Let me be clear, I don’t want affordable health care. I want health care. Affordable health care implies that when I need it, I have to reach into my wallet and pay for it, as I would do with an affordable lunch or affordable pair of shoes. Affordable health care implies that we are all on our own, in the market, and buying what we need with our own individual funds. That’s not what I want. I want health care.
I want health care in the same way that I want national security. I do not want affordable national security because I am not willing to put a price on our national security. I know it is not free. It will cost us all. We will pay for it with our taxes. I know that some of us are more at risk from foreign and domestic threats at one time or another and I do not expect those individuals to have to pay more for national security. We are all in this together.
It is the same with health care. I know that some of us are more at risk of injury or disease at one time or another and I do not expect those individuals to have to pay more for health care. We are all in this together. It does not matter to me if the threat to our health and safety is cancer, ISIS, diabetes, Aryan Nations, heart disease or Al-Qæda; they are all threats to our health and safety.
When our nation was under attack on 9/11, no one said “let’s find an affordable market solution to this”. No, we found a solution. Further, we did not look to the private sector for the solution, we looked to our government. It should be the same with health care.
To the naysayers who might jump in about how government can’t do anything right and market solutions are a panacea, let me remind them that Osama bin Laden is gone and the health care in the USA carries the highest cost in the developed world, with some of the worst results.
So, no thank you, I do not want affordable national security or affordable health care. I want national security and
I want health care.
Bankruptcy. Medical bills are often the cause of people going bankrupt. Making healthcare affordable — even without improving its quality — would alleviate a fair bit of suffering.
Economic outlook. A key problem with health care, especially in the U.S., is that its costs rise at a much faster rate than inflation and a faster rate than the growth in the federal budget. The long-term solvency of the U.S. economy depends crucially on bending the cost curve so that we’re not forced to cut Medicare or Medicaid and so that the federal debt will not balloon.
Unnecessary care. There’s quite a bit of evidence that extra procedures and extra care soak up lots of money without increasing happiness or even health. Care could indeed be made both better and more affordable. Gawande’s recent book Being Mortal (which I heartily recommend) recounts stories of cancer patients whose first round of chemotherapy has not reversed their cancer. Such patients will frequently go onto a second and maybe third round (if the second has not shrunk tumors) even though a third round (with a third kind of drug) almost never brings about an improvement and always detracts from quality of life. This is the kind of extra spending that patients (or their families) are tempted to ask for or even demand, and that oncologists all too readily administer.
…but I’m pretty sure he is advocating single-payer, which has consistently proven most effective on both health and cost sides of the equation.
We all remember the hysteria when the ACA tried to reduce unnecessary care. End of life counseling was referred to as “Death Panels” bu conservatives. My guess is that reducing unnecessary care is seen by conservatives as slowing the sales figures and quarterly stock increases of medical companies. I have not read Being Mortal, but I have read several reports about “how doctors die” and they, in general, do not take the same “desperate measures” that the rest do.
Yes, I am aware of the bankruptcy, economics, and unnecessary care. I wrote this piece to counter the “conservative” arguments that health care is best provided through markets and that anyone who does not want the market approach is a leach who just wants others to pay for the things they want.
Where do you draw the line (or do you) for those who don’t attempt to contribute to their own well being. I knew a women who smoked, developed lung cancer, stopped smoking and was treated with chemo and radiation. Two years after finishing her treatments she was doing ok.
She started smoking again and the cancer returned to her lungs. She was well paid executive with great benefits so she received treatment again, this time it was unsuccessful. Whether she could pay or was on the taxpayers dime I don’t think she should have received the second round of treatments.
We may be in this together but if you’re in a tug of war and everyone on your team is not pulling as hard as they can they shouldn’t be on the team.
Where do you draw the line with the cost of an ambulance and police cars when an irresponsible teenager drives too fast and flips over on a curve, crashing into the woods? Where do you draw the line when wealthy corporations develop a dangerous product that is so addictive, people like the woman you knew can’t quit?
You don’t draw a line because it’s rarely that black and white.
What you bring up here is the standard “free rider” objection to any broad based ideal, that such things cannot succeed because individuals have an incentive to shirk responsibility.
For whatever reason, the world is not like that. People vote, give to charity, cooperate with neighbors and friends, are agreeable to sacrifice for future generations, work together.
Sure, there will be some people who will take advantage of others, but fortunately for us all, Bernie Madoff is the exception, not the rule.
Conservatives tend to dwell on the exceptions to the rule, that somehow individual examples like the smoker CEO can disprove a wide swath of evidence from social science backing up the idea that most government run systems actually provide more comprehensive health coverage to a broader range of people. We saw this with the damage one single con artist did to the Great Society.
