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    US Health Care: You Don't Need What You Have
    By News Staff | October 2nd 2012 07:59 PM | 75 comments | Print | E-mail | Track Comments
    The Affordable Care Act controversy rages on. In this week's BMJ, journalist Jeanne Lenzer says the basic assumption that US people don't have enough health care is misleading and in reality, Americans have too much - and that unnecessary care costs an estimated $800 billion per year. 

    The article arrives as an international conference named 'Preventing Overdiagnosis' was announced for September, 2013 in the United States, hosted by The Dartmouth Institute for Health Policy and Clinical Practice, in partnership with the BMJ, Consumer Reports and Bond University of Australia.


    The U.S. medical establishment prides itself on saving everyone it can.  Some contend that overly aggressive treatment is estimated to cause 30,000 deaths among Medicare recipients alone each year, while unnecessary interventions are estimated to account for 10-30% of spending on healthcare, or $250-800 billion annually. Examples range from the overuse of screening tests, commonly called defensive medicine, since it is needed to ward off spurious lawsuits, and imaging technology to questionable surgery.

    The doctors contend overtreatment leads to patient harm but the onus of the modern movement is bringing down costs so that the government can afford to get into the health care business. Currently, Office of Management and Budget estimates to provide the high-end treatment people get, even when the prognosis is not good, estimate tens of thousands of dollars in new taxes for citizens.

    Because health care has become a political football, rationalizations about overtreatment are receiving significant attention from the American media and politicians. The doctors in the article identified several reasons for overtreatment, including malpractice fears, biased research, patient demand, and financial conflicts of guideline writers in the modern, government-mandated 'teach to the protocol' environment. Several speakers highlighted the way physicians are paid and trained in the US as central factors, and nearly 80% believed that more radical payment reform is necessary to reduce the problem meaningfully.

    But as these initiatives begin to move forward, they will face formidable challenges from the medical professionals in the healthcare industry (who don't think they are overpaid) and the general public who fear that the overtreatment argument is just laying thee groundwork to ration care, reports Lenzer.

    Advocates of reducing treatment disagree. "Rationing means that you are limiting necessary care. What we are proposing is limiting unnecessary care – harmful care," argues Dr Diane Meier, Professor of Geriatrics and Internal Medicine at Mount Sinai School of Medicine.

    Jerome R Hoffman, Emeritus Professor of Medicine at the University of California, Los Angeles, said: "There's already lots of rationing in healthcare; wouldn't it be better for us to decide what should be available, based on what's best for our health, rather than having insurance companies decide, based on what's most profitable for them?" U.K. NHS patients and doctors disagree that government should be deciding who to save and claim it is just a 'death pathyway', since some claim they kill 130,000 patients per year rationing care
    , while others contend that resources wasted on unnecessary care are better spent treating and preventing illness in the underinsured or uninsured. But the underinsured and uninsured should not exist under the Affordable Care Act.

    Comments

    I didn't read Lenzer's article, but I've never heard anyone say "US people don't have enough health care." What people say, and it's true, is "not enough US people have health care."

    Hank
    Well, yes and no. The poor do, and the rich do. And the old do.  So the government decision to tax the middle class and force them to buy insurance is not really solving that problem, since they will pay far more.  Like making college educations a 'right' or offering a chef for every home, all it does is drive the price for quality way up, make low quality more expensive and help a tiny minority.
    Gerhard Adam
    Except that it's precisely those people that don't think they need insurance that are part of the problem.  Whether it be from accidents, sports injuries, or pregnancies, the notion that somehow people of a certain age use less insurance simply isn't true.

    As for your chef analogy?  Sorry, but that's how it currently works.  We have absolutely no hierarchy of medical care beyond exchanging specialists.  Many typical office visits don't require a doctor, but instead of capitalizing on nurses, physician's assistants, etc. we insist that even the sniffles requires a doctor's presence.

    Then when that is coupled with hospital's being able to charge whatever they can get away with, it's little wonder that costs keep going up.  People don't get billed based on the costs of the actual medical treatments.  They get billed based on the money that hospitals are looking to recover, so if you need an aspirin, you can be confident that part of that cost is going to pay for that shiny new MRI machine, whether you ever use it or not.
    Mundus vult decipi
    Supposedly 30,000,000 uninsured Americans will be covered under ACA. That's your tiny minority!

    Just about every country in the world has universal health, and none have universal chefs. Many do have universal access to college education, and I think that's lovely. I bet it more than pays for itself, too.

    Hank
    Supposedly is the key word.  The Supreme Court had to decide that and it made a decision that confused everyone.  Basically, they can force you to buy one thing in the marketplace, which means they can force you to buy any thing.  The Court did not care how many people were involved, since that number was made up. You may agree people are not adults until age 26, for example, but the Supreme Court did not rule on that; young people choosing to not have health insurance because they did not need it and did not want the expense are now going to be a burden, not a revenue stream.

    The problem is people conflate health insurance with health care. They are not buying health care, they are buying health insurance.  And they have no choice.  
    I said "Supposedly" 30,000,000 because I am properly skeptical, but not a prisoner to ideology. OK, make it 20,000,000? 10,000,000? You pick a number. How tiny is your tiny minority?

    The cost of health care - and insurance - is ridiculous, but as has been posted here, that's not a product of legislation.

    Hank
    It certainly makes a difference.  How much will you spend to insure 10% of the population?  How about 3% of people?  Again, if you are writing a check, you get a voice.  Why not ban smoking and fast food and make people join a gym?  Why not limit the salaries of doctors and nurses? Why not lower the speed limit to 5 MPH so car accidents do not happen and ban swimming pools?

