health care debate

[Jeanne Boyarsky]

First of all, yes I know this is the meaningless drivel forum. I've heard rumors that this forum used to be able to have interesting discussions/debates in a NICE way (before I joined.) Curious if that is still the case. So remember:

BE NICE

Be careful with politics - "I think" often helps soften what could be perceived as inflamatory

A person is not an opinion - don't attack anybody

if any moderator is tickled even the slightest bit the wrong way with how this thread is going, he or she is free to delete posts or even the whole thread. Debate about why a post was deleted will not be entertained.

If this goes well, MD may become more interesting. If not, it'll show me that I shouldn't start interesting threads.

Now, on to the topic. What do you think of the US health care debate? If you aren't familiar with it, wikipedia has a nice writeup.

And for those outside the US, what works/doesn't work in your current system.

[Jeanne Boyarsky]

I'll start. I think* a tremendous amount of waste exists in the current system and it could certainly be made better. At the same time, I can easily imagine how the system could be made worse. I haven't yet been able to tell whether the proposal is in the better or worse category.

I'd certainly like to see some things changed - make it easier to get insurance, make insurance more affordable for people 50-65, etc.

* did you see the "I think" - I'm making clear what is fact and what is opinion.

[Bear Bibeault]

Even putting aside the whole subject of the uninsured (though I'm not saying that's not an important subject), things are seriously broken when good money is paid for premiums and much-needed health care is denied at the whim of a profit-hungry insurance company.

[Pat Farrell]

I think that the current "debate" is not a debate, and its not about "health care".

Ignoring the first point, which is major but unsolvable, I'll focus on the second.

What started out as a "health care" issue quickly became a health insurance issue. They are not the same. In the US, we really don't have health care "insurance" in the sense we have home owners insurance (where you pay a little bit, don't expect to claim, and the claims are big). Rather we have some sort of pre-paid health care payment system, typically employer paid. As a result, while "most" people have some sort of "insurance" there are a large number who don't. If you don't work for a large company or belong to a large union, getting the "insurance" is really expensive, far too expensive for most folks.

My personal belief is that we would be better off if we really had insurance, which means you pay for your own health care until something terrible happens, and then the insurance pays the huge costs. This is a big change from what we have today, and I don't expect that the politicians will support it.

Every developed Western country has some flavor of universal health payments/insurance. except the US. Even some Asian countries have it. I believe we have a moral obligation to provide health care for everyone, no matter how poor or where they live. I seem to be in the minority here.

I don't expect much out of the US Congress.

[Bear Bibeault]

Pat Farrell wrote:My personal belief is that we would be better off if we really had insurance, which means you pay for your own health care until something terrible happens, and then the insurance pays the huge costs.

Interesting and thought-provoking.

Any such plan would be predicated on a major restructuring of current medical pricing, which is completely out of whack and geared towards payment by insurers and not by clients.

Routine medical care would need to be affordable for even low-income citizens for any such plan to work.

Cynical curmudgeon that I am, I don't think it could ever happen.

[Bear Bibeault]

There'd also need to be allowances for those that can't afford even "afforable" health care. Unlike televisions, health isn't something you can just say "only buy what you can afford" to.

[Pat Farrell]

Bear Bibeault wrote:Any such plan would be predicated on a major restructuring of current medical pricing, which is completely out of whack and geared towards payment by insurers and not by clients. Routine medical care would need to be affordable for even low-income citizens for any such plan to work.

My wife's grandfather was a country doctor in the 1940s through 1960s. He never made a lot of money. A lot of US doctors seem to believe that they are entitled to be rich. They spent a zillion years in school, ran up huge debts. They expect it. I don't know if they deserve it, or earn it, but that's another topic.

Clearly a country as rich as the US could subsidize low-income folks to get normal preventative health care. Which is something that the current system doesn't do, it is really "sickness care" as most folks don't get any care at all when they are healthy. We all know that changing the tires and keeping the brakes working is part of the price of owning a car. Why don't we do the same for people?

We don't treat the less off when they have a cold. But if they ignore it and it becomes pneumonia, then we fix it. This is just wrong.

[Jeanne Boyarsky]

Pat Farrell wrote:Clearly a country as rich as the US could subsidize low-income folks to get normal preventative health care.

Some municipalities do have something. For example, New York City has Health Plus.

Pat Farrell wrote:We don't treat the less off when they have a cold. But if they ignore it and it becomes pneumonia, then we fix it. This is just wrong.

And I think that's the root of the problem.

You both raise a good point that insurance != care.

[Steve Luke]

Pat Farrell wrote:My personal belief is that we would be better off if we really had insurance, which means you pay for your own health care until something terrible happens, and then the insurance pays the huge costs. This is a big change from what we have today,

This might not be that far off from what is being proposed by some people, though the terms are different. A high deductible plan means you pay up to a specific amount of money for your health care per year. This usually includes your routine doctors visits and basic medications. After this high deductible is reached then you get the insurance company to jump in and start paying for the rest, which normally occurs if something big happened, or if you have a lot of medication / small things happen. Using 'health savings accounts' would help people pay that initial deductible rate using pre-tax money.