The problem with MSNBC, Vox, and some of us here, including yours truly, is that we use graphs or stats to back up our points instead of stories. So here is a story. I was unemployed, diagnosed with asthma, and in desperate need of medicine and Obamacare was there for me. It is still there for a single mom with an autistic son who couldn’t get healthcare through our firm. It’s still there for a Marine’s daughter I know at UIC med school who is still covered under Tricare, and but will need it next year when she turns 27. It’s still there for my former roommate who is working three different jobs to pay the rent and put food on his table. And thankfully Medicare is still there for my parents, and hopefully can be available for all of us. Any horror story in the media can be refuted by my own story which I was happy to share.
I agree.
The executives in the cigarette companies are personally responsible for offering an addictive, lethal product. Shame on them. Our healthcare costs would be far lower if they showed some personal responsibility.
They get cancer or some other lung problem and die pretty quickly.
They usually pass on before they start collecting retirement benefits.
That’s one of the actuarial problems we face today- increasing life spans. When 50%+ of the US population smoked, people were dying much earlier.
It’s the overweight people who are causing health care costs to go up.
If the patient is alive, the care should be considered.
The approach you propose ignores the value of human life.
There are no “free riders” on the health-care train.
In my mind that’s one of the overriding issues in health care costs.
So we treat excessively because there’s no reason not to- that patient or family wants it, and they don’t have to pay the cost. The doctor and hospital get paid so they have no incentive not to do it.
If it’s all on the government dime (a system which I support, by the way) then there has to be rationing. Costs will explode.
BTW why is dental care and mental health never generally considered as universal health issues? Seems we’d get a lot more bang for our buck spending money there rather than other places.
There was a provision in the Affordable Care Act that allowed physician to bill insurance companies for time spent with a patient to go over end of life issues and come up with a living will. This was shot down by Palin and the Republicans who cried out “Death Panels”.
In La Crosse, Wisconsin, 96 percent of people who die have an advance directive or similar. Nationally, only about 30 percent of adults have a document like that. La Crosse, Wisconsin spends less on health care for patients at the end of life than any other place in the country. Story Here
Preventative care is a better option than rationing care after preventable disorders are already manifest (and requiring treatment).
We want to make it easier, rather than harder, for our least-affluent residents to get 6-month teeth cleanings, so that we don’t have to pay ER doctors to remove abscessed teeth and treat the resulting infections later.
I think that outcome-based approaches are more valuable than straightforward cost-benefit analyses of acute care costs.
The first thing that would happen would be government would start paying the bills. The next thing after that would be people would start utilizing the system more heavily.
The sooner people start getting health care, especially preventative health care, the sooner our costs will start to decline. People who are treated earlier cost less than people treated later. The problems we face today are not because too many people get health care, it is because too few get it.
The thing that’s happening right now, for people like me who have health insurance and health care, is that ANY excuse for “follow up” procedures is enthusiastically promoted because each procedure is profitable. Providers perform as many procedures as they can, whether or not they actually DO anything, because they make a profit on each procedure.
We pay a larger share of our GDP right now than any of our first-world counterparts, yet we come in last on any outcome-based metric. We pay a larger share of GOP right now for health care administration costs than any of our first-world counterparts. I’m not sure the ACA has significantly improved that.
I suggest that we need MORE people seeing doctors sooner, while we simultaneously need our consumers and health care providers to spend less time and money on health insurance.
Government-sponsored single-payer health care, along the lines of the rest of the civilized world, will reduce our overall spending on health care now and in the future.
As Benjamin Franklin said, “an ounce of prevention is worth a pound of cure.” This would address one critical fault with the current system of consumer medicine. It’s been well documented that the higher ones deductible, the less likely one is likely to seek preventative care in the hopes that “it will just go away” and when it does not, then instead of a minor treatment with meds or other preventative therapy, more costly measures are needed.
The idea that people would start utilizing the system more heavily for expensive treatments is simply absurd.
If we were talking about Lexus automobiles or IPads, sure, it would be abused. This is different, completely different. When was the last time anyone got excited that the new MRI machine was in and they wanted a test drive? Or does it even make sense that anyone would elect to have an unnecessary heart bypass? No. Medical care is not comparable with markets in this way.
Guess that depends… if you go to the doctor with knee pain and the doctor says it is a sprain and to just R.I.C.E. and come back in three weeks if it does not improve…. A lot of people will “demand” to try out that new MRI machine because it will not be a cost to them.