    If you believe in one government intrusion but not all of those, then it is subjective and arbitrary and that is bad policy.   What we instead need to do is find a solution that benefits the most people with the least cost and the ACA is not it.  In terms of gross cost a reduction in defensive medicine and a cap on a lawsuit judgments costs 30 million people nothing but in a free market, costs would come down and those 30 million could all have it if they want.  Forcing states to allow out-of-state insurers would do the same thing yet the federal government did not mandate that.  Saying 'everyone is forced to buy a product because they will some day need it' has never been done in American history. It was done in feudal Europe, of course, Lords of the manor would force local villages to buy wine from the big boss, but it was hoped that we could go forward as a culture and not backward.  We're basically serfs again and we will buy what the noble tells us to buy or pay the price.
    We're serfs again! Mhm. Seriously, that's the sort of thing I expect from AM radio, not Science 2.0. (I expect the parallel bias, but I expect it to be couched in prettier arguments. I can get Freeper anywhere!)

    The individual mandate was stupid, I concede that. All legislation is ugly and mostly misses the mark, as far as I can tell. I concede ACA is a mess generally, but I think and hope it will be a better mess than we had without it. Blame the insurance industry for the mess - they wrote it. Blame bribery and partisanship for making it this way. it's awful! But to steal from Churchill: our system is the worst in the world, except for all the others that have ever been tried. If you don't like it, suggest improvements.

    You never answered what your "tiny minority" was. 3% is ten million people. It's a small minority, but it's a vast horde of people to brush aside by quoting factoids and statisticoids. It's kind of, like I said before, evil.

    It stands to reason that 3% of the people could be insured by raising rates (or lowering costs...) by something like 3% on the rest. Unthinkable! LOL.

    How much would I spend? Voluntarily? Nothing! That's why this isn't something to leave entirely up to the magical market and individual consumerism. Same as roads and wars. I wouldn't voluntarily spend anything on those either. Most people wouldn't, yet most agree they're needed.

    Libertarian ideals works perfectly - on planets with one person on them. The market models that economists study are like ideal gases - there aren't any. It turns out that cooperation is 1,000 times more common and necessary than competition. It's healthy to inspect that, seeking improvements, finding balances - but it's "evil" to work against it on principle.

    Gerhard Adam
    Saying 'everyone is forced to buy a product because they will some day need it' has never been done in American history.
    Oh come on.  Tell me the last time you had a choice in purchasing car insurance?

    Since that "some day" is unpredictable, that it is the height of irresponsibility for people to claim they don't need insurance.  Since it is illegal for them to make that decision based on their driving record, it is most certainly illogical to allow them to make such a claim if they are actual biological organisms.

    There is NO ONE that doesn't need medical coverage.  Unless they're prepared to sign a waiver that they will pay cash on demand for treatments, such arguments have no merit.  So when the 25 year old comes in with a torn hamstring, or the pulled shoulder from playing baseball, then can pay cash for their surgery.  Similarly, they can pay cash for when they have children, etc.

    The point of insurance is to have everyone pay, whether they use it or not.  To suddenly argue that you should only have insurance when you need it is an economy fairy tale. 
    Mundus vult decipi
    Hank
    Actually, anyone smart buys uninsured motorist coverage because it clearly is not the same thing.  I have never had a government employee come to my home or business and force me to pay for any insurance, yet the federal government is telling the IRS they will do just that.  Is it different in Oregon, are you really forced to buy car insurance and will a government employee visit you or garnish your income if you do not?

    Gerhard Adam
    I know of no state where you can get your car registered or buy license plates without proof of insurance.

    I just did a cursory check, but looks like California is no different, and requires proof of insurance or self-insurance.  In short, you must be able to demonstrate financial responsibility before you are legally authorized to drive a car.

    http://www.dmv.ca.gov/pubs/brochures/fast_facts/ffvr18.htm

    Types of financial responsibility:
    • A motor vehicle liability insurance policy
    • A cash deposit of $35,000 with DMV
    • A DMV issued self-insurance certificate
    • A surety bond for $35,000 from a company licensed to do business in California.
    Mundus vult decipi
    Hank
    Still not the same thing, the government does not garnish your wages or send someone to audit you if you do not register a car.  Perhaps today it will be possible to make car insurance mandatory, since the Supreme Court says the federal government can force me to buy health insurance or broccoli or anything else they want.
    MikeCrow
    I'm waiting for the autonomous cars to become available, I so want one. But I also want to still be able to drive when I want. But I suspect at some point after they become affordable they will become mandatory! I'm just hoping you'll still be able to get a drivers license if you want.
    Never is a long time.
    Gerhard Adam
    So getting ticketed (from what I understand fines can be up to 800$+) or potentially going to jail aren't the same thing.  I guess if you want to split that hair. 
    Perhaps today it will be possible to make car insurance mandatory..
    If you have a state DMV license plate, then it is mandatory. 

    But by that argument then anything the government does with your taxes is "forcing" you to buy whatever they choose.  Does it really matter if you send it to them first? 

    So your beef isn't with them "forcing" you to buy insurance as much as it is with the fact that they aren't simply collecting the money from your taxes and buying it for you.
    Mundus vult decipi
    Hank
    You're already splitting hairs.  Now you are contending no one can get a driver's license unless they own a car, which is not true.  There is zero point in continuing to argue that forcing a lot of people to buy health insurance is going to give people better health care.  Car insurance is downright pedantic - if anyone else made that comparison you would be flipping out. 
    Gerhard Adam
    Who said anything about a driver's license?  I said DMV license tags.  You know ... the little plates you put on your car?  Insurance is mandatory if you want those [i.e. intend to actually drive it rather than leave it sit in your driveway].

    Moreover if you get pulled over, a police officer has the right to demand proof of insurance and if you don't have it you will likely get ticketed [officer's discretion].  How is this anything but mandatory?
    There is zero point in continuing to argue that forcing a lot of people to buy health insurance is going to give people better health care.
    Maybe I'm naive, but whoever said anything about "better" health care?  Isn't the objective to get health care to those that currently don't have it [so, in that sense something is better than nothing].  The other aspect was some nebulous claim that it could reduce overall costs [which will never happen].
    Mundus vult decipi
    "The other aspect was some nebulous claim that it could reduce overall costs [which will never happen]."

    Never happen why? Because this particular law doesn't try very hard? Or because it's axiomatically impossible? Or just impossible in the face of political and economic resistance?

    As a cynic, I agree that it'll "never happen." As an optimist, I think we should keep trying. Getting rid of the health insurance industry might be a good start.

    Gerhard Adam
    There is no incentive to reduce costs, for anyone.  Therefore they won't come down.  The net effect of the law is to guarantee income to the insurance companies, which in turn will guarantee income to the medical profession and it will be business as usual, with costs continuing to rise out of control.

    Economics never works in the absence of incentives.
    Mundus vult decipi
    "There is zero point in continuing to argue that forcing a lot of people to buy health insurance is going to give people better health care."

    It will definitely provide (everyone forced to buy it with) better care! How can you even suggest it won't? 30,000,000 people will have a nearly 100% increase in "better" health care. (Or 20,000,000, or however many you want. Make it eleven people if you say so! In which case it will be very affordable won't it!)

    But, like the article suggests, better might not even be good.

    Wait, who's splitting hairs? You're making a huge, argument-ending distinction between obtaining a license and being legally allowed to drive? it's not even a large hair.

    Pedantic? It's a pretty close parallel. Costs about the same, is mandatory in most states, is almost equally universal, and non-compliance results in fines. (DMV fines are much greater than IRS fines, too.)

    There is zero point in continuing to argue that forcing a lot of people to buy health insurance is going to give people better health care.  
    In Canada everyone contributes to health care through increased taxation. There are excessive administrative costs. People overuse the system by showing up in emergency departments and clinics for minor problems. There are excessively long waiting lists, even for cancer.  So those who can afford it turn to private insurance, which will pay for most of the cost of private clinics. These have mushroomed in number in recent years because of the poor service in government centers. If you belong to a union, you are again in many cases forced into buying more medical insurance, where often the employer makes a $0 contribution.


    In the U.S. my wife's employer paid the entire portion of her individual medical insurance. When she gave birth, the Kaiser Hospital seemed like a Hilton compared to the typical Quebec hospital. (I even got a bed!)The U.S. simply has to get rid of its malpractice lawsuits and most of its associated lawyers. Then private medical insurance will be affordable for more people. But if you put the whole operation in the hands of the government, you're asking for trouble!
    Gerhard Adam
    Two problems with your example.  The most obvious is that you aren't actually paying for medical insurance, and simply shifting it to the employer makes people behave as if it is "free".   As many people are beginning to discover, it isn't quite as workable when the employer begins to reduce their expenses and the burden shifts to the workers.  It's easy to favor the current system when one isn't actually paying for it.

    Malpractice insurance is a red herring argument.  This is the legal system the U.S. has elected to employ, so it isn't reasonable to argue that one can have an adversarial system and then allow no adversaries.  The simple truth is that if physicians policed themselves better there would be fewer lawsuits.  In the case of frivolous lawsuits, the problem isn't malpractice insurance, it's policing the legal system.  The idea that a doctor can do millions of dollars in damage and have limited liability is preposterous on the face of it.

    However, the second problem is the continuous presumption [which isn't true] that somehow one doesn't have to wait in the U.S. healthcare system. 

    While I can't speak to your experiences directly, I also have many friends and relatives that live in Canada that have absolutely no problem with the healthcare system there [similarly in Europe].  As with anything, I'm sure there can be good, as well as bad experiences.  However, the one inescapable fact is that the U.S. spends nearly 1/3 more of it's GDP on healthcare than Canada does, which is exacerbated by the fact that the U.S. GDP is also significantly higher than Canada's. 
    Mundus vult decipi
    The idea that a doctor can do millions of dollars in damage and have limited liability is preposterous on the face of it.
    Millions in damage? You mean if a patient can't work for over a decade as a result of a botched up operation? The government can foot the bill. Otherwise, wouldn't it be better just to the suspend the doctor's license?  In a more drastic situation, if I lose a loved one due to a medical error, how's giving me money going to fix anything?

    MikeCrow
    Considering that medical care can run into the many hundreds of thousands of dollars, I think everyone should be required to get insurance, because even if you aren't sick, at some point you're doing to want care. It isn't economically feasible to force insurance companies to cover the sick, and not also get the income from the healthy.

    But, I'm not sure the federal gov has the powers to mandate it. IMO what they need to do is put it out for a vote, everyone gets covered, everyone has to buy it, or not.
    If the vote is yes, then they need to remove some of the restrictions on the ins companies, allow them to compete, maybe run them as a puco at a fixed profit, say based on customer satisfaction.
    Never is a long time.
    Gerhard Adam
    I still say eliminate health insurance.  It's a non-viable business model and can never be made to work properly.
    Mundus vult decipi
    MikeCrow
    I don't agree, I think it can provide a useful function to healthcare.
    Never is a long time.
    Hank
    It's already mandated. The Supreme Court is kind of the final word on that.
    Heh - yet you argue too!