I think this would also relieve some of the strain from the health care system. More people paying up front will be less likely to visit the doctor's office for routine things, like sniffles or scrapes. It might free up doctors' time so they can treat people who do come in more thoroughly, and takes burden off of the insurance companies reducing the costs of insurance.

One of the things that makes it nearly impossible for the 'health insurance for all' approach, in my opinion, is the requirements for what gets covered. If a company provides health insurance they must provide a certain set of coverages, required by law. These cost money. If the same coverages are required then the price can't scale. It is like mandating every car be hybrids, have built-in 6 CD changers, standard A/C, moon rooves, titanium wheels, highest level of airbag coverage, powered everything, remote access, etc... then saying they need to be priced so everyone can afford them. It isn't scalable, by removing features you make the car more affordable, but if you want more features, expect to pay a premium. If health insurance companies are allowed to provide a-la-carte coverages then they can provide cost-effective policies for people who need the care. Without flexibility in coverage you are left with trying to shuffle around who pays (and in the end it always ends up being us).

[Ehsan Rahman]

Most Brits this side of the pond love the NHS. I think it works. It’s not the best system though. I think the best is in Singapore, where citizens pay taxes for general healthcare and also have a mandatory mini-saving account for the catastrophic illness in later life. (Source: ‘The Undercover Economist’).

My opinions about the US healthcare system:
- Overall, it does have a bad system for the population as a whole for being the world’s biggest economy.
- I think it’s just ended in the state now where insurance companies are powerful enough to influence mass opinions.
- I think that although the “survival of the fittest” approach does spur innovation (& US has some of best healthcare technology in the world), I think with healthcare model is wrong in terms of group boundaries. Currently the group boundary is to every family: afford health insurance to protect a single family. But this doesn’t help the nation as a whole, especially the poor who support the low level economy. To take capitalism to the extreme, the fire brigade, public teachers and even the army would have to serve per family. But this isn’t that case: these civil servants serve the public as a whole via tax (well, except those who privately school their kids) for the benefit of the nation. A healthy nation with education & safety from fire = more productive nation = higher GDP.

Not sure how Obama will do, the corporate system is rather powerful at Senate level I think (Sickowas a good film btw).

[Jeanne Boyarsky]

Ehsan: What an interesting post. I enjoyed reading the BBC articles. And I hadn't known about Singapore's health care system despite having a relative who lived there for a few years.

All: I appreciate the use of "I think" in this thread. So far we have 12. Including 6 by our clear winner Ehsan I have high hopes for this level of interesting conversation and "I think" to continue on Monday around the world. Posting early so I get this in before Monday starts in Asia.

[Ehsan Rahman]

Hey Jeanne, thanks. It's nice to discuss a practical topic and read views of others. Friend in the states tells me his shares in health insurance companies have been performing well recently. Here is another interesting link on US healthcare.

[Paul Clapham]

I live in Canada, so I get the American points of view sloshing over the border regularly.

What sort of surprised me was that there were people who have well-reasoned arguments for whatever they wanted to propose, but there is also a ton of just plain loony ideas too, some of them violently expressed. The amount of idiocy out there is astonishing. Sure, you see a lot of that in U.S. politics but this topic seems to have more of it than usual.

[Pat Farrell]

Paul Clapham wrote:I live in Canada, so I get the American points of view sloshing over the border regularly.

What sort of surprised me was that there were people who have well-reasoned arguments for whatever they wanted to propose, but there is also a ton of just plain loony ideas too, some of them violently expressed.

Oh, I wish we had the Canadian system. But I don't think the politicians dare even mention it.

I too am amazed and disgusted at the loonier arguments. The whole secret death boards conspiracy is remarkable.

And yet the sane, well reasoned cousin idea can't be talked about. Its a fact that if you are a 70+ year old drunk with a failing liver, you are not likely to get a liver transplant, there are not enough of them, and so the boards are likely to give the liver to a 40 year old who is not self-destructive. (perhaps there is a place to argue about what actions are or are not self-destructive, but most folks treat it like the Supreme Court did pornography -- you know it when you see it. So heavy drinking, smoking, unprotected sex with hundreds of partners, etc, are pretty clearly self destructive)

[Bear Bibeault]

Paul Clapham wrote:The amount of idiocy out there is astonishing.

It's very disheartening. The loudest and most vocal, and therefore the ones that get the most press, are those that are the least informed about what's really being proposed. They're just dupes of the beneficiaries of the current system, believing whatever FUD is being fed to them without any fact-checking of their own.

[Ulf Dittmer]

I don't have much knowledge about the various proposals, but I thought this writeup by Paul Krugman about why a market-based approach won't work was interesting.

[Steve Luke]

Ulf Dittmer wrote:I don't have much knowledge about the various proposals, but I thought this writeup by Paul Krugman about why a market-based approach won't work was interesting.