I am sure there is a remedy for that, and I doubt that “a lot” of people would be this way. Again what’s brought up here is the standard “free rider” objection to any broad based ideal, that such things cannot succeed because individuals have an incentive to shirk responsibility. I hear it over and over again. Somehow, this problem does not exist in nations with universal single payer. Why would it be a problem in the USA? Are we that immoral and selfish as a people?
Have you ever worked at a company that starts a dental plan? The have very low caps at first (typically $1000) because everyone rushes to get dental care. That is the historical experience of the insurance companies. There is no reason to think that if free or low cost medical care was suddenly available, that many people wouldn’t rush to get treatment for things they had been ignoring, just like the dental example.
People get more dental work because they can finally afford it. Your example is just further proof of my point. Left untreated, people lose teeth and that just leads down the path of the inability to eat properly, infections, and a host of ailments that would be otherwise avoided with proper dental care.
http://www.theguardian.com/healthcare-network/2015/apr/24/rationing-care-fact-of-life-nhs
For most Americans, the average HMO is about as soulless, centralized, and rationing as a state run entity. The big difference is, the very wealthy can bypass the rations and get concierge care, jumping the line over people that are less affluent and less healthy that need the care now. We can switch to an NHS style model, let the rich fly to Thailand to jump in front of the line, as many are already doing, and they can bare the risks involved. The rest of us will have access to care, when we need it, where we need it, without worrying about how to pay for it.
I’m only postulating that if you (a theoretical BMG proposer) wants to make dramatic changes, then they would have to be able to bring on board the people who are satisfied (except maybe about cost) with the current system.
I think that going the route proposed by the poster would result immediately in many many unhappy people. Perhaps this could be overcome at some point, but I think preparation would be needed. While a net improvement in US health care may rapidly result, those that have the health care now would find getting what they currently have more difficult.
The U.S. already rations care. Rationing in U.S. health care is based on income: if you can afford care, you get it; if you can’t, you don’t. A recent study found that 45,000 Americans die every year because they don’t have health insurance. Many more skip treatments that their insurance company refuses to cover. That’s rationing. Other countries do not ration in this way.
If there is this much rationing, why don’t we hear about it? And if other countries ration less, why do we hear about them? The answer is that their systems are publicly accountable, and ours is not. Problems with their health care systems are aired in public; ours are not. For example, in Canada, when waits for care emerged in the 1990s, Parliament hotly debated the causes and solutions. Most provinces have also established formal reporting systems on waiting lists, with wait times for each hospital posted on the Internet. This public attention has led to recent falls in waits there.
In U.S. health care, no one is ultimately accountable for how the system works. No one takes full responsibility. Rationing in our system is carried out covertly through financial pressure, forcing millions of individuals to forgo care or to be shunted away by caregivers from services they can’t pay for.
The rationing that takes place in U.S. health care is unnecessary. A number of studies (notably a General Accounting Office report in 1991 and a Congressional Budget Office report in 1993) show that there is more than enough money in our health care system to serve everyone if it were spent wisely. Administrative costs are at 31% of U.S. health spending, far higher than in other countries’ systems. These inflated costs are due to our failure to have a publicly financed, universal health care system. We spend about twice as much per person as Canada or most European nations, and still deny health care to many in need. A national health program could save enough on administration to assure access to care for all Americans, without rationing.
Have you ever had an MRI? It isn’t fun. I’ve been hearing this “people will abuse health care if it isn’t expensive” argument for decades. It’s BS. The number of people who go to the doctor when they aren’t sick, or demand procedures the doctor thinks unnecessary, is minuscule. Is there any evidence that people in countries with single-payer do those things? No, there isn’t. Now you can trot out your America is different” routine.
and there are a lot of studies that show there is unnecessary treatment because the doctor is “covering their behind” and there is also unnecessary treatment because there are nutcases out there who look for that (I’m related to one). There’s also the whole “doc shopping” routine. If demand increases these things will all increase as well.
Just a hypothetical. If all of a sudden opioids were available (via prescription) for free or cheap, you don’t think hundreds of thousands of new people would be showing up complaining of chronic pain?
Have you ever worked at a company that starts a dental plan? The have very low caps at first (typically $1000) because everyone rushes to get dental care. That is the historical experience of the insurance companies. There is no reason to think that if free or low cost medical care was suddenly available, that many people wouldn’t rush to get treatment for things they had been ignoring, just like the dental example.
And the problem with that is…? In the long run that is probably actually a plus.
