You had a good idea, but your premises are wrong. Notably, your insurance is "tied to [your] pension". Assuming an average retirement age of 65 and that people will live to be 70 (to match your numbers), that's two colonoscopies per person, for a cost of $2,400,000 to (hopefully) prevent treatment for 70 colon cancers, so it has to cost less than $35,000 for it to make sense.

On the other hand, even that premise is wrong. If you don't check for it, you don't know you have it until you're months from certain death. It's probably a lot cheaper to pay for palliative care for those few months than actual cancer treatment for what (the patient would hope) would be a lot longer.

Excuse my hastily constructed sentence; some of us have work to do. I hope you don't think that advances your argument. Please allow me try to conform to standard sentence structure. Anyway, here goes (fingers crossed):

The plan will take over the private system using force in the form of coercion and the economic realities employers will face.

Stu

Okay, gotcha.

Can you be more precise about the coercion involved?

By economic realities of employers, do you mean that it will be cheaper for them to pay into the public fund than provide their own group health insurance? I'd say that for small businesses, probably 15 employees or fewer, you're probably right. But these tend to be the businesses that also don't currently provide any coverage.

Sure. I was specifically referring to the provision regarding making private insurance illegal. Forcing those whose changes in life necessitate obtaining new coverage to a) enter the government plan or b) pay the IRS penalty for not carrying a qualifying plan (catastrophic coverage is evidentially penalized as well even if you had it before the bill) is coercion in my book.



I'd say it's true for businesses large and small. For small business it's a means of staying afloat since they will be forced to either pay a fine or pay for government run employee insurance (many will still go under as a result). The first medium and large businesses to adopt the government plans would gain competitive advantage over competitors still paying for their own. Over the course of time the natural tendency would be for the other businesses to follow suit just to remain competitive with the early adopters.

Stu

Who said those were the only two options. Individual plans as we know them -- open only to healthy people -- will end. In their place will be plans where anyone must be allowed to join, and pay the same premiums regardless of health. Insurance companies will be able to offer these plans, and perhaps the government will operate one which must have premiums matching expenses eventually.

UPS and FedEx compete every day with the post office, and win hands down. The DMV in California is plenty efficient to communicate with by mail, lets you make appointments online, and if it weren't for our obstructionist minority party, would be operating just fine. Our military seems to operate just fine though it's never seen the need to try and cut costs as it's always fully funded.

Yes. Having private health cover allows you to jump the queue for certain elective procedures, and gets you in a nicer-appointed hospital in certain circumstances, but you'll never be denied NHS care because of it.



Pretty much. I don't know what kind of encouragement that companies get to offer it, but either it's just something that you do to attract people -- i.e. it's an expected part of the benefits package, like employer-matched pension contributions, or the company figures that healthy people get more work done.

That said, I didn't sign up for my company's scheme, partly because (as Peter says) I'd end up paying extra tax, and partly because I can never get past the "how much do you drink per week?" question on the application form.

The company I work for has contracts with the USPS. I forget why, but we needed them to mail us something. It came via FedEx.

Fully funded might be a matter of perception. There are a bunch of things that I know of (working mainly with one branch) that were available for them, but they weren't able to afford it.

Shoot, one of the guys I work with (former F-16 pilot) tells horror stories of losing flight time because his squadron didn't have the money to replace canopies when they needed to (the canopies are prone to abrasion and need to be replaced occasionally). The Army could have had fully integrated Level 4 UAV control in the cockpit of their attack helicopters ages ago but didn't have the money (it was first demonstrated in 1998 or 1999). Special Operators (SEALs, Special Forces, Marine Recon, etc) often buy their own equipment because their units can't afford the stuff they need (which is specialized and different from the rest of the unit).

Ugh, I could go on forever about this topic

Can you admit that, at least initially, the options offered are more than just a "government plan"?

Yes, the marketplace will be set up by the government, but the majority of the options offered are from private companies. It's like the farmer's market. The government pays rent on the land where the farmers can come and sell their products, but it's still the farmers making sales.

Also, it's important to note, providers are not required to accept all insurance plans, just like they're currently not required to accept all insurance plans, including Medicare. People would then be forced to get reimbursed directly, and, if they didn't like the reimbursement amount, they would be free to change plans.


Businesses with a payroll under $250,000 are exempted from both requirements, and businesses with a payroll under $400,000 are not required to pay as much. Given that this is only an issue for companies that don't currently provide insurance, and companies that don't provide insurance almost universally have low-wage employees, a $250,000 payroll is likely equivalent to at least eight employees (twice minimum wage at 2000 hours a year).


It's not free. It still has to be paid for.

That said, I'm unclear on how businesses are intended to interact with the insurance exchange. My guess is that they can choose as many plans as they want to provide to employees. Since they're required to contribute a certain percentage of the premiums, they might choose not to include more expensive plans.

"In 2001, FedEx cemented a groundbreaking deal with the USPS to deliver all of the post office’s overnight packages and express deliveries. In turn, FedEx was allowed to put its drop boxes in post offices around the country."

Most of my recent USPS "saver" orders from Amazon ship first via FedEx. In fact, the USPS tracking numbers don't even work on the USPS site until just before delivery. Basically the packages are carried most of the way by FedEx and then, at least the documentation/tracking, is handed off to USPS at delivery time.

Here's an interesting link regarding the recent health care talk...
http://daringfireball.net/linked/2009/08/10/ibd-hawking

I laughed when I first read the Hawking bit. I wish you guys in the US sincere luck and good fortune in this process. Canada isn't without its faults, minor and serious, with its own healthcare systems (my experience being specifically with Ontario's)

Yes. Peter linked to that story in the third post in this thread.

Does that mean I get a free link now? The Onion, as ever.

Peter

Bitt,

As you mentioned, you weren't excluding anybody from the US, but I didn't want to jump in prematurely.

Now that the topic has drifted down a bit I figure it is safe now to say this. Health care reform in the U.S.A. is Dead. I wanted to Hope (TM), but the more I think about it, the more I believe that it has been dead for quite some time.

I don't think it's dead. The lack of a public option in this scenario isn't fatal. You're still giving people access to group coverage that they don't currently have, and there is still a lot of administrative reform that, I believe, will help.

The way to bet the future is that every employer, currently offering health care, would make a rush to dump their employees into the government system. This in spite of what Obama said about being able to keep one's current plan.

Here in Canada, employers still offer/provide supplementary health care benefits, on top of the government baseline.

I imagine that kind of concept would continue to exist in your country as well.

Don't get me wrong. I believe that some months from now, somebody in the government will hold aloft a charred cinder and declare victory for health care reform. But it won't be anything I would recognize as reform. The boundaries of the political discussion were so narrow, and the range of the corresponding media coverage so limited, that they precluded that. The main thrust for Obama -- I'm going to start calling him President Hope -- has been to make sure that the drug companies and insurance companies don't get upset. In that respect President Hope is no different from any of the other zillion US politicians on their payroll. I don't know this gent Taibbi, but a friend forwarded his (long) piece in Rolling Stone:

http://www.rollingstone.com/politics/story/29988909/sick_and_wrong

The best summary paragraph, I think from page 6:

"But Reich's comment assumes that Obama wants to give the bill coherence. In many ways, the lily-livered method that Obama chose to push health care into being is a crystal-clear example of how the Democratic Party likes to act — showering a real problem with a blizzard of ineffectual decisions and verbose nonsense, then stepping aside at the last minute to reveal the true plan that all along was being forged off-camera in the furnace of moneyed interests and insider inertia. While the White House publicly eschewed any concrete "guiding principles," the People Who Mattered, it appeared, had already long ago settled on theirs. Those principles seem to have been: no single-payer system, no meaningful public option, no meaningful employer mandates and a very meaningful mandate for individual consumers. In other words, the only major reform with teeth would be the one forcing everyone to buy some form of private insurance, no matter how crappy, or suffer a tax penalty. If the public option is the sine qua non for progressives, then the "individual mandate" is the counterpart must-have requirement for the insurance industry."