What he describes as reasons market-driven healthcare won't work are the reasons why the current system, which is not market-driven, is failing. Everything he describes stems from the fact that the current health care system is a bunch of local monopolies. You as a consumer have no choice, so insurers just see your health care as a cost and fight you over it.

If you had a choice it wouldn't be the same. When your local car dealership refuses warranty repairs you go to the next dealer, you never buy from them again, and you tell your neighbors. If it was bad enough you sue them. Their reputation goes down and they can't maintain business. They lose. When your health insurance refuses to pay you can sue them, you can complain, but it is meaningless, you generally can't change providers, and if you can you only have 1 or 2 other companies to choose from.

For government run healthcare, it would truly be nice but I don't trust it to work. Look at the post office versus FedEx, UPS, and DHL - one of the four is going bankrupt, guess which one? And if you think it is different with health care, ask the Veterans Hospitals. They have poor standards of care, buying new equipment takes a year of paper work, and you are at the whim of what the current congress says the budget should be this year, so your coverage would fluctuate from year to year.

[Pat Farrell]

Steve Luke wrote:What he [Paul Krugman] describes as reasons market-driven healthcare won't work are the reasons why the current system, which is not market-driven, is failing.

Plus a couple of points on Krugman. He is very smart, but he is an admitted he leans left/progressive, so he's not unbiased. Second, he is paid to write provocative columns.

This doesn't mean he is bad, or even all wrong, but he has a horse in this race.

[Paul Clapham]

Pat Farrell wrote:

Steve Luke wrote:What he [Paul Krugman] describes as reasons market-driven healthcare won't work are the reasons why the current system, which is not market-driven, is failing.

Plus a couple of points on Krugman. He is very smart, but he is an admitted he leans left/progressive, so he's not unbiased. Second, he is paid to write provocative columns.

I'm pretty sure he's one of the people I heard on NPR (driving through southern British Columbia, no Canadian radio stations in range, remember what I said about American culture sloshing over the border) talking about this. As I recall he was saying that the single-payer system was better in several ways, but he didn't see any way for the US to get there from where they are now.

[Pat Farrell]

Paul Clapham wrote:As I recall he was saying that the single-payer system was better in several ways, but he didn't see any way for the US to get there from where they are now.

Also lost in all the noise is that "single payer" is not enough to define what one means. For example, the Canadian system has one payer (the Canadian government or a health fund) with lots of doctors, so Canadians can go to nearly any doctor or hospital and its all paid for.

In contrast the British (UK) system has one payer and one provider. You go to a NHS facility or doctor, and it covered.

So more carefully, the Canadians have a "single payer, many provider" system
while the British have a "single payer, single provider" system.

(I'm sure that I'm glossing over many technical details.

So when radio talk hosts or politicians say "we don't want a single payer system" what do they mean? British? or Canadian?

[Dan Walin]

In reply to this comment:

A lot of US doctors seem to believe that they are entitled to be rich. They spent a zillion years in school, ran up huge debts. They expect it. I don't know if they deserve it, or earn it, but that's another topic.

I heard someone say something I thought was interesting. He said he wants doctors to make a lot of money. The more money they make the more appealing the profession is and, as a result, the smarter students in college tend to pursue medical degrees. This person thought that if the incomes of doctors decreased to similar levels of some of us other mortals, then the smartest students in college would then pursue other careers that could be more lucrative. The net result would be that the quality (intelligence and knowledge, at least) of doctors would be reduced resulting in lower quality health care. It's interesting - not sure how true it is but it sounds like it makes some sense.

[Pat Farrell]

Dan Walin wrote: the smarter students in college tend to pursue medical degrees. This person thought that if the incomes of doctors decreased to similar levels of some of us other mortals, then the smartest students in college would then pursue other careers that could be more lucrative.

I think this analysis is off a bit. I'd say its more that smart students who are really motivated by money could be seduced into a field that pays a lot of money. And then, if you decreased the money, the money motivated would chase other goals.

But I have not found that large of a percentage of folks driven by money. Most folks want to do something that they enjoy, are good at, etc, and more than a few want to improve society or the world while they are at it. So working at an RDBMS company can help the world better organize its data and perhaps find some knowledge.

I posit that a fair number of folks aim for levels of success, say a better than average middle-income salary and a nice house. Within the level, more money (say $10K a year) isn't very important. You want a nice car, you don't need the newest model BMW.

I mean, if you want to get rich, you really should not be hanging around JavaRanch.

[Jeanne Boyarsky]

Steve Luke wrote: Look at the post office versus FedEx, UPS, and DHL - one of the four is going bankrupt, guess which one?

I don't think this is a fair comparison. The post office is crippled by the need to mail letters below cost, go to every house/apartment, keep branches open in every community, etc. (Manhattan has 37 post offices because whenever they threaten to close one the community is up in arms.) Or maybe the "federal health care system" would be saddled with a bunch of restrictions. Right away or later. In which case, it would become a very fair comparison.

Dan Walin wrote:This person thought that if the incomes of doctors decreased to similar levels of some of us other mortals, then the smartest students in college would then pursue other careers that could be more lucrative.