Though, again, it’s a geffen good in my view, so profitability is very difficult, especially now that pre-existing conditions can’t be excluded. I suspect we will continue to see consolidation until there are about 3-4 national HMOs left with the purchasing power to be effective, and it’ll then be significantly easier to nationalize them into an NHS style system or a Canadian system.
A lot of this is the AMA’s fault. Had they not lobbied hard against Truman’s plan, we could’ve gone single payer around the same time as Europe, they proposed HMOs as a ‘private sector alternative’ around the late 60s and Nixon on boarded it. It’s very big business now, but in Truman’s day, you still paid out of pocket to the Doctor for most expenses and just needed the Blue Cross card for hospital treatment. And for awhile, they were one of the few national names in town.
then something has to give, especially if there are no market forces at work.
I’m not so sure why attacking the notion that affordability is important wins points off conservatives.
The problem with the conservative position is that an unregulated free market in insurance quickly leads to cheap policies that only offer the appearance of coverage. And purchasing cancer treatment say is very different from purchasing a commodity; it’s different enough that a free market confers none of the usual benefits (innovation and efficiency).
That’s why I compare it to national security. What conservative wold ever run on platform of “affordable national security”? They want it regardless of cost. Hell, they want a military bigger and bigger and bigger each year without once ever mentioning cost. Their argument is that a huge military is cheaper than a lost war and so no matter what it costs, we spend it because it’s less expensive than not having it. I use the same argument for single payer universal coverage.
In fact, there are significant problems with how money is spent on national security.
Our approach to national security is to spend everything we can spend, and then some, to make sure we have more everything than anybody else. Surely our experiences since Vietnam have demonstrated that overwhelming (and overwhelmingly expensive) military might does not provide “national security”.
We approach health care with the same unrestrained spending and unconcern about effectiveness. The biggest difference is that we are more open about where the money comes from with health care (as opposed to “national security”) security.
At least some of our lost wars (Vietnam, Iraq 2003) were far more expensive than the threat they purported to manage. Meanwhile, AQ demonstrated that our domestic “national security” has rather more to do with how passionately our enemy wants to attack us and rather less to do with steps we take to prevent it. We have shredded our constitutional rights and jettisoned our freedoms (such as freedom to travel) in our utterly ineffective pursuit of domestic “national security”.
I do NOT want us to take the same path towards health care. We saw an inkling of what may lie in our single-payer future with a proposal for yet more government tyranny in the comments upthread, this time in the name of “health”.
I enthusiastically agree that we need government=sponsored single-payer universal coverage. I think the European approach is an excellent starting point.
Finally, so long as we’re discussing national security and health care in the same conversation, there is another aspect of this worth remembering — America provides out-sourced military services for pretty much the rest of the friendly world. A reason why our allies are able to spend as much as they do on their government-sponsored health care is that the US provides virtually ALL of their “national security”. Yes, it’s true that each maintains token military assets (most purchased, in one form or another, from the US — “made in the USA” is still a favorite label on military toys). Still, the US is the big kid on the block. We like it that way, it means we don’t have to worry so much about pesky democracies deciding to challenge our international decisions.
This year, seventy years after the end of WWII, we still very intentionally keep German and Japanese military might at token levels (that we set). This is a direct result of our WWII experience.
Our other-winged friends sometimes like to whine that we’re “not the world’s cop”. Actually, we ARE. We have very intentionally made sure that our allies have far weaker military forces than ourselves, and we work very hard to ensure that maintain some interesting force multiple over those who are not our allies (like Russia and China).
When we are the only person in a neighborhood with a gun, we ARE the cop — like it or not.
For all the benefits of government-sponsored single-payer health care, the risk that we will spread the abuses resulting from our “national security” paranoia into our approach to health care is the aspect of single-payer that I most fear.
That was just an effort on my part to explain to right wingers that everyone has to pay for is not a bad thing in and of itself.
…at least in terms of care, notwithstanding the horrendous VA backlogs we’ve been hearing about.
….national health providing that great care like the VA has wouldn’t have similar backlogs.
That’s the difference, in part. The VA is not run by the Centers for Medicare & Medicaid Service. That’s one reason we would not see backlogs.
I think the new fighter jet is a waste of money.
Congressional Dems used what has been called “sequestration” betting that the Republicans would never ever allow intrusive cuts in defense spending, but sequestration happened. Defense officials have been yelping for a few years now, and it isn’t even on the radar in the GOP presidential debates.
I think that a significant slice of that right-wing caucus wants spending cuts, period– to domestic and military budgets. No, that does not jibe with the invade everyone, always rhetoric, but nothing they do makes sense.