I am perhaps neither as cynical or optimistic as he. Revolt? Ha.

There are a few ways to interpret that.

If you mean that the companies would stop offering healthcare altogether, then they have pay a tax penalty based on their payroll. Smaller companies might do that. Maybe. But they're likely to either not currently be offering health insurance at all, in which case they're probably small enough that the penalty won't apply to them, or, if they are offering it, their costs are probably pretty high. I fail to see a downside in this situation.

If you mean that the companies would stop coming up with their own plans and instead offer the plans that are available in the government-sponsored marketplace, but still share the costs with the employees, I don't really see how that's different from the company simply finding a new plan, and, as a point of reference, I've worked for my current company for about 2.25 years, I have had three different health plans, and that seems not out of the norm based on prior experience and conversations with other people, so I don't see how that's much different either. The point being, your employer is already likely inclined to change insurance plans every year; what difference does it make if that plan was defined by some HR rep or someone else?

Personally, as someone who's interested in the welfare of the United States and its people, I couldn't give a flip about the "public option" (as far as I can see, the only thing that the "public option" supposedly provides is competition for the other insurance companies, and I think it makes more sense to deal with that via antitrust laws, though that is, admittedly, a more underminable approach), and I believe that healthcare reform without a requirement that everyone have some base level of health care is worthless.

I'd personally rather see single-payer with the assumption that everyone has a government-defined base level of coverage rather than wasting time verifying coverage, etc. I rather like the British system where that's the case and then those who want to can buy "enhanced" coverage if they want. But that's not going to happen, because the American public is afraid that they'll have to wait six months for that free hip replacement that they currently can't afford at all. But that's neither here nor there.

In January, I argued with a friend over coffee, saying that Obama was crazy to launch a full-throttle effort on health care reform. With this being such a hot-button issue for the right and their media surrogates. I argued that Obama needed to build up some cred points first (fix the economy, show progress in Iraquistan). The fact that he launched into this I ascribed to ineptitude, hubris, whatever. Maybe Ted Kennedy's last wish. I predicted that Obama's reform initiative would die the death of 1000 cuts. I told my coffee friend that if Obama mentioned the term "single payer" once in 2009 in any sort of affirmative sense (like "We are looking at that"), I would give my friend $100 cash.

I didn't have to worry about my $100. I think Obama pretty much banned the utterance of that term anywhere within 10 miles of the White House. And he jumped so fast and so high to assuage the anxieties of Pharma and Insurance, that I could no longer conclude that this was simply a new president getting buffeted by the consequences of his premature effort. This is simply a fact that, as Taibbi says, this was in the cards all along. And I should have no more illusions about President Hope. Who won't get get my vote in 2012.

We spend way too much on health care but leave millions without care and exposed to financial ruin. Our health care outcomes and metrics suck compared to countries we often take the chance to deride.

Whether explicit or implicit, all health care systems impose some form of rationing. Ours just happens to do that by leaving people without care. If we expect to provide care for more people without increasing overall costs, we'll need to figure out how to drive costs out of the system. Other than muttering about "competition" none of the half-baked, half-hearted current allusions to "reform" seem to do anything I can understand that really addresses the cost issue. On the contrary, the body politic including President Hope have worked very hard to make sure that the 31% cut of the take that is more of less wasted on insurance-related administrivia is institutionalized for the next 100 years. But the insurance companies are very relieved. Still on their guard, but relieved a great deal.

So I'm with Taibbi. I think the fix of the special interests was in all along.

I have been a provider and a patient im military acute care settings and a patient in the VA system. Now there was certain stilted quality to some of the standardization of procedure in those settings, but they got the job done. I got pretty darned good care, something that was more than once noted by civilian docs and dentists down the road years later.