One of my friends is currently in med school. She has the "pleasure" of 12 hours shifts including standing through the middle of the night, more loans that I can imagine and a life filled with studying and working. And is thinking of choosing a field that pays low (for doctors.) I think there's a desire to help people at work here. She is certainly smart and could have spent the last few years earning what we do if she wasn't pursuing her passion. My point is that salary isn't the only motivator.

I'm curious thought on the "pre-existing condition" problem. Does it work at ensuring people don't wait until they get sick to get insurance. Or discourage people from switching insurance? Or discourage them from going to the doctor in the first place?

[Steve Luke]

Jeanne Boyarsky wrote:

Steve Luke wrote: Look at the post office versus FedEx, UPS, and DHL - one of the four is going bankrupt, guess which one?

I don't think this is a fair comparison. The post office is crippled by the need to mail letters below cost, go to every house/apartment, keep branches open in every community, etc. (Manhattan has 37 post offices because whenever they threaten to close one the community is up in arms.) Or maybe the "federal health care system" would be saddled with a bunch of restrictions. Right away or later. In which case, it would become a very fair comparison.

Yeah that was my point, it won't be designed to 'break' right away - hopefully with all the bright minds in on the discussion it would be a great, well designed system. But down the road there will be a lot of bad decisions based either on internal congressional politics or voter pressures from either densely populated areas or rich people. Give it a few years - just enough time that we depend on it - and government will break it. The comparison to other courier systems was made because these private companies can respond to the market and can compete in a changing environment without an act of congress. A government funded system can not do that, it is slow and resistant to change so even if nothing is done to 'break' the system it eventually grows old and is unsuitable which amounts to the same thing.

Schools are another classic example of being slow to change with the environment and thus causing lots of problems. Social Security another.

Anyway, I guess I should stop now :-) You all get the point.

[Joe Ess]

Steve Luke wrote:Yeah that was my point, it won't be designed to 'break' right away - hopefully with all the bright minds in on the discussion it would be a great, well designed system.

The problem I see is the health care system is broken, the proposal to fix it is expensive and the solution is something that is supposed to happen once this new bureaucracy is in place:

Now, over the short term, if you add 47 million Americans to the rolls of the insured, you're going to add costs to the system, and you're particularly going to add cost to the federal government - about $100 billion a year, says the Congressional Budget Office.
The hope is that over the long term, more than 10 years, which is not what the Congressional Budget Office looks at, there will be ways to change the system -to change the incentives, to change how the system is structured, how doctors provide care, how insurers do things - that will perhaps save money both for the federal government and for the system as a whole. That is the goal of this entire exercise. That is why everyone is still at the table trying to do this: to save the government money, to save the system money.

NPR: Listener's Health Care Questions Answered

Call me cynical, but given the impending doom of Medicaid - Medicare and Social Security, I don't see the health care problem getting fixed any time soon, even if the proposal moves forward.

[fred rosenberger]

Jeanne Boyarsky wrote:I'm curious thought on the "pre-existing condition" problem. Does it work at ensuring people don't wait until they get sick to get insurance. Or discourage people from switching insurance? Or discourage them from going to the doctor in the first place?

My sister worked at job 'A'. She got pregnant. She switched to job 'B'. The insurance company at her new job told her they would not cover the pregnancy because it was a pre-existing condition.

[Paul Sturrock]

"pre-existing condition"!? You mean in current American health care terms pregnancy is classed as an illness? Wow.

[Pat Farrell]

Jeanne Boyarsky wrote:I'm curious thought on the "pre-existing condition" problem. Does it work at ensuring people don't wait until they get sick to get insurance. Or discourage people from switching insurance? Or discourage them from going to the doctor in the first place?

Its to keep sick people from getting insurance. Insurance companies only want to provide insurance to people who never use it.

Not all that different from car insurance folks, get a lot of speeding tickets, cause accidents, and your rates go way up until you become an "assigned risk" and pay insane prices.

Economically, the insurance companies need a lot of young healthy folks in the pool to pay for the old folks. So you have to buy your plan in the pool when you are young. The young folks tend to not need any health care, except guys who crash motorcycles and women who get preggers.

[Pat Farrell]

Paul Sturrock wrote: You mean in current American health care terms pregnancy is classed as an illness?

Again, its not about health its about money. Even a simple delivery costs money, and if there are problems, the costs go up fast and high. The health insurance companies do not care about health or illness. They focus on money.

If you take two otherwise healthy women of say 25, one preggers, one not, which is going to cost more over the next year?

[Paul Sturrock]

Isn't that deliberately penalising women though? It seems mightily unfair to have that sort of stuff tied up with a woman's job.

[Pat Farrell]

Paul Sturrock wrote:Isn't that deliberately penalising women though?

Only preggers ones.

At least in the US, there are a lot of cultural penalties for mommies. There was a solution, the myth of SuperMom back in the late 70s. I think SuperMom was more evil than the blatant discrimination. No woman can keep a high powered job, raise the family, cook like Julia Child, and look like Catherina Zeta-Jones. Its damn near impossible to do any one of that list.

