The Senate Health Care Bill is in trouble. Thanks to Lieberman, it looks like the plan to expand Medicare to cover a portion of the uninsured is finished. I've got ten minutes before I have to take a kid to an emergency appointment with an orthodontist (thank you, dental plan), but I am going to squeeze out a short rant.
We need health care reform. I've been to an urban emergency room. When my son, Ian, was 18 months, he became seriously dehydrated due to a bad bout with the flu, and he needed an IV. We ran down to the emergency room at Columbia Presbyterian at 168th Street. The room was packed to brim with families. Packed. People were eating their dinner in the waiting room, because they had been there so long. It was dirty. When Ian was finally well enough to leave, I carried him out of there at 5am to get a cab rather than wait two hours for Steve, because I was worried that he was going to catch something there.
For many people, that emergency room is the only health care that they know. They wait until they are really sick, because they can't get antibiotics for strep throat.
The Senate needs to pass a bill to help those people in the emergency room.
They also need to figure out the lunacy of billing. Why does a doctor bill a Medicare patient $150 for an office visit, while a privately insured patient is billed $75?
We need something now.
Senate Democrats have not helped matters. I can't blog about a health care bill, if the bill mutates every day or so. I can't keep track of the latest plan. If I can't keep it straight, nobody can. We can't call our Senators. We can't rally support on our blogs.
Apt. 11d 
We need something now.
That line is probably half of the difference between a progressive reformer and a whatever it is I am. I can’t help but think how things could get worse. For me, “I can’t keep track of the latest plan” is a very good reason for trying to stop whoever is trying to make the plan.
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Well, MH, that’s the definition of a “conservative”, risk averse behavior I guess. But, preserving the status quo can cause disaster, too, on climate change, on hesitating in 1939, or 1929, personally, in not looking for the new job, not investing in Google, . . . .
Health care in the US is a slowing dying system. Laura is speaking as a visitor to an urban emergency room. But, I number among my social group lots of physicians. They don’t necessarily like any specific plan, but they feel that the current system is a stack of cards, stuck together with duct tape and gum, relying on over-payments to some, and underpayments to others, and a messy dense impenetrable financial accounting system that survives by hiding all these costs from the various users and payers. Efforts to extract efficiencies from inefficient areas creates ripple effects, collapsing parts of the house of cards. Urban emergency rooms are on example; long term care, unnecessary mammograms & CT scans are another, and to stretch even further, so is the slow choking of small businesses & big businesses as they realize that they cannot hide the costs of health care (from their employees, owners, or consumers).
We need something, and, not doing something now will mean disaster down the road.
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But, preserving the status quo can cause disaster, too…
Yes. But making somebody stand-up and say this is the basic plan and giving everybody time to consider it seems the bare minimum for a plan in an area that is bound to involve a massive shuffle of something everybody comes into contact with.
They (or several different ‘theys’) would have had plenty of time to articulate a coherent plan and try to sell it on its merits. Instead they tried to rush everybody and have so far done nothing but rouse public opinion against any plan. Few people have a detailed understanding of the U.S. healthcare system. Most people have bought a used car and, as they get experience, develop near-reflexive defenses against the hard sell. As Gollum said, