Health Reform Without a Public Plan: The German Model - Economix Blog - NYTimes.com

Health Reform Without a Public Plan: The German Model - Economix Blog - NYTimes.com:

"What if that [public option] plan were sacrificed on the altar of bipartisanship? Would it be the end of meaningful health reform?

"Not necessarily, if the health systems of the Netherlands, Germany and Switzerland are any guide.

"None of these countries uses a government-run, Medicare-like health insurance plan. They all rely on purely private, nonprofit or for-profit insurers that are goaded by tight regulation to work toward socially desired ends. And they do so at average per-capita health-care costs far below those of the United States — costs in Germany and the Netherlands are less than half of those here."

When I get in discussions of HC reform with my friends who are more committed to a single payer solution than I, I point out that most countries we look to as exemplars of excellent universal health care do not, in fact, use the single payer model, but use some hybridized form of the Bismarckian, or Social Health Insurance model, such as Germany. This may explain why the American College of Physicians made its policy recommendations in 2007: though single payer was recommended first, a hybrid system was neck and neck and felt to be more achievable.

Dr. Reinhardt explains the overview beautifully here, and I cannot improve upon it. He, as always, provides great framing to his points that can be appropriated for the discussions you have on the topic. For more details on the German system, go here.

Sphere: Related Content

What Is ‘Socialized Medicine’?: A Taxonomy of Health Care Systems - Economix Blog - NYTimes.com

What Is ‘Socialized Medicine’?: A Taxonomy of Health Care Systems - Economix Blog - NYTimes.com:

"Socialized medicine refers to health system in which the government owns and operates both the financing of health care and its delivery. Cell A in the chart represents socialized medicine.

"Social health insurance, on the other hand, refers to systems in which individuals transfer their financial risk of medical bills to a risk pool to which, as individuals, they contribute taxes or premiums based primarily on ability to pay, rather than on how healthy or sick they are."
...........
"Former Mayor Rudolph Giuliani of New York has exemplified the perennial confusion in this country over socialized medicine. In his ill-fated presidential bid, and subsequently as a supporter of Senator John McCain’s bid for the presidency, Mr. Giuliani routinely decried as socialized medicine (or “socialist”) any proposal presented by Democratic candidates, because typically the latter advocated tax-financed subsidies toward the purchase of health private insurance or expansions of public insurance programs. But technically none of them advocated socialized medicine.

"Perhaps Mr. Giuliani was unaware that Americans all along the ideological spectrum reserve the purest form of socialized medicine — the V.A. health system — for the nation’s veterans. I find this cognitive dissonance amusing. Indeed, if socialized medicine is so evil, why didn’t Republicans privatize the V.A. health system when they controlled both the White House and the Congress during 2001-06?

"Mr. Giuliani also seems to forget that, in 1996, he found social health insurance a perfect solution to the financial problems faced by former Mayor John V. Lindsay, who fell on financially hard times during the 1990s as a result of chronic illness. "

The chart in the piece is a little tough, the text is better, specifically the first two paragraphs above.

But to me, the key is do we want to continue to decide who can get health care and health insurance based upon their luck? And I don't mean luck in being financially successful, I mean luck in not getting a chronic, life threatening, debilitating illness. And if we get lucky, and make it to Medicare without a big illness, do we really want to rely on that luck holding out for our children, our nieces and nephews, our grandchildren? I don't.

Sphere: Related Content

Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries -- American College of Physicians, -- Annals of Internal Medicine

Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries -- American College of Physicians,:

When we were talking last week about the lack of single payer advocates at last week's summit, I didn't realize that ACP was there. The President of the ACP was there, though I don't know his persoanl feelings about reform, I did go back and look at the recommendations published by ACP last year.


"Paying for Health Care

"Recommendation 1a: Provide universal health insurance coverage to assure that all people within the United States have equitable access to appropriate health care without unreasonable financial barriers. Health insurance coverage and benefits should be continuous and not dependent on place of residence or employment status. The ACP further recommends that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:

"1. Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals' freedom to make their own health care choices. [CMHMD Note: I guess it shows how complicated this all is. ACP considers Japan single payer and France a hybrid sytem, but most consider both single payer. In any case, neither have significant problems with waiting times.]