    MikeCrow
    It is?

    Oh, yeah. But it hasn't settled well with a lot of people, and IMO(and lots of others) the SC did so in an unusual method.
    Lastly, if the other guy wins, it will be revisited.
    Never is a long time.
    Gerhard Adam
    ...patients and doctors disagree that government should be deciding who to save...
    Who does decide?  It is clear that patients aren't going to decide they don't deserve "saving", and unless a doctor is concerned enough to actually waive their fees, their opinion is largely irrelevant.

    So, how does such a decision get made?  We have unlimited demand [since everyone will face death] with finite resources ....
    ...medical professionals in the healthcare industry (who don't think they are overpaid)
    Show me any individual in a job that thinks they're overpaid and this might become relevant.
    Mundus vult decipi
    MikeCrow
    My Dad decided he was done when his lung cancer "came back" about 6 months after his chemo.
    Never is a long time.
    Gerhard Adam
    As did my Dad [different type of cancer though].
    Mundus vult decipi
    There is a difference, in that you have the "choice" whether to drive at all. I suppose you also have a choice whether to seek medical attention for a laceration or just die of sepsis for lack of a $5 co-pay on an antibiotic. Sadly, that happens.

    But most people have no effective choice about whether to drive - I don't! - and are indeed "serfs again." LOL. And I'm pretty sure it's for the better - and I'm sure it could be done better, too.

    Hell, we're all forced to buy "war insurance," and it's a third of the federal budget. We're forced to buy many things. I was forced, after I bought a house, to buy flood insurance in a place that has never significantly flooded. (Blame the gov't? Nah, blame the insurance lobby.)

    Gerhard Adam
    I suppose you also have a choice whether to seek medical attention for a laceration or just die of sepsis for lack of a $5 co-pay on an antibiotic
    No actually you don't have that choice, especially if it involves someone else, like a dependent.  Choosing not to get treatment is only a choice if no one actually knows about it, and it's rather trivial, only potentially becoming more serious later.

    If so, even then someone can readily step in [and definitely if you become unconscious] and can have you treated, regardless of whether you are insured or not.  In some cases, people have gone to court and had the court order medical treatment because of the legal standard often assuming that anyone refusing treatment isn't competent to make such a decision [especially if it is life-threatening].

    So ... no ... we don't have a choice. 
    Mundus vult decipi
    My comment above was meant to be a comment on your comment above...

    I think you misunderstood. I said driving was a choice, thus auto insurance isn't strictly mandatory - you can decline to drive. (I suppose you can decline to eat, too.) So mandatory auto insurance isn't precisely parallel to mandatory health insurance - but it's damn close.

    As for the example of the laceration - plenty of homeless people and weirdos get injured and don't seek medical attention. Surely some people die as a result of not seeking attention. Some "treat themselves" when they shouldn't. Aren't there religions that prohibit medicine? An injured person who was really dedicated to not getting treatment could hide from public health authorities in a cave. In a perfect libertarian world, everyone has a right to die of sepsis, and no one can be forced to chip in for public health. I love it when people say that's okay by them - shortens my xmas card list.

    Wait, who's splitting hairs? You're making a huge, argument-ending distinction between obtaining a license and being legally allowed to drive? it's not even a large hair. thanks for sharing

    Given that medical care can run into hundreds of thousands of dollars, I think everyone should be required to get insurance, because even if you are not sick, at some point you will want to do care. It is not economically feasible to force insurance companies to pay for the sick, and there will also be a healthy income.

    The government CAN and does mandate stuff. Only issue is, can a federal government do it across the nation?
    A state government can, that is long settled.
    Interestingly the new law forces you to buy "an" insurance, not "insurance product A" or "insurance product B".
    So it can be argued people are not being forced to buy a product (A , B etc) but be responsible (having "some" insurance, no matter from which company).

    Hank
    Sure, the only issue is the federal involvement, since is it not in the enumerated powers. And the Supreme Court decision at least found some limit for the wildly overused Commerce clause, so perhaps we will get back to sanity.

    It would be perfectly fine for a state to mandate health care, just like they can allow abortion or gay marriage or no smoking without controversy, and have. It's when the federal government does it that problems happen.  That is why it is perfectly right for Mitt Romney to have championed something in Massachusetts while being against it federally (and obviously it makes for good politics while running against the president who created it).
    Gerhard Adam
    It would be perfectly fine for a state to mandate health care, just like they can allow abortion or gay marriage or no smoking without controversy, and have.
    It's a silly way to run a country.  Effectively it increases costs for everyone, provides no consistency in the laws nor their application and simply increases the bureaucracy.

    The idea that states don't have to recognize each other's laws is a bad joke.

    Yeah, I get the constitutional aspect of it, but it's still a silly way to run a country.
    Mundus vult decipi
    Hank
    Centralization and heavy-handed distant government is a much sillier way to run a country, as we saw.  The more removed government is from people, the more social authoritarian and even totalitarian it becomes.
    Gerhard Adam
    I disagree, which is why you're facing Prop 37 and we're not.

    It is interesting that with the love affair we have in the notion that government should be run like a business, that I can't think of any business models that propose a decentralized management style [I'm talking about matters regarding corporate policy and implementation].
    Mundus vult decipi
    Hank
    Well, no, Prop 37 is democracy at work, not centralized government. It's silly to say flawed referendums mean democracy is a failure.  We have had failed ones in the past - gay marriage being a famous one - but gay marriage failed in the home of gay marriage precisely because it was badly written, just like Prop 37, and people had to vote against something they believed is or create billions of dollars in lawsuits. The paternalistic notion that only elites can make informed decisions is in defiance of democracy.  
    Gerhard Adam
    That's an interesting distinction you're making, since clearly Sacramento is just as centralized as Washington, D.C..  After all, we're not talking about a dictatorship.