National Security: Pay X to protect Y from existential threat posed by Z. In this instance, X = whatever, Y = America and Z = malevolent states and/or actors
Health Care: Pay X to protect Y from existential threat posed by Z. Here X = whatever (we can afford’) Y = America(n) and Z = malevolent organisms like viruses, bacteria and the vicissitudes of life.
The difference, at least in what I’m hearing from johntmay say, is that some think thus: America is worthy of protecting, and therefore damn the cost, whereas an American… well, those same people who say damn the cost regarding national security also say some Americans are worthy and some are not, and some Americans cost a damn sight more than others…
I think we pay too much for both health care and national security. As Barney Frank used to point out: The US Air Force is the largest air force in the world… the second largest air force is the US Navy. We tend to provision our health care in the same way, but it drives up the cost and doesn’t actually make us all that much healthier, which is what I’m hearing kbusch saying.
…is probably a better analogy than national security since it is a service that families are directly involved with.
If so, that would not be the best analogy. You might as well comapre it to AFDC/TANF.
I think John is making a moral argument for single payer that isn’t focused on the kinds of specifics policy wonks tend to focus on. I also think too often affordable care has been used as a dodge by conservatives or neoliberal Democrats to avoid the obvious solution that every other country has adopted. ACA is banking it’s success on increasing coverage and driving costs down, it has definitely succeeded in the former while the literature seems to be split on the latter. Frankly if you were to tell me to choose between the status quo and a more expensive single payer system that covered everyone, I would still pick the latter.
While Bernie Sanders has discussed how single payer is cheaper than the system we have, it was still too expensive for his small home state to implement. So these are the kinds of discussions we will have to have. Gawande’s piece in the New Yorker awhile back about standardization of treatment is instructive, and that is the kind of bulk purchasing power and standardization (dare I say, rationing) that the government can do in a single payer system.
At the risk of pulling a Friedmen, I met a Canadian at a cocktail party and she said that the system was just as inefficient, and annoying as ours. But she knew she was covered, and she didn’t have to pay out of pocket for it. And that’s the big difference. I think reformers try and offer single payer as a panacea to the actual delivery of healthcare, and that’s just not what I care about. I just want to make the economic case that the community rather than the individual should bare the bulk of the burden for healthcare. In many ways in our patchwork system, the community is already bearing the burden, care is being rationed, and terrible centralized bean counters are making health care decisions instead of patients-the difference is-they are doing so in a system focused on maximizing profits rather than health outcomes. And that is what we are all trying to change.
Both guys received their diagnosis about the same time and both died within months of each other. Neither knew one another and I did not tell either one about the other. Part of the reason was guilt and shame as an American. One friend lived in the USA and the other in Denmark. I could not bear to tell my American friend while he was worried about coverage, paying his deductibles, making sure that a particular health care provider would take his insurance, and the rest of the arcane obstacle course of American health care that a friend of mine in Denmark had none of those worries, none at all. In fact, when it was discovered that his type of cancer would be best treated by a specialist in Germany, the Danish government flew him to Germany for treatment. Not once did my Danish friend or his wife ever have to worry about the financial aspect of his disease. They were able to focus on his health and their remaining time together.
Whenever I hear anyone brag about our healthcare or disparage any of the single payer universal care systems of the developed nations, I just think about my two friends.
But, to me the post just begs the question: At what price? Single payer isn’t free, and it isn’t necessarily affordable. The cost is driven by access, outcomes, and public will (probably many other things, too). It’s no different with national security. What are you willing to pay for? New missile systems, new planes, new boats, better intelligence, more soldiers, better VA care? Those answers, too, should be driven cost, and outcomes. Will you pay more for better outcomes? If you’re demanding something from the government, you’re really just demanding it from yourself and your fellow citizens. What are you wiling to pay for health care and national security? Public policy is nothing if not choices. I want health care and national security, too. I’m willing to pay to get it—the question is how much and the answer must be based on some type of cost/benefit.
That’s an easy one. At a price that is efficient and egalitarian.
high productivity, at lowest necessary expense and fair.
comes to us from Alaska:
https://www.adn.com/article/20151103/alaskas-already-high-health-insurance-rates-set-get-even-higher-2016
If you have a small pool of possible subscribers and a minority with substantial costs, it will drive up insurance premiums for everyone. Once that happens, insurance costs enter a sort of death spiral: premiums rise substantially, only those for whom it would be really cash-positive buy insurance, those subscribers are all high risk and expensive, and the premiums rise again. Eventually health insurance costs $1,000,000 per year and only two people buy it.
By contrast, single-payer places everyone in the same risk pool, Alaskan smokers along with Portland joggers. The whole thing stays affordable.