"2. Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector. (See the ACP's proposal for expanding access to health insurance as an example of how a pluralistic system can achieve universal coverage [69].)

"Recommendation 1b: Provide everyone access to affordable coverage—whether provided through a single-payer or pluralistic financing model—that includes coverage for a core package of benefits, including preventive services, primary care services—including but not limited to chronic illness management—and protection from catastrophic health care expenses.

"Recommendation 1c: Until there is political consensus for achieving universal coverage at a federal level, Congress should encourage state innovation by providing dedicated federal funds to support state-based programs with an explicit goal of covering all uninsured persons within the state. (See the ACP position paper, "State Experimentation with Reforms to Expand Access to Health Care" [70].)

"[ACP]Comment: Universal health care insurance is necessary to ensure that everyone within the United States has access to needed health care services of high quality. The federal government should assure that all persons within the borders of the United States also have access to health care services without undue financial barriers and that health care services provided are adequately reimbursed. The ACP recommends 2 alternatives: a system funded solely or principally by government (federal and state), commonly known as a single-payer system, or a pluralistic system that incorporates existing public and private programs with additional guarantees of coverage and with sufficient subsidies and other protections to assure that coverage is available and affordable for all. The ACP has proposed a step-by-step plan that would achieve universal coverage while maintaining a pluralistic system of mixed public and private sector funding."

^{------------------------------------------}

^{SO, ACP advocates either a single payer model, or a social health insurance model (i.e., a hybrid system) as the path to paying for universal health care. This is where I come down as well. I think it would be very useful if we could get a majority of physicians to accept this either/or approach with the caveat that we vigorously campaign to allow NOTHING LESS than this to be our line in the sand.}

Sphere: Related Content

EzraKlein Archive | OBAMA'S HEALTH CARE PLAN EXPECTS AN INDIVIDUAL MANDATE.

EzraKlein Archive The American Prospect:

"Administration officials have been very clear on what the inclusion of 'universality' is meant to communicate to Congress. As one senior member of the health team said to me, '[The plan] will cover everybody. And I don't see how you cover everybody without an individual mandate.' That language almost precisely echoes what Senate Finance Chairman Max Baucus said in an interview last summer. 'I don’t see how you can get meaningful universal coverage without a mandate,' he told me. Last fall, he included an individual mandate in the first draft of his health care plan.

"The administration's strategy brings them into alignment with senators like Max Baucus. Though they're not proposing an individual mandate in the budget, they are asking Congress to fulfill an objective that they expect will result in Congress proposing an individual mandate. And despite the controversy over the individual mandate in the campaign, they will support it. That, after all, is how you cover everybody."


While I favor a single payer system as the best solution, it doesn't take a rocket scientist (or Ezra Klein) to see where the winds are blowing.

I have become comfortable with this approach. Although mandates have not worked out as well as we'd like in Massachusetts, it is hard to argue that they have not worked in Switzerland, Germany, Japan and other countries. I would argue that the chief differences are two:
1.) Spending enough money to actually give everyone a comprehensive benefits package (think Medicare, not Medicaid)
2.) Serious regulation of private insurers so that they cannot cherry-pick, deny, drop, obfuscate, etc

If we spend enough money in some private-public mix and if we regulate the insurers so they function more like the contractors who cut the checks for Medicare (the regional "carriers") and we subsidize those who cannot afford health care or insurance, we may not have single payer, but we will at least have a truly universal, fair, system.

AND THEN, if we still think we need to, we can work on transitioning to a true single payer system.

OK, let me have it.

Cheers,

Sphere: Related Content

Annals of Public Policy: Getting There from Here: Reporting & Essays: The New Yorker

Annals of Public Policy: Getting There from Here: Reporting & Essays: The New Yorker:

"Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” In the battles between Betamax and VHS video recorders, Mac and P.C. computers, the QWERTY typewriter keyboard and alternative designs, they found that small, early events played a far more critical role in the market outcome than did the question of which design was better. Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area—even if prices, taxes, and competition are stiffer. “The long shadow cast by history over location is apparent at all scales, from the smallest to the largest—from the cluster of costume jewelry firms in Providence to the concentration of 60 million people in the Northeast Corridor,” Krugman wrote in 1991.
With path-dependent processes, the outcome is unpredictable at the start. Small, often random events early in the process are “remembered,” continuing to have influence later. And, as you go along, the range of future possibilities gets narrower. It becomes more and more unlikely that you can simply shift from one path to another, even if you are locked in on a path that has a lower payoff than an alternate one."

It's actually hard to get a representative paragraph out of this article. It is definitely worthwhile reading, as is everything Gawande writes, and begins with an overview of how universal healthcare took hold in England, France and Switzerland, and then makes the case for "path dependence", which starts the section I've quoted above.

Because I haven't written it in a while, Ill repeat a story. At a debate among single payer advocates and antagonists at Duquesne University last year, I asked the representative of the very right wing Fraser institute of Canada, which of the world's nations systems he could live with us modeling ourselves after. Switzerland was the answer, and he conceded that the hybrid of using competing insurers and providers while requiring universal coverage with subsidies may be the second best solution for America. After laissez-faire capitalism, of course.

But it does make the point that the combination of path dependence and bits of common ground could lead us to real change.

Sphere: Related Content

FORA.tv - Zeke Emanuel: Scrapping the Health Care System

FORA.tv - Zeke Emanuel: Scrapping the Health Care System (Audio only here- You may have to register.)

A lecture done for the Commonwealth Club of California on January 8, 2009.

As in his book, "Healthcare Guaranteed", he lays out his case for Health Care reform, which is for a social health insurance program. I actually agree with him, and he makes his case well. I think he gets a couple things wrong, in a way that is not helpful.

First, he spends some time being very dismissive of the single payer option. His arguments are two-fold. First, making a system work for 300 million people is impossible. Second, that continuing a fee for service system makes cost control impossible.

I happen to agree that working for a social insurance model is the best way to go, for a variety of reasons, that he covers well.

However, he is almost patronizing of those who advocate for single payer. This wouldn't be so bad if he hit the mark on his criticisms, but he does not. And it irritates and antagonizes those who would naturally on his side, if he persuaded instead of ridiculed.

Regarding managing 300 million accounts/people/policies: Our current Medicare system does not attempt to manage all of its members within a single entity. Medicare functions as the central agency, but regional carriers handle the day to day operations. And in Canada, the single payer system is broken into manageable chunks by province. There is no reason we could not implement our system in such manageable chunks.

His second argument is that fee for service is the real problem, not insurance company waste, and that we will get the most bang for our buck with payment reform rather than cracking down on insurers.

Maybe there are single payer advocates who advocate for the current reimbursement system, but I don't know any of them. So, in that sense, it is a straw man, but he really loses me when he he argues that we cannot have high performing, efficient organizations like the Cleveland Clinic or the Mayo Clinic under fee for service. I'm sorry, but those systems operate in a fee for service payment system. They have done some unique things within that system, but they are a model of how to make a fee for service system work properly. So, attacking single payer because it mandates no reform in payment models is silly and it antagonizes people who should be engaged, not belittled.

He additionally makes the case that insurance companies are not to blame for our problems and indicates that most of us would behave as these execs and employees would if placed in the same circumstances. Fine, I'll concede that, but the problem, single payer advocates point out is that the circumstances are the problem, not the employees. A system that rewards denial of care leads to massive bureaucracies designed to deny care. So, sorry, they are a big part of the problem.

And, while I'm in a critical mood, I do have a problem with suggesting VAT as a method of payment. We already have the most byzantine taxation system in the world. Why add another layer of complexity that will surely be more regressive into the mix. If you want to fund via taxes, fund via taxes. At least the income tax is somewhat progressive. And people are not completely stupid: if you tell them their taxes will go up $8000 but they won't have to pay $12,000 in health insurance premiums and another $1000 or two or three out of pocket, they'll get it.

This is intended in a spirit of constructive criticism so that we can advance the debate together.

Sphere: Related Content

A Structural Description of Social Health Insurance

A structural description

When one moves from this inside view to a more detached, outsider

’s perspective, SHI systems can be described in more structural terms. This structural understanding incorporates seven core components that exist across all eight studied countries, and that can be considered to comprise the organizational kernel of an SHI system.

2

Risk-independent and transparent contributions

The raising of funds is tied to the income of members, typically in the form of a percentage of the member’s wages (sometimes up to a designated ceiling). This has two equally important characteristics. First, contributions or premiums are not linked to the health status of the member. If a member has a spouse and/or children, they are automatically covered for the same income-related premium and under the same risk-independent conditions. Second, contributions or premiums are collected separately from state general revenues. Health sector
funding is transparent and thus insulated from the political battles inherent in public budgeting.