    There's nothing presumptive in a centralized government about "elites" or anyone else making decisions without voter input.  In addition, it doesn't even preclude local decisions being made.

    It is simply a matter of some issues being national and thereby requiring some standardized approach.  I realize that we can't simply change the Constitution arbitrarily, but it seems that any social/political situation that has the potential for having ramifications across state lines should be under the jurisdiction of a central federal government [gay marriage is one such example].  Either national standards need to be established, or other states should be compelled to recognize a legal status assigned by another state.
    Mundus vult decipi
    Hank
    I don't see the benefit, I see a check and balance if states are not forced to adopt every crazy measure of every other state or, worse, the runaway abuse of the commerce clause. If California wants to decide all cars should run on solar power why force people in other states to have terrible cars that cost more?   That stupid overbearing federalism is why we have a Department of Education that collects tens of billions of dollars and then gives it right back to the states it collected the money from.  Communism failed, time to let it go.
    Gerhard Adam
    If California wants to decide all cars should run on solar power why force people in other states to have terrible cars that cost more?
    Spoken like a true Californian.  :)

    However, there are 49 other states that would keep that kind of decision in check.  That's all part of the checks and balances, is to prevent individual states from running amok because of localized interests that have national consequences.

    That certainly doesn't mean that the federal government is perfect, or even a good instrument for some of the policy decisions, but part of the problem with something like the Department of Education is having to ride herd on all the individual states. 

    However, if your original point was simply about having other states recognize California's laws, there's no problem, because the law doesn't having any inter-state ramifications.  However, something like marriage definitely does.  While such a law would certainly affect manufacturers in other states, it would do that under the present system anyway, so nothing changes there.
    Mundus vult decipi
    Hank
    The Supreme Court had ruled that under the commerce clause, almost everything had interestate ramifications.  Otherwise, a person growing medical marijuana in California wouldn't be a federal issue.  But it was, because he could use that money to buy things from other states, they said.

    As I said, the only upside to the flawed Affordable Care Act ruling was they did actually find a limit to growing federal power abuses under the commerce clause.

    You seem to be changing and adopting my position that de-centralization is better than a distant bureaucracy slapping on one-size-fits all legislation. I welcome you back to sanity. :)
    The thing about healthcare is about risk. By not paying for healthcare, but being covered against risk anyway is like mooching off of others. It is just not as obvious as mugging someone in a dark alley, but it amounts to same thing. Making it a state issue will not work since moochers will stay in non-mandate states, moving to mandated but better healthcare states when they need it. Healthcare being one of the most expensive commodity, if it doesn't fit into commerce law, I do not see what does.

    Also, there is no "distant" government anymore like the colonies. Everything is under the microscope and on record. Technology has reduced all distances and old ideas of "distant" federal goverment versus "local" state government makes no sense.

    Hank
    The thing about healthcare is about risk. By not paying for healthcare, but being covered against risk anyway is like mooching off of others.
    Insurance was never intended to be free health care, that is not the definition of health care. All of the people being taxed did not ask for this, they instead are told they have to pay for it and some day they will benefit from it.  That is not a choice.  Government does not pay my car insurance or house insurance or anything else, so forcing people to buy it and then telling them they are mooching if they don't is not valid.
    Point is not about using healthcare or not. Point is about everyone having a non-zero health "risk". This risk is mitigated in the US ... as oppesed to third world countries (say). This "risk" needs to be paid for. So, either carry insurance, *any* insurance of your choice or pay penalty.... this is NOT "buy tiger brand insurance only" ... Where is the choice being affected here?

    Gerhard Adam
    All of the people being taxed did not ask for this, they instead are told they have to pay for it and some day they will benefit from it.  That is not a choice.
    Sorry, but I think you've really gone off the reservation on this one.  There are numerous things we don't have choices about that the government elects to do.  The government does require that you have car insurance if you intend to drive a car.  Your mortgage holder will insist that you have house insurance.   The only choice is to not participate in this particular areas.

    However, unless you have a divine exemption, you cannot choose to get sick or injured, or even die.  So, to argue that one has a choice regarding health insurance makes no sense.  This isn't something that anyone can opt out on, because the reasons for using it aren't choices either.  In fact, it is preposterous for anyone to be so bold as to even suggest that they don't need health insurance.  

    In fact, as you know, I would argue that health care should be a government service just like police and fire protection, as well as national defense.  It is absurd to suggest that one's health is relegated to the same category as deciding to buy a new car.  We are all participants and contributors to this society and we should be able to benefit from that.  The government collects more than enough taxes to ensure such a service is available. 

    I have to pay for the military regardless of whether I feel threatened, or regardless of whether I agree with the prevailing foreign policy.  I have to support police, regardless of whether I've ever been the victim of a crime, and similarly I don't get to hire firemen only because I've experienced a fire.

    This attitude about health care always reminds me of the actor, Craig T. Nelson's "brilliant" quote:
    CRAIG T. NELSON (5/28/2009): I've been on food stamps and welfare.  Anybody help me out?  No.
    Unfortunately that's what people that don't need health insurance sound like.
    Mundus vult decipi
    MikeCrow
    I would very much disagree, the military is managed by the federal gov, and fire and police are not. Fire and police have to manage on a budget, and can't just print money when they run out. The military can (and probably should be able to), but they are anything but thrifty.

    Healthcare is better managed in the commercial sector, where not managing your budget results in going out of business, and it behooves them to work with the hospitals to reduce costs. There's very little of that done by the military and contractors.