Now the VA has taken some knocks and had its problems, but you would think that many folks familiarity with thinks like "universal" military coverage and Medicare would make folks more comfortable with the notion of some big evil single payer system like Canada's or the UK's.

Some of this I think is tied to the great American value of individual versus collective good. I worked on a hospital-based research study and travelled to study centers in, among other places, the US and Sweden. This was a totally non-invasive study. A 30-minute standardized interview about medication history and medical conditions. In the US, you'd spend 20-30 minutes explaining the study and about 1 in 5 people would agree to the interview. In Sweden, informed consent took about 10 minutes and more like 4 out of 5 would agree. Doing something for the general good of others. Not high on the list here in the US.

But I think this is really something that politicians and the media leverage. The general distrust of institutions and the "What's in it for me?" factor. The primary problem standing between welfare and the people of the United States is that in this single-party democracy all of the key players have already been bought and paid for by special interests. Your welfare doesn't figure in.

No one will ever get any positive credit for the economy or the war. Might as well wait for Godot.

Of course there's no mention of single-payer. That would be a death knell for any reform at all. So many people are so vocally opposed to it that having the government touch health care at all sends them into a tizzy, god forbid that the government do something useful in that space. So I chalk that up to simple pragmatism.

The only thing I require from this is that all Americans have basic health insurance. I want them to be able to go to the doctor when they get sick. I want them to not have to worry about whether they can afford medicine or not. If that involves using existing insurance companies, fine. I don't really care. They do a reasonable enough job now for those of us lucky enough to be able to afford it. (Not that there's not room for improvement.)

The rest of the stuff, as far as I'm concerned, is icing. Yeah, I'd prefer to get rid of the administrivia with a single-payer system. I'd certainly like to see some more oversight of insurance so that people aren't rejected for things they should be covered for. I'd like to see an effort to reduce duplicated effort and general waste. I'd like to see doctors be able to practice medicine and not be paper-pushers. And most of those things (barring the single-payer system) are being addressed in the current proposals.

The insurance and pharmaceutical industries are certainly being deferred to to some extent, but those industries employ a lot of people, and the last thing we need to do in this economy is put more people in danger of losing their jobs. I don't relish the idea of the duplicated effort involved in having all these companies doing the same thing, but that duplicated effort does employ people. I'd be happier about it if it were hundreds of small companies rather than a handful of huge ones, but there's still some benefit in having redundancy, as far as employment goes. I also don't relish the thought of lining the pockets of the already superwealthy with taxpayer money, but if that's what it takes to get healthcare to everyone and avoid losing more jobs, tell me who to make my check out to.

I meant to make this point earlier, but I find it laughable that all of these self-described "progressives" are all over this idea of the government providing competition being a panacea. "Capitalism: yay!" is a talking point that they would lampoon in any other situation.

That's sort of a broken-window argument, though, at least regarding the insurance "industry". You could pay for a lot of unemployment benefit for former medical-insurer employees with the overall cost benefits of (say) the NHS over the current US system, and the NHS is far from a model of efficiency. Or, alternatively, they could all get jobs doing something productive instead.

I agree with you that the priority is getting healthcare for all -- and that whether this happens through general taxation, or through public insurance, or through private insurance, is a detail Congress can decide on whichever way they like. But if they go down the private insurance route, I don't think Barack Obama will get his wish to be the last president to have to deal with the mess.

Peter

That argument just won't fly in the US, for a variety of reasons. People decry the so-called "welfare state", so it won't work politically. Unemployment insurance in the US is a gigantic pain in the ass for everyone involved, and it's already overtaxed. Not to mention the fact that it's just bad juju to put more people out of work than already are. US unemployment is at something like a 25-year high, double what it was just a couple of years ago. Add on to that that it's administered by the states and not by the federal government, and that's just a recipe for disaster.

I could argue that what you're suggesting is a broken-window argument, too, that by breaking the window of insurance industry employment, there are net benefits.

What I think we can all agree on is that whatever course is taken — whether it be government-controlled insurance or private insurance, or we do nothing at all — there's still a broken window.