Sickness funds as payers/purchasers Premiums are either collected directly by sickness funds (Austria, France, Germany, Switzerland) or distributed from a central state-run fund (Israel, Luxembourg, the Netherlands) to a number of sickness funds (Belgium employs both methods). These funds are private not-for-profit organizations, steered by a board at least partly elected by the membership (except France and Switzerland), and usually with statutory recognition and responsibilities (Israel is an exception). The rules under which these sickness funds operate typically are either directly established by national legislation (Austria, France, Germany, Luxembourg, the Netherlands, Switzerland) and/or tightly controlled through a state regulatory process (Israel) (Belgium is an exception). The sickness funds use the revenues from members’ premiums (health tax in Israel) to fund collective contracts with providers (private not-for-profit, private for-profit, and publicly operated) for health services to members.

Solidarity in population coverage, funding, and benefits package Depending on the country, 63 per cent (the Netherlands) to 100 per cent (France, Israel, Switzerland) of the population are covered by the statutory sickness fund system. In countries with less than 100 per cent mandatory participation, typically it is the highest-income individuals who are allowed (Germany) or required (the Netherlands) to leave the statutory system to seek commercial
health insurance on their own (small exceptions exist for illegal immigrants, for people with objections by principle and for civil servants). Funding for all members is equalized either within national state-run pools (Israel, the Netherlands); within regional government (Austria) or foundation-based (Switzerland) pools; through mandatory risk-adjustment mechanisms (Belgium, Germany, Israel, the Netherlands); or through state subsidies (Belgium, France). In all eight SHI systems, the state requires the same comprehensive benefits package for all
subscribers.

Pluralism in actors/organizational structure SHI systems incorporate a broad range of organizational structures. Both within as well as between SHI countries, the number and provenance of sickness funds may vary widely, based on professional, geographic, religious/political and/or non-partisan criteria. Nearly all hospitals, regardless of ownership, and nearly all physicians, regardless of how they are organized (solo practice, group practice etc.) have contracts with the sickness funds and are part of the SHI system. Professional medical associations, municipal, regional and national governments, and also suppliers such as pharmaceutical companies are all seen as part of the SHI system framework.

Corporatist model of negotiations
Negotiations typically occur at regional and/or national level among ‘peak organizations’ representing each health sub-sector involved. This corporatist framework enables the self-regulation and contract processes to proceed more smoothly, with substantially more uniformity of outcome and substantially lower transaction costs. A corporatist approach among a group of ‘social partners’ (sick funds, health professionals, provider groupings and supplier groupings)
is also consistent with policy-making arrangements in other parts of the social sector in the seven studied European countries (less so in Israel).

Participation in shared governance arrangements
As befits the pluralist configuration described just above, SHI systems typically incorporate participation in governance decisions by a wide range of different actors. The most visible manifestation is the traditional process of selfregulation by which sickness funds and providers negotiate directly with each other over payment schedules, quality of care, patient volumes and other contract matters. Medical associations, hospital associations and other professional groups frequently have some decision-making responsibilities as well.

Individual choice of providers and (partly) sickness funds
Members of sickness funds can usually seek care from nearly all physicians and hospitals. In six of the eight studied systems, a referral to see a specialist is not required (Israel and the Netherlands are exceptions). Increasingly, members can also choose to change their sickness fund (Austria, France and Luxembourg are exceptions).

These seven characteristics – risk-independent contributions, sickness funds as
payers, solidarity, pluralism, corporatism, participation and choice – comprise
what is described in many writings about SHI systems as the ‘core structural
arrangements’ (Glaser 1991; Hoffmeyer and McCarthy 1994; Normand and
Busse 2002). Combined, they can be taken as the institutional mechanics of how
an SHI system is organized.

Sphere: Related Content

World Health Organization Report on Social Health Insurance Systems

in Western Europe.

It's 313 pages, so, no, I haven't read it yet, but I want the resources at our fingertips when the time comes...