[fred rosenberger]

I think it was Ned Flanders who equated Insurance with gambling...and he's right. You're making small bets (monthly premiums) that pay off when you get sick/crash your car/get robbed/etc.

for every dollar insurance companies pay out, they need to take in $1.25 (not actual values, just an example) to cover their expenses. that means that SOMEONE has to pay in more than they get out.

If you have a pre-existing condition, the insurance company knows you are a 'bad bet', and so they don't want to cover you.

There's a video on youTube that's being passed around that equates this to the Fire Department saying "You had a BBQ going in your back yard, which is a pre-existing condition, so we're not going to put out your house fire" or something like that. I can't get to it from work, or I'd search for the link.

Even though the U.S. Federal government doesn't always have the best track record at running large programs, wouldn't the fact that they don't have to turn a profit or answer to investors help them not be so ruthless?

[Jeanne Boyarsky]

Paul Sturrock wrote: It seems mightily unfair to have that sort of stuff tied up with a woman's job.

An yet, I'm much more worried about getting sick and having that declared pre-existing. A pregnancy is over after 9 months. Some problems stay with you forever. I wonder if swine flu is a pre-existing condition (if grows more dangerous) - after all, people knew about it already.

fred rosenberger wrote:

Jeanne Boyarsky wrote:I'm curious thought on the "pre-existing condition" problem. Does it work at ensuring people don't wait until they get sick to get insurance. Or discourage people from switching insurance? Or discourage them from going to the doctor in the first place?

My sister worked at job 'A'. She got pregnant. She switched to job 'B'. The insurance company at her new job told her they would not cover the pregnancy because it was a pre-existing condition.

I thought there was some sort of waiver if you went straight from one health insurance to another it wasn't supposed to count? Not sure of the details though.

fred rosenberger wrote:There's a video on youTube that's being passed around that equates this to the Fire Department saying "You had a BBQ going in your back yard, which is a pre-existing condition, so we're not going to put out your house fire" or something like that. I can't get to it from work, or I'd search for the link.

I want to see! Now you have something to do after work. Besides play with your daughter - which is way more important.

[Selvakumar Kumar]

A burning issue.

Here in India it is mostly one-to-one dealing, where the patient goes to Doctor and pays him on hand for small treatments (cold, fever etc.. ).
But there are government hospitals where the treatment is free, but the quality and hygine leave much to be desired
(Still government hospital treatment is very effective and good for most middle/lower class people).

When it comes to bigger treatments/operations the problems comes in for the common man. He should shell out their whole life
earnings(if any..) to pay for a heart surgery or liver transplant or die out of that disease. I think government co's won't be of much
help either.

I have watched the movie SICKO and I wonder what would happens if everyone has to pay premiums for their treatments.

The moment you make anything as business the private players will find loop holes to make more profits.
The doctors working in government hospitals, usually runs their own private clinics in the evening for extra bucks, though it is their own right.

Here the banking firms slowly has started trying to sell the health insurance products along with other core products.
Apart from LIC (the government run insurance firm) there is not much legitimate orgnaisations in the country to correctly/legally
settle the claims. IMHO.

- Selvakumar

[Jeanne Boyarsky]

Selvakumar Kumar wrote:Here in India it is mostly one-to-one dealing, where the patient goes to Doctor and pays him on hand for small treatments (cold, fever etc.. ).

You go to the doctor for stuff that minor? For a prescription or something else?

When I have a cold/fever/virus, I stay home and in bed. I don't want to get out - I want to focus on getting better. The annoying thing isn't health insurance here. It's easy to get an appointment and the co-payment that insurance doesn't cover is low. It's more that if I'm going to the doctor:

I'm not getting better

I'm exposing other people to my cold

I'm being exposed to whatever they have while my immune system is weak from my cold

At the same time, most employers want a doctor's note if you are out more than a day or two. So you have to extend the period you are sick to have the doctor take your temperature and write a note. I'd like to think the doctor has something more productive to be doing with his time.

[Paul Anilprem]

Jeanne Boyarsky wrote:

Selvakumar Kumar wrote:Here in India it is mostly one-to-one dealing, where the patient goes to Doctor and pays him on hand for small treatments (cold, fever etc.. ).

You go to the doctor for stuff that minor? For a prescription or something else?

Interesting to see the effects of cultural/developmental differences between US and India. How do you know that what you have is a minor cold/fever/virus? In US, you probabaly don't even know the names of the following diseases but in India they are quite common. A fever in India could very well because of : malaria, dengue, chicken guniya, monkey gunia, typhoid, jaundice. A minor cough could be because of TB, pneumonia. For women, UTIs are very common. All these diseases, if left untreated are fatal and it is best to have a doctor look at you for things that you might ignore as minor. You just don't know what you've.