    But, as I said above I think there should be a mandate (or a vote on whether there should be one). And then we can change insurance companies into the yin for the medical industries yang. I see that relationship as useful. And then make sure both are open to competition and remove pre-existing condition clauses.

    Competition always improves performance. The government doesn't have competition nor the threat of bankruptcy when they don't manage their expenditures.
    Never is a long time.
    Gerhard Adam
    Healthcare is better managed in the commercial sector, where not managing your budget results in going out of business, and it behooves them to work with the hospitals to reduce costs.
    If this is better management, then we should be concerned.  Healthcare outpaces virtually every other element in our economy, so I have no idea where you got this idea.

    With healthcare representing 17.9% of GDP, while the military is 4.8%, the comparison isn't even in the same ballpark.
    Competition always improves performance.
    What competition?  That's precisely my point.  Insurance companies reduce or eliminate competition for healthcare, which is precisely why there is zero incentive for the healthcare industry to bring its costs under control.  Health insurance simply shields the healthcare industry from actually having to deal with market forces.

    Arguing that police/fire are under a different government control than the military is irrelevant.  It is government and not private sector.  Everyone, even the military, operates under budgetary controls.   Insurance companies will never be a viable cost control mechanism, since they represent an unworkable business model regarding healthcare.  Costs will continue to go up, and there's absolutely no viable economic model to propose an alternative.

    Health insurance can't ever work, since there is no business that can exist that must ultimately always pay out more in benefits than it can ever collect in premiums.  This is precisely why the incentives we've seen insurance companies pursue is to reduce their liability by claiming "pre-existing conditions" and trying to extend their coverage to those that don't need it.
    Mundus vult decipi
    Hank
    What competition? That's precisely my point. Insurance companies reduce or eliminate competition for healthcare, which is precisely why there is zero incentive for the healthcare industry to bring its costs under control. 
    I remain skeptical that health insurance companies lobbied the government to prohibit multi-state health insurance policies.  It is a de facto government monopoly system, since Blue Cross Blue Shield licensees are for-profit corporations that get government contracts and protection and can go across state lines, while no other companies can. Without being able to market across state lines, these fat government monopolies stay in place.

    That is not competition.
    Gerhard Adam
    While that's a relevant point regarding how insurance companies are managed, it has nothing to do with healthcare costs themselves.
    Mundus vult decipi
    Hank
    The argument cannot then be that it will get cheaper if the pool of money is suddenly bigger and the government can force people to pay it. That has never once led to more efficiency of cost.  Not once.  
    Gerhard Adam
    I never claimed that it would get cheaper with this system.  I've said before, that healthcare will NOT get cheaper under any of these plans because the health insurance industry is a buffer to healthcare which has no incentives to control costs.

    However, what is interesting is that your point about no multi-state businesses, is a direct result of your support of states making their own choices and setting their own policies.  It had nothing to do with federal government mandates.  These laws came about because each state could do their own thing.
    Mundus vult decipi
    Gerhard Adam
    Don't know where you got the idea that Blue Cross Blue Shield was a national company while others are prohibited from competing.  Each BCBS entity is a separate company when doing business in any state.
    Mundus vult decipi
    Hank
    I didn't say it was a national company, I said they were allowed to cross state lines and regular insurance companies are not - and they are allowed because of special protected status no other insurance company gets, which they get from the government. 

    By all means continue to argue that more government will fix a problem government created, anyone who makes a profit is evil, etc. But at least look up why companies are restricted and don't say competition is the problem, when there is none allowed. It's like arguing car companies could make cars just as cheap if they had to create separate companies for each state and only sell them in their state - except Blue Car, which could be in 14 states and get 90% of state and municipal government workers and then we could pretend the regular crippled one-state-only car companies are why costs for cars are so high.
    Gerhard Adam
    By all means continue to argue that more government will fix a problem government created, anyone who makes a profit is evil, etc
    The problem your describing occurs precisely because of the government intervention you supported; state control.    BCBS cannot operate across state lines, so I don't know where you got that from.

    Moreover profits aren't evil, but it makes little sense to argue about the profitability of companies that contribute nothing to actually providing healthcare and then suggest that they can bring down costs regardless of the configuration they are in.  Insurance companies cannot do anything to control costs, except as it pertains to their own premiums. 

    The problem is the healthcare industry itself, and without that changing, you can wave your arms all day long about how to deal with insurance companies and it won't change a thing.  It isn't about competition between insurance companies, it is about their back-end costs which they have to negotiate with provider.  There isn't a single credible argument making the claim that out of state providers have any means, better or worse, for negotiating with providers to provide improved health care.

    Since you specifically mentioned states controlling health care, then this is a direct result of that practice.  Each insurance company [including BCBS] exists as a separate entity within each state so that they can comply with state mandates regarding insurance coverage. 
    Mundus vult decipi
    MikeCrow
    Insurance companies cannot do anything to control costs
    That's like saying Walmart has no influence over the cost of their merchandise.

    First they can facilitate better management of care, improve the sharing of data, and the reduction of duplicate testing. These alone will save a significant amount of money.
    Second they can negotiate the cost of services with provides because they represent many customers they have leverage.
    Lastly if everyone has coverage, providers won't have to charge excessive amounts to people who can pay for services, so they can remain profitable when providing care to people who can't pay.