From the introduction:

The concept of social health insurance (SHI) is deeply ingrained in the fabric of health care systems in western Europe. It provides the organizing principle and a reponderance of the funding in seven countries – Austria, Belgium, France, Germany, Luxembourg, the Netherlands and Switzerland. Since 1995, it has also become the legal basis for organizing health services in Israel. Previously, SHI models played an important role in a number of other countries that subsequently changed to predominantly tax-funded arrangements in the second half of the twentieth century – Denmark (1973), Italy (1978), Portugal (1979), Greece (1983) and Spain (1986). Moreover, there are segments of SHI-based health care funding arrangements still operating in predominantly tax-funded countries like Finland, Sweden and the United Kingdom, as well as in Greece and Portugal. In addition, a substantial number of central and eastern European (CEE) countries have introduced adapted SHI models since they regained control over national policy-making – among them Hungary (1989), Lithuania (1991), Czech Republic (1992), Estonia (1992), Latvia (1994), Slovakia (1994) and Poland (1999).

Also, I'm going to add a topic Tag of "Social Heath Insurance" and cross tag all my "Bismarckian" ones so that it becomes clear they are the same thing.

Sphere: Related Content

Mayo Clinic Health Policy Center Recommendations

Mayo Clinic Health Policy Center Recommendations

IV. Provide Health Insurance for All

Provide guaranteed, portable health insurance for all individuals, giving them choice, control and peace of mind.

Requires action from: Insurers, employers, the government and individuals

• Require adults to purchase private health insurance for themselves and their families. Employers could continue to participate by buying insurance for their employees or giving them stipends to purchase it. However, the individual could own the insurance.
• Appoint an independent health board (similar to the Federal Reserve) to provide a simple coordinating mechanism for individuals to select a basic
  private insurance option. Allow people to purchase more services or insurance,
  if they choose.
• Provide sliding-scale government subsidies to help people with lower incomes
  buy insurance.
• Realign the health system toward improving health in addition to treating
  disease.

This is, more or less, a Bismarckian or "sickness fund" type system. I would argue against leaving the employers in the loop, as salaries/wages can easily be designed to provide appropriate compensation without including it as a benefit. Just makes it easier to administrate.

I'd further argue that a more strenuous effort needs to be made to make the benefits provide and the cost to consumers of a "standard" policy uniform accross the nation. The way other countries have done this is to stricly regulate the costs and benefits of the basic plan very rigidly, and then allow insurers to compete in the non-basic elements of a plan, such as optical, dental, wellness, etc.

I think this approach will win support from essentially all Democrats and more than a few Republicans. It seems to already be in the works.

Sphere: Related Content

FRONTLINE: sick around the world: five countries: health care systems -- the four basic models | PBS

FRONTLINE: sick around the world: five countries: health care systems -- the four basic models PBS:

"These four models should be fairly easy for Americans to understand because we have elements of all of them in our fragmented national health care apparatus. When it comes to treating veterans, we're Britain or Cuba. For Americans over the age of 65 on Medicare, we're Canada. For working Americans who get insurance on the job, we're Germany.

For the 15 percent of the population who have no health insurance, the United States is Cambodia or Burkina Faso or rural India, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if you're sick enough to be admitted to the emergency ward at the public hospital.

The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it's fairer and cheaper, too."

From the truly terrific PBS/Frontline site for "Sick Around the World"

Sphere: Related Content

Miles Mogulescu: Why Not Single Payer? Part 6: New "Health Care For America Now" Coalition May Reflect Divisions in the Movement for Universal Healthcare - Politics on The Huffington Post

Miles Mogulescu: Why Not Single Payer? Part 6: New "Health Care For America Now" Coalition May Reflect Divisions in the Movement for Universal Healthcare - Politics on The Huffington Post

We all saw sicko, but many of us also saw Frontline's Sick Around the World program : http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

Certainly Single payer can work and might be the best system possible, but I don't think the Bismarkian systems of Germany, Switzerland and others can be dismissed out of hand. If you go to the frontline website and watch the show, be sure to read the supplementary materials, especially he interview with Uwe Reinhardt. http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/interviews/reinhardt.html

I had not given Bismarkian systems much thought until I heard a representative from the Stark Raving Loonie Party (Sorry, that's Python - I meant the Fraser Institute of Canada) actually confess that he could see working with reform along the Bismarkian lines:http://cmhmd.blogspot.com/2008/03/single-payer-debate-at-duquesne-u-31008.html

Further, Sen. Ron Wyden and others have introduced a plan along these lines, so HR 676 isn't the only ball in play at the moment.
Wyden Press release: http://wyden.senate.gov/newsroom/record.cfm?id=297073&
Other commentary: http://www.blueoregon.com/2006/12/progressives_re.html

So I guess I'd say not to discount the Wyden plan out of hand as not being "pure" single payer. because we have examples of this system working as well as single payer can.