For a middle class person in India, the cost of visiting a good reputable doctor isn't much. Probably about 200-500Rs for 2 visits (followup visits after starting treatment are usually included.). Basic medical tests such as CBC, Urine, and Stool routine, are also quite affordating. CBC is like 150Rs, Urine/Stool are like 100 Rs. Specific tests for things like Malaria and TB are also affordable (about 200-300Rs). Super specific tests for things like Dengu and Chicken Guniya are expensive (relatively speaking) and are about 1500Rs.

I, personally, on the onset of any fever above 100, make sure that I do the CBC and take the report with me to the doctor.

So much for the "minor" stuff.

Regarding "major" things like cancer, by pass surgery, transplants etc. things are quite expensive for middle class people in India as well. Though one can buy insurance for a list of specific diseases from any of the N number of insurance companies. Insurance plans are complex but, I think, are quite fair in terms of payouts. You get what you pay for. As a simplified example, you can buy insurance just for heart attack and for medical fees and not for hospital room charges, in which case, you will be paid only for any heart operation but you will not be refunded the room charges. So basically, one can get customized policies. If you can pay more, you can have insurance for N number of diseases + room charges, food charges, nurse charges, and what not. There is cashless settlement system as well between insurance companies and the hospitals.

OR

You can also go to Govt. hospitals, which usually have the following characteristics:

Pros: anybody can go, practically free, and usually have the best doctors in the city/country. They are almost always associated with Govt. Medical Colleges. No insurance or anything is required. There are nominal fees (usually 10-50Rs for every consultation) and a little higher fee for operations.

Cons: highly overloaded (people literally lie on floor in the lobby), unhygenic, careless para medical staff, perrenially short of even essential medical supplies such as cotton, saline drips.

There are also local govt. clinics/dispensaries meant for "minor" sicknesses. They usually only have "out patient" facilities meaning they don't have any overnight stays. Then there are govt. maternity hospitals, which are specifically meant for pregnant women. They are also almost always overloaded. A woman delivering a baby on the floor is not uncommon.

OK, I painted a very bad picture but there are good and very good govt. hospitals as well. Heath care is actually a state subject in India and every state is on a different stage of development and that is reflected in the govt. hospitals. There is huge disparity in income levels in India and govt. hospitals strive really hard to cater even to the poorest of the poor. Despite the bad picture that I painted above, I am actually quite proud of the work they do. In fact, Govt. hospitals are the only saviors when private hospitals give up on you.

For people who can afford to pay, they can choose which private hospital they want to go to for major surgeries/treatment depending on their paying capacity. There is a whole range of them (in terms of cost structure). As you might have heard, the absolute cost of heath care is quite low in India as compared to other countries even in top private hospitals and a lot of people from developed countries (including US and Canada) come here for such procedures aka medical tourism.

Because of huge number of private hospitals and pathology laboratories, there is a good competition and that keeps a check on their prices.

I have experienced US as well as Indian health care system and I am definitely more comfortable with the Indian system. I think it is a good blend of socialism and capitalism.

[Steve Luke]

Selvakumar Kumar wrote:
The moment you make anything as business the private players will find loop holes to make more profits.

Personally, I have no problem with people looking to make profits off of health care or health insurance. A company that can make a profit is motivated to provide the service efficiently. The problem comes when there is no choice, then the profit-driven company doesn't have to worry about losing customers or competing to grow into more customer market areas. Profit and competition combined drive innovation, efficiency and affordability. Remove either of the two and problems arise.

fred rosenberger wrote:
Even though the U.S. Federal government doesn't always have the best track record at running large programs, wouldn't the fact that they don't have to turn a profit or answer to investors help them not be so ruthless?

A solution not driven by profit or driven by investors won't control costs and will lack the motivation (and funds really) to grow, change, or modify their course of action. The federal government is a bureaucracy and bureaucracies are not nimble so if a mistake is made it festers for a long time. If the population's need changes it takes a long time to adjust to it. It just is not a very efficient way of controlling things.

Remember, too, that any US Fed program will be driven by investors - the US citizens. We have are say now, then generally once every 2 or 4 years after the decision is made. Whatever decision we make now we have to live with until motivation to change is big enough in congress to act on it. If we choose to have a single payor program we will be paying for it for that time period with little (or no) say in the specific direction of the course of action.

I have been dumping a lot on a 'government run' system pretty much out of 'feel' and 'fear' (I feel like it is a bad idea, and I think even if it starts out good it will end up bad). I haven't really contributed a 'solution' because I don't think I have a good one available. What I would like to see is reduced regulation specifically to allow more companies to enter the health care / insurance business (I don't think there should be a 'hands off' approach by the government but it should encourage more / smaller companies to enter the field rather than discourage it). The goal would probably be insurance with multiple tiers of buy-in. The more you pay the more options you get.

Employers would then provide pre-tax funds as an account for paying to the employee's provider company-of-choice. Employers may be able to negotiate with some insurers to provide higher tier services for lower cost to their employees (so from an employee's perspective it would make sense to take the employer's insurer of choice, but they would not be required to as they would have access to the account for using a different company if they wanted to).