    Then if the insurance side of things are adjusted to allow competition across state borders and between companies with portable coverage, they have motivation to work with providers to manage expenses. These changes together will make a
    significant reduction in the cost of healthcare without reducing the amount or quality of care, and still allow the free market the incentive of profits to continue innovating new techniques and technologies. Socialized medicine offers no such incentive.
    Never is a long time.
    Gerhard Adam
    It's an interesting economic fantasy, but it isn't true.  I can't even begin to imagine how crossing state lines makes a bit of difference, since the health providers don't have interstate facilities.  Each state is a separate domain and yet somehow despite state mandates, you concoct some idea that costs can be controlled.

    Here's my prediction.  Given the opportunity not a single insurance company will choose to offer services across state lines.  Instead they would likely opt for the BCBS Association model where each company operates separately and independently in the markets in which they compete.
    That's like saying Walmart has no influence over the cost of their merchandise.
    They have control in the same way that insurance carriers do; controlling their own costs.  Unless, of course, you're referring to Walmart coercing suppliers to reduce their prices, but that wouldn't be very "free market" sporting, would it?  I'm equally sure that you're not suggesting that insurance companies can dictate what doctors charge for services, or what fees they're allowed to collect.  So, in effect, they can control nothing.  They can simply indicate what they've always done ... what will they pay for and what won't they pay for.  That doesn't solve any problem, it simply creates a two-tiered pay system where the insurance pays for part of the treatment while the patient is on the hook for the rest.
    First they can facilitate better management of care, improve the sharing of data, and the reduction of duplicate testing. These alone will save a significant amount of money.
    How?  They have no managerial authority or any authority over healthcare operations.  Do you actually believe they even look at what healthcare providers do, beyond examining whether its covered or not?
    Second they can negotiate the cost of services with provides because they represent many customers they have leverage.
    Where's the evidence of this?  There is a single shred of evidence that even the largest insurance companies have ever influenced the costs of healthcare providers.  Their only influence is in determining what simply won't be covered.  That doesn't change a doctor's recommendation for treatment.  It simply puts the insurance company in the position of determining a medical outcome, which is the one thing everyone is supposedly opposed to.
    Mundus vult decipi
    MikeCrow
    Your lack of imagination does not necessarily represent reality. There is so much wrong in this post, I don't know where to begin.
    First, insurance companies already operate across state lines, I had BCBS of California through my employer, and I live in Ohio.
    Walmart coercing suppliers to provide better terms is free market, no wonder you think the way you do about free markets, you don't understand it.
    Insurance Co's already tell Dr's what they will get paid for a procedure, it's called "reasonable and customary" prices. If they don't pay enough, Dr's drop them (like many are talking about with Medicare because they want to reduce payments even more). It would be useful to be able to switch Ins co's, if they didn't pay enough to keep their customers preferred Dr's. My Ins co's are okay, I haven't had any issues with getting covered with my Dr.
    Dr's on the other hand, accept a lower payment, because they get paid with a lot less hassle than having to take payments and carry costs for a year or two waiting for the customer to pay them. This is why if you don't have Ins, and you can pay up front, you can negotiate a reduced payment with most Dr's.
    I'll also point out, both my wife and myself have been called by nurses that work for my Ins Co, to discuss our conditions, our Dr's, and treatment, providing a sounding board for our care. Sure it's good for their business, but it's good for my healthcare as well, they didn't try to talk me in or out of anything, but wanted to see if I had any questions, and if they could be of any help.
    Every time I go the the Dr, the insurance co provides a statement listing my care, the Dr's charge, and what they paid. That seems to be proof to me they have an impact on the cost of care.
    Lastly, I've not had any treatment not covered by ins. I've had to get pre-authorization from 3 different Ins co's for my wife's biologics, all 3 approved the treatments which have ranged from ~$2,000/mo to $8,000/mo, and my rotator cuff surgery cost me Zero out of pocket.

    Now, I do admit I have good Ins, and when I was on COBRA it wasn't cheap, and when my COBRA was getting ready to expire I had to join a small business association to get access to ins because of a pre-existing condition, but I did, and I maintained coverage, and while it was expensive (which I paid out of my pocket), it was cheaper than paying for the care (though I suppose I could have gotten medicaid, or gotten care, and just not paid for it like so many others do).
    Never is a long time.
    Gerhard Adam
    Are you really going to equate the hundreds and thousands of individual healthcare providers [that would all have to be separately negotiated with] with a single-source manufactured vehicle?

    Perhaps if BCBS were providing the care you might have a point.   So unlike your example of "Blue Car", they are not a single-source provider of anything.  They are simply the billing company and are incapable of offering anything except local services.

    The other problem is that you're trying to equate a manufacturing process which can clearly benefit from an economy of scale, which healthcare providers cannot do.  There's no "economy of scale" in treating cancer patients [for eample].   In fact, the healthcare industry operates on the exact opposite principle in essentially refusing to consider economies of scale by sharing resources between hospitals.  Again, insurance companies can do nothing about that.
    Mundus vult decipi
    Thread's getting too skinny.

    As to letting insurance companies compete across state lines - I bet the result would be further concentration and oligopolization. Less competition, not more. It's a pet project of special interests, and has virtually nothing to do with a solution.

    As to medial malpractice - it's like 1% of the picture, and thus a complete red herring. It's another pet project of special interests, and also has virtually nothing to do with a solution.

    As to anecdotal experiences of foreign health care systems - skip them. We should all know how valuable anecdotal evidence is - and most of them derive from fiction anyway. Here's a true one though, for balance: An American pal of mine, a young, unskilled worker, tore his ACL on the job. He had no employer-provided insurance (and was told he'd be fired if he left work due to the injury!) He later went to the emergency room, was charged a couple thousand dollars for routine exams, for which he could not realistically pay, and never did pay - the US taxpayer paid. He couldn't possibly get surgery or other treatment without coming up with cash. so he didn't get surgery, and in fact he had to work on the torn ACL for weeks while it "healed" wrong, or he'd lose his lousy (but irreplaceable) job. He was mildly disabled for years afterward. Then he married a Canadian, moved to BC, walked into a clinic, arranged for the surgery, and voila. No unbearable waiting lists or anything. He didn't say whether the rooms were nice enough - but he did get his knee repaired, which he couldn't do in America.