Cheers,

Sphere: Related Content

Report boosts bipartisan health plan - Yahoo! News

Report boosts bipartisan health plan - Yahoo! News:

"Sen. Robert Bennett, R-Utah, the other sponsor of the legislation, said the report confirmed that the plan would not only cut health-care costs but actually save money in the long run.

'I am convinced we can reach our goal to improve coverage and provide affordable, private health insurance to every American,' Bennett said at a news conference with Wyden and other Senate supporters of the bill.

The so-called Healthy Americans Act would replace the current employer-based health insurance system with a system in which the government requires, subsidizes, and oversees a system of private health care plans that individuals select. The coverage would be guaranteed to be as good as that which federal employees receive, and the government would subsidize health care for people up to 400 percent of the poverty level.

The plan is paid for in part by changes to the tax code, including a new tax on employers of between 3 percent and 26 percent. Wyden labels the tax 'employer-shared responsibility payments' and notes that they would replace money employers now spend to provide private health insurance for their workers.
The employer payments are expected to generate up to $100 billion a year in federal revenue.

'Employers like this plan, and the reason they like it is because it cuts their current and future health care costs,' Wyden said."

Obviously, the torpedos are being loaded into the submarines already, but this may represent an opportunity for real reform and, although not single payer so much as Bismarkian/sickness fund style plan, I can live with it. And, more importantly, even many free marketeers can live with it, too.

Sen. Wyden's press release is here, and it lists current Senate co-sponsors.

Sphere: Related Content

Six steps to bring about true health-care reform in Utah - Salt Lake Tribune

Six steps to bring about true health-care reform in Utah - Salt Lake Tribune:

Dr. Joe Jarvis of Utah has written a nice opinion piece for the Salt lake Tribune identifying six important areas to address in health care reform discussions. Some I have addressed here in the past, such as the Moral hazard myth. His number one is:

"Health underwriting: Every critically ill or injured person will be treated in our health system whether they have health insurance or not. Therefore, we should not waste resources trying to identify persons likely to have critical illness in order to exclude them by price or refusal from acquiring health financing. Community rating, guaranteed issue and risk-sharing will increase health system efficiency and eliminate the unfunded mandate that is cost-sharing."

After seeing the Frontline Sick Around the World Program and web site, and also after attending the Single Payer Debate at Duquesne University earlier this year, it may be that the path to reform in the US might have to be the path of Bismarckian universal healthcare. It seemed that even the far right Fraser Institute's spokesman at the debate was willing to grant that this might be a reasonable way to provide universal access in the US and not violating the hard charging laissez-faire types ideology too badly.

Sphere: Related Content

Household Income, US Census Data

Household Income-2005--Part 1:
"Table HINC-05. Percent Distribution of Households, by Selected Characteristics Within Income Quintile and Top 5 Percent in 2006

[Source: U.S. Census Bureau, Current Population Survey, 2007 Annual Social and Economic Supplement. Numbers in thousands. ]



I always get confused when I hear people talking about middle income families/households, and it alwasy seems to me that if you are in the DC or other elite groups, $100K or even $200K puts you squarely in the middle class.

As you can see by the table (if you can't read it, follow the link to the Census Bureau), the true middle, is between $37K and $60K for the true middle quintile and between $20K and $97K for the 3/5 in the middle.

Now, just to follow up on something I heard McCain (and the usual propogandists agains National Health Insurance systems of any kind) say is that you'll be taxed to death. Now, if you are in the middle 3/5, and you are paying, for argument's sake, $12K for healthcare (either out of your wages or paying it yourself), how, again, do you lose by adopting a single payer or Bismarck style insurance plan?

And I guess I learned something from Frontline and Uwe Reinhardt: I have to add "Bismarckian Insurance Plan," to my categories/tags.