Medicare / Medicaid would be government subsidized accounts payable to providers who provide certain levels of coverage under certain costs or at government-negotiated prices.

I have no idea if it makes financial or economic sense, it is probably too simplistic, but it is the 'kind of' situation I would see as a scalable, market-driven approach.

But I would also like to hear from Canadians, Brits, and others (anyone from Singapore?) about their systems. I hear a lot of bad (crowded hospitals, long queues for doctor appointments etc...) and a lot of good (low prices, prescription availability, ...) What have been your experiences? Things I would like to hear would be:

1) 'Normal Joe' situations: No special conditions, maybe some minor stuff, like broken bones, sprains, or temporary disease.

2) 'Chronic' situations: Asthma, heart disease, MS, diabetes, things that have constant cost, and things that have regularly recurring hospital visits.

3) 'Extraordinary' situations: Car accidents, catastophic disease, things that may happen just once but require a lot of specialized care

4) Kids in general. From pre-natal care, to delivery, to dentistry and preventative stuff through early teen years.

Where do your systems excel? Where would they be lacking? Are you happy overall? What can we learn from your system?

[Frank Silbermann]

Pat Farrell wrote:

Clearly a country as rich as the US could subsidize low-income folks to get normal preventative health care.

I take issue with America being described as a rich country. The U.S. is a very poor country; aside from wilderness the government owns that we'd like to preserve, the amount of money owned by the country is in the negative-trillions. (It _is_ a country that contains a good number of rich people, but we need to distinguish between their money and the nation's money.)

It's clear, though, that we are in a health-care crisis, in that even well-educated people like me are at risk of suffering long-term unemployment, and therefore, at risk of suffering a medically-caused financial disaster. Also, it's quite likely that older workers like me are subject to unprovable age-discrimination in the hiring process due to the higher cost of putting older workers onto the corporate medical plan. These are strong arguments in favor of socialized medicine.

I do have some fears about it, though. One is that the employment of doctors will become as politicized as the hiring and promotion of police and firemen (see recent court cases). I fear that, as with K-12 urban education, I'll end up having to pay BOTH for my own medical care out-of-pocket AND through my taxes for other people's inferior government medical care. The tax burden can only increase as the percentage of rich and middle-class people in our society continues to decrease, as it has since the 1970s (when rich and middle-class people sharply cut their birthrate -- but not so much the functionally-illiterate poor).

[Paul Clapham]

Steve Luke wrote:Employers would then provide pre-tax funds as an account for paying to the employee's provider company-of-choice. Employers may be able to negotiate with some insurers to provide higher tier services for lower cost to their employees (so from an employee's perspective it would make sense to take the employer's insurer of choice, but they would not be required to as they would have access to the account for using a different company if they wanted to).

Steve, what I don't get is why employers have to be the primary conduit for health insurance. What happens to people who aren't employed? Self-employed people, retired people, unemployed people, students... add them all up and that's a lot of people left out in the cold for no good reason.

But I would also like to hear from Canadians, Brits, and others (anyone from Singapore?) about their systems.

(I'm Canadian.) It was November 2007. My wife went to the doctor for something routine. The doctor listened to her innards and said "That sounds kind of odd, we should get that checked out. Go for this test." So she went for the test, and within a couple of days she got a call from the doctor, "Come in ASAP". So she did, and found that there was something in the scan which could be cancer (one of the serious kinds). First thing in January she was in for the operation, having bumped a bunch of people with less serious situations. As it happened the excised bit turned out not to be cancerous, but you can only find that out by taking it out and looking.

This cost us nothing but the taxes we already pay. And it wasn't contingent on her, or me, having a job. I much prefer it that way.

Edit: Another thing I recall reading somewhere -- don't remember where -- is that one of the best things that could be done for small businesses in the US would be for the responsibility for employee health insurance to be taken off their backs. And I think there's something to that. I work for a US-based company and their health-care costs for Canadian employees are considerably lower than the equivalent costs for US employees. Just another reason to outsource the jobs...

[Steve Luke]

Paul Clapham wrote:

Steve Luke wrote:Employers would then provide pre-tax funds as an account for paying to the employee's provider company-of-choice. Employers may be able to negotiate with some insurers to provide higher tier services for lower cost to their employees (so from an employee's perspective it would make sense to take the employer's insurer of choice, but they would not be required to as they would have access to the account for using a different company if they wanted to).

Steve, what I don't get is why employers have to be the primary conduit for health insurance. What happens to people who aren't employed? Self-employed people, retired people, unemployed people, students... add them all up and that's a lot of people left out in the cold for no good reason.

The goal here is to move money off of the government and onto the individual. This has probably a lot to do with political philosophy as much as anything else, but I am a fan of the small government, and a more direct path of cash from me to the insurer seems more efficient to me (every administrative step along the way costs something, and we end up paying for it, so lets cut out the most administrative steps as possible).