    I just lost my insurance, so... I'm SWM46 ISO SF, must be Canadian. Pics not necessary but send proof of citizenship. Dog lover a plus.

    I have learned from Science 2.0; I've learned about nuclear physics, cosmology, all sorts of things. One thing I've learned is that presumably educated and intelligent people generate more elaborate, but no more rational, rationalizations than do presumably less educated people of presumably lower intelligence; and they're no more susceptible, as a class, to reason, than the trolls on other websites.

    You know who's right? Me!

    Not that I have the "right" facts, or the "right" opinion - I have the right attitude. I can change my mind, when evidence demands it, and frequently do. I could give a hundred examples (but I'm slightly embarrassed about each of them).

    Hank
    As to letting insurance companies compete across state lines - I bet the result would be further concentration and oligopolization. Less competition, not more. It's a pet project of special interests, and has virtually nothing to do with a solution.

    As to medial malpractice - it's like 1% of the picture, and thus a complete red herring. It's another pet project of special interests, and also has virtually nothing to do with a solution.
    Who cares about fake competition?  That leads to rich cities banning Wal-Mart so they can have their 'downtown' stores and poor people can't shop there.  Supposedly American health insurance costs too much and competition brings it down, including if consolidation happens.

    I agree malpractice is not the direct concern - but defensive medicine is a far more expensive problem. And defensive medicine happens to prevent malpractice liability.
    Gerhard Adam
    That leads to rich cities banning Wal-Mart so they can have their 'downtown' stores and poor people can't shop there.
    Oh please ... you can't really believe that. 
    Mundus vult decipi
    Oh please ... you can't really believe that.

    Why not? Tens of millions of people believe it. Though I doubt tens of thousands have given it a moment's thought.

    'Fake' competition? I don't get it.

    Health care 'supposedly' costs too much? Costs are the highest in the world, higher per capita and "per outcome" (or whatever) than anywhere else in the world. Costs are rising way ahead of other sectors (food, energy, housing), and -way- ahead of economic growth. It's 'supposedly' bankrupting us.

    Defensive medicine may avert potential malpractice claims - but is it just a coincidence that it generates revenue for doctors and labs? If malpractice is a small concern, then it should be inefficient to spend a 'large' amount on defensive medicine to avoid a 'small' expense of malpractice suits. So, by your theory, it shouldn't even be happening. So, I don't think it's about malpractice (much) at all.

    Competition between health insurers isn't the same as competition between health providers. The middle man prevents useful competition between providers that might arise if consumers were making decisions in a functioning marketplace. They largely can't make any choices at all in this system! Most employers offer one health insurer, maybe with varied plans, but not much to choose from - not enough to generate competition. The magic of the market fizzles where the consumer can't make choices; where it isn't their own money they're spending; where middle men have already made most of the choices for them.

    One reason costs are rising is that competition is happening in the wrong places, between the wrong entities. That's readily fixable.

    Costs also go up because of introductions of new technologies, an aging populace... lots of reasons, which are seldom if ever addressed in the corporate-dominated "debate." All we hear about is the corporate pet projects, like interstate competition and malpractice relief - and endless (intentionally distracting, well funded) debate about whether women's reproductive organs are a legitimate health issue.

    Cut out the middle man! What's so hard about that? You shouldn't have to be a rocket scientist...

    Hank
    Cut out the middle man! What's so hard about that? You shouldn't have to be a rocket scientist...
    This part I agree with. Health insurance and other 'benefits' are leftovers from World War II, when wage controls prevented companies from competing for employees, so they had to invent other ways to look attractive to key people.  So they invented this benefit concept but an individual person can't write off the cost of their health insurance benefits while an employer can.  Clearly if that were fixed, we could eliminate the middle man - both the government and healthy insurers.

    Until I moved to California, I had a dentist and a doctor who took no insurance and they charged accordingly. If we had actual tort reform, costs for malpractice and defensive medicine would plummet and doctors could compete too.

    You keep using the word competition, but you don't mean it.
    MikeCrow
    an individual person can't write off the cost of their health insurance benefits
    Now it's quite possibly a recent change, but when I was under-employed, I was able to deduct my insurance costs.
    Never is a long time.
    Hank
    If you were making a lot less money and paying your own health insurance, it exceeded 7.5 % of your income.  That first 7.5% did not get deducted or you did something wrong. Clearly, that 7.5% is a huge blockade to buying individual health insurance, since it is more than 43 states charge in income tax and quite a bit of money to lose for people who already don't make much. Changing the law so medical costs are deductible from $0, like they are with businesses, would solve a lot of insurance problems.
    MikeCrow
    It was all turbotax (and that's my story), and no 7.5% hurtle.
    I think it's something like if you're self employed, you can deduct your health ins cost.
    Never is a long time.
    Hank
    Yeah, you said under-employed, not self employed. Self employed, you are the employer so you can deduct it.  Regular people would get an audit if they tried to say they work full-time and have a side business that pays their health insurance but getting rid of the 7.5% would be the easiest solution for everyone - except government unions who need to find new ways to bleed the public.
    MikeCrow
    My bad, I did consulting work while I was laid off.
    Never is a long time.
    You keep using the word competition, but you don't mean it.

    Then perhaps you'll tell me what I do mean?