This thread got off on the wrong track, though. I guess what I really wanted answered, put more bluntly, is: are we in the US complete laughingstocks on the world stage?

Laughingstocks would be too strong a word. (Unlike that whole Gore/Bush hanging chads thing; you were laughingstocks then.) Really it's more like a tragedy than a comedy: the Aristotelian flaw of self-interest leading unexpectedly but inexorably to a catastrophic outcome. Even those of us who are pretty sure that you'd be better off with state healthcare (or, for different examples, without pork-barrel politics or without the Second Amendment) can't easily see a politically-viable way of actually getting to those beneficial outcomes starting from the corner you're now painted-into.

In a way (and this is probably a lefty's rather than a general view), the example of the US is like a shepherd moon steering us away from "capitalism without compassion" just as the Soviet Union steered us by example away from "socialism without opportunity".

Peter

Politically, it makes some sense to try to avoid killing insurance companies altogether. That guarantees that they will pull out all the stops to try and kill the legislation.

On the other hand, when you start talking about mandatory enrollment with mandatory plans and benefits, now the insurance companies can run the actuarial numbers and sort out that they don't necessarily get killed. That's more-or-less how the Swiss system works. Insurance companies will happily sell you extras, above the mandatory minimums (e.g., would you like a private room the next time you're stuck in the hospital?).

I'd be perfectly happy if the U.S. ended up with Swiss-style healthcare. Much better than what we've got now.

Bitt, sorry if the thread is gone awry. I did consciously wait until it was down on page 3 or 4!


On the contrary, I think if Obama did not get ensnared in this fake town hall battle for the health care right-of-center, his popularity ratings would be higher now and they could be even higher next year if unemployment bottomed out and started to improve. For what other reasons have his ratings gone down?


Maybe death knell in 2009-2010. But the guy wasn't even able to utter or acknowledge or study what is far and away the most rational, greatest-good-for-greatest-number solution.


I think the counts of screaming crazies at town hall meetings are too high. "So many people are vocally opposed to it". Well I think a lot of that has to do with how you start and develop the discussion and who you ally with.


I like to think of myself as a pragmatist and I hear this a lot in the recent context, but when politicians go on and on about being pragmatic, it sounds like excuses to me. And special interest money sloshing around in their pocket.


I'd get prepared to be disappointed. I want all the same things, but you aren't going to get more care for the same money without driving cost out somewhere.


Where you put this as a preference, I have to say again: 31 percent of cost.


I didn't watch him last night, but apparently Obama made a point of no denial of care for pre-existing conditions. Great (really). All other things being equal that means more care and that increases costs.


I'll have to look harder, but I'm not seeing it. I'm seeing an illusion with 1300 insurance companies casually keeping the Potemkin village in place until this minor storm passes.


Pharma people aren't going to lose their jobs and this otherwise really doesn't seem like a good argument. Tobacco companies employ a lot of people. Plus, if we really took the long view and planned to phase out primary private insurance in 2013-2014 in favor of single payer, all of those insurance executives would have time to get retrained as nurses. They wouldn't be unemployed for long!

But special interests and payola have again won the day in the USA. I can't really decide if it is better to be a laughingstock or a tragic figure.

Perhaps to realign this thread somewhat with it's original outreach goals, I could ask:

Hey, Canada! Hey, UK! How did you do it?

How come you could do it and we can't?

What transformations do you think would be needed if this tragi-comic country is ever to do it?

I wasn't blaming you.


I'm not talking about reality. I'm talking about perception.


This is based on the fallacious argument that insurance companies cannot make money by insuring people. This is clearly an insane argument, as insurance companies are currently making money doing just that. I think that's one of the complaints. And, although I haven't seen any studies, I don't think that you'll find that the uninsured are significantly sicker than the insured; there are huge numbers of people who are healthy but can't afford insurance.


Fuck cost. I want people to have the opportunity to be as healthy as possible.

Personally, I'd rather have something flawed that has a chance of getting signed into law than a perfect solution that will never happen.