The employer as the conduit is then an efficient way to do a bunch of things:
1) Make it easier to get insurance (for the employed)
2) Make it pre-tax money used to pay for insurance (only possible if you take money out before the paycheck gets taxed)
3) Work as a benefit for employees (i.e. motivation to go get a job, get a better job)

But the employer need not be the only source for insurance. It is the individual buying insurance. With more 'tiered' approaches to insurance, more competition for customers then there can be 'low cost' insurances affordable to individuals. Wouldn't it be nice if a local bank, hospital, and 5 local med/dent offices could get together and provide insurance to locals using their services without being excluded from other national insurance policies/coverage? And if the local or state government can afford it (meaning local individuals are willing to take the increased tax burden) then they can subsidize a bunch of local medical institutions to provide extremely low cost insurance (I particularly like this aspect of it, local and state governments are more agile and responsive than federal, they can provide more adequate regulation and rules since their populations are smaller and therefore easier to target, AND the money you spend in local/state taxes goes back to the local economy via the hospitals, medical practices etc... they pay to keep insurance down).

So, again all just speculation I have no idea if this is being discussed as a real alternative, with a competitive and profitable landscape you would generate hopefully more efficient plans, which drives costs down, which drives price down, which makes it 'affordable' to the individual and for more local subsidization.

So groups that you talked about above:
Self-employed people
More choice here. You can either afford the care you want, go with lower tiers to get affordable care. Incorporate and register yourself so you can take money out of your pre-taxed income to buy yourself insurance. You probably wouldn't have the negotiating power a bigger company has to get lower prices on the tier you want but that is part of the trade-off you take with the benefits associated with self-employment.

Retired people
More problem here. I guess it depends on if they qualify for Medicare then you would have the subsidized government funded account for your health care. If not, you have other options as described. Long-term care becomes a real question I haven't thought about in this context...

Unemployed people
Several options. One is there is currently a 'Cobra' system for insuring individuals between jobs. This should/could be continued if deemed needed. Also, there are unemployement checks already just role a certain level of that insurance payment into the plan. For those unemployed for medical reasons (injury or whatever) then I would guess smart people would have to analyze how best to fit a (hopefully pre-tax) insurance payment account into injury settlement, or disability compensation. If you are unemployed for long enough that you no longer can get unemployment compensation and you don't have a disability that prevents employment then you have to make compromises like you would with every other aspect of your life - look for lowest cost insurers, even if the doctors who are available aren't the ones you like or want, or the hospital you have to go to isn't the best, or whatever is the way this hypothetical tiered system would use to generate cost-effective alternatives ...


Students
This has a lot to do with the student's situation. As it is kids going to college full time are claimed under their parent's/guardian's insurance so I don't see that as a needing to change. Adult full time students would probably require some consideration. Perhaps the school could act as the payment conduit for their students - they can negotiate prices with the insurance companies as well as employers can though it is hard to imaging how to get the payment pre-taxed. Some schools may be able to act as insurers themselves (especially if they have an associated medical school).

I guess the point is that with smart people thinking about it a lot of concerns can be brought up, identified, and probably addressed. I have no solution to retirees and probably not good answers to unemployed, but I am sure there are answers to those cases. There are probably a lot bigger problems with the system which I am too ignorant to think off and so compromises would have to be made. And there is a lot of nebulous hypotheticals in there (like what defines 'tiers' of coverage and what should be considered bare minimum, and how those tiers can actually shave costs etc...).

I think if they were allowed to the competition would come quickly. Small groups of doctors, hospitals, and medical universities would get together to provide insurance because it would be both an extra way of making profit, but also help their paperwork, reporting practices, etc... to be able to deal as locally as possible. Banks and credit unions would get in the fray because the others would need to borrow money to front costs and invest/insure money for availability at payout, insurance is a good payout and banks are always looking for ways of distinquishing themselves in local communities (one of the reasons a lot of the sports arenas' naming rights are bought by banks.) I think if allowed many localities and states would take opportunities to invest in insurance providers as well, probably partnering with medical universities, again to take in some of the profit, but also to provide low-cost coverage for people who couldn't otherwise afford more expensive tiers or who don't qualify for federal funds.

Paul Clapham wrote:

But I would also like to hear from Canadians, Brits, and others (anyone from Singapore?) about their systems.

(I'm Canadian.) It was November 2007. My wife went to the doctor for something routine. The doctor listened to her innards and said "That sounds kind of odd, we should get that checked out. Go for this test." So she went for the test, and within a couple of days she got a call from the doctor, "Come in ASAP". So she did, and found that there was something in the scan which could be cancer (one of the serious kinds). First thing in January she was in for the operation, having bumped a bunch of people with less serious situations. As it happened the excised bit turned out not to be cancerous, but you can only find that out by taking it out and looking.

This cost us nothing but the taxes we already pay. And it wasn't contingent on her, or me, having a job. I much prefer it that way.

That timeline sounds good, not like you had to wait for a long time before a doctor or hospital was available for the operation. What is particularly interesting is that the test response came in a matter of days - no lack of processing resources or back-log either. <independent of the health coverage debate>I am glad your wife came out ok.