Cheers,

Sphere: Related Content

Single Payer Debate at Duquesne U, 3/10/08

SEPP Organization - SEPP Events

(The link above takes you to the details of the event.)

I attended the debate last night among Dr. Scott Tyson and Gariel Silverman, arguing the single payer case, and Sue Blevins and Nameed Esmail, arguing against at Duquesne University last night. First, props to Duquesne: Great venue in the Power Center, easy parking, nice facility all around. And props to both groups for getting attendance to a surprisingly high level (over 200, I'd guess). Pro-single payer were in the majority, I'd guess, by a significant amount.

I'll cut to the chase: Jerry Bowyer, moderator, at the end of the evening, asked if the discussion had changed anyone from their pro or anti single payer or undecided camps, and only a handful of hands went up. Sigh. But, not, of course, unexpected.

To those of us who are familiar with the issues and arguments for and against single payer, and familiar with the players (esp. Mr. Esmail's Fraser Institute), there were not many surprises. My most pleasant surprise was Dr. Tyson's excellent performance. Powerful, personal and passionate, Dr. Tyson did a very good job of making the moral, practical and economic case.

As my bias is obvious, I won't pretend to disguise it. I found the same old arguments from the status quo/free market/every man for himself side very tiresome indeed. I'll just toss out a few "highlights."

Single Payer advocates see Canada as a Panacea solution for America's woes. I don't know of any, but it somehow forces single payer advocates into the silly position of defending Canada's system, even though it is not the one we would emulate. From now on, we should respond to the Canada graphics with ones comparing us to Germany, France, Belgium, Japan, or almost anyone, and leave Fraser to shit on their own country as they seem wont to do. Heaven forbid they offer constructive solutions. And by this, I mean ones that at least 30 or 40% of the Canadian population would at least consider.

Showing a spending chart showing Canada at the high end of spending on healthcare compared to the rest of the world, and omitting the US, cause we're so off the charts as to make the chart look laughable.

Arguing that taxation sufficient to pay for healthcare would strangle economic growth. This is just too brain-dead to answer, especially sitting in a country that spends 16.5% of its GDP on healthcare. And especially from an economist who said, specifically, that there is no "government money" only our money in government's hands.

Waiting times in Canada are intolerable and/or deadly. Please click here.

$32 Billion in Medicare fraud annually is an outrage and a scandal. I don't know the source or veracity of this figure, but the 2006 Medicare expenditures were $408 billion, meaning 92% of the money gets where it's supposed to, which needs work, but isn't awful. And the suggestion that I think Ms. Blevins made was that she preferred private insurer's solution: deny care first, and then sort out who was trying to scam you, rather than covering claims in good faith and then going after the perps. I'm all for getting the perps, but not until I've made sure the patients are taken care of first. Silly me.

Patients in Canada often have to wait 10 or 12 hours to get a hospital bed when admitted through the ER. Imagine our shock. (He did know Pittsburgh was in America, right?)

Veterans Administration hospitals are horrible places. Dr. Tyson did try to set Ms. Blevins right on this one, though I think she didn't believe him.

You cannot pay for treatment in Pennsylvania outside of your contract with your health insurer.
This one got my attention. I hope somebody will post a comment for me about it, because I'd never heard this before, and it seems exceedingly odd.

The usual "anecdote-off," for which I'll just refer you to our special section.

I was pleased to see Mr. Esmail's praise of other systems, particularly those of Switzerland, Japan, France, Sweden, Germany and some others. He rightly pointed out that the old PNHP proposal, from 1993, was fairly beholden to the Canadian model, but there are newer proposals from PNHP, and besides, they are not the only proposals out there. As has been often pointed out by our side, and always ignored by theirs, we need a uniquely American system, pulling from the best of all other extant systems. Though Mr. Esmail did seem gratified to sear Dr. Tyson say this, I doubt it was the first time he heard it. (You don't suppose he didn't watch Sicko, even as an academic exercise?) Oh, and Esmail even admitted we were rubbish for Mental Health care, too.

Oh, and a personal shout out to Scott Tyson for his wonderfully dismissive treatment of HSAs. Made me chuckle and even snort a bit!

OK, folks, that's all I can remember at this late hour, but please add your comments to remind me of things I forgot to mention....

Cheers,

Sphere: Related Content