. The doctors decides on the tests. I will say I am receiving better care than I was in the US when my premium was $1700+ a month in addition to deductibles, When we were not employed we had difficulty finding coverage at ANY price. </p>
<p>The higher Canadian taxes we pay are not larger than the $1700 X 12 premiums. We saved money.</p>
<p>The Taiwanese system sounds a bit like a less-complex version of the French one. </p>
<p>The Taiwanese are running into the problem you’d expect – too much use of medical services for the money they are willing to spend. This is going to lead to 1) restriction on services, 2) increased taxes, or 3) adding copayments (like the French have done). </p>
<p>Allowing patients to find providers they prefer, and having provider income tied to the number of patients they serve/amount of services they do motivates providers to meet the needs of patients. This is a good thing. Removing all out-of-pocket costs encourages unlimited use of the system. This can be a bad thing. The French system provides a minor disincentive to use medical services (adding copayments, except for the very poor who are excused from copayments), which reduces usage and cuts costs.</p>
<p>Unlike the US, French hospitals are nearly all government-owned and operated. The exceptions are mostly fee-for-service surgical centers who exist to serve those with deep pockets. Are we in the US willing to give up our top hospitals, most of which are “owned” by private foundations, and deal with the cost and difficulty of nationalizing chains of privately owned hospitals to go to a French system? I don’t think so, and this is why I see us favoring a super-Medicare system that covers everyone.</p>
<p>Medicare, despite lots of criticism from all us citizens, provides insurance coverage at a very low overhead. You could do a lot worse than recast Medicare as a single-payer insurance system with simplified Taiwan-style identification cards and extended benefits (most notably, real prescription coverage). I don’t know how to reimburse medical insurance companies for the destruction of their industry by government fiat. Someone smarter than me will have to deal with the ethics of unemploying tens of thousands of people and robbing millions of stockholders of their equity.</p>
<p>The thing that scares the living daylights out of me are the ever-growing holes in our regional emergency medicine network. As the number of uninsured has grown, our city’s emergency rooms have been innundated, been financially unable to cover costs, and have shut down. The remaining emergency rooms are even more crowded, and patients get turned away and directed to other emergency rooms–more time in transit. Even with good insurance and financial resources, what happens if we are (heaven forbid) in a car accident in an area where there’s no nearby emergency room? </p>
<p>This isn’t a problem that families can prepare for by making individual financial choices; it’s an issue that must be addressed by cities, counties, states and/or the US.</p>
<p>First let me say, I hope this works. But I honestly have to admit I hope to be in that part of my career where I can choose whether or not to be a part of it. </p>
<p>mini, your setting is the perfect example forme. I worked as Chief of psychiatry in a setting much like that, serving a population of maybe 75k if I remeber correctly, various “levels of care”, with the savings theoretically given back to the people who helpd prevent costly hospitalizations. Started out great, but was overwhelmed within a few years. My pet peeve with it was the over-reliance on medications, and i truly believe it is settings like these that are behind the explosion of “spectrum” diagnosis and the off lable use of medication. Things that could have been remedied by 10 sessions of psychotherapy where in the short run, less costly to give a major psychiatric diagnosis, and treat with medication. This became a problem when enough psychiatrists could not be hired to keep up with the demand, and the “medication stopped working”. So new diagnsosis were developed, new medicatios were tried, and non-mds made the reccomendatios to use them. I believe these medications cost more than therapy when you factor in how long they are used for and the medical complications that come form them.Perhaps most importantly, it became very frustrating work for me. Understanding the psychosocial factors that belled into the mental health ones, but also understanding that a pot of health insurance money is not intended to cover things like housing. </p>
<p>Seeing only the sickest and least likely to imporve patients is demoralizing over time as well. So mercymom, in the setting you describe, there is not simple allergy evaluation or treatment to add a little job satisfaction for the doctors? I’m imaginig in mental health, that would mean antidepressants from the p[harmacist, and only when they “stop working”, do they see a doctor? How does therapy happen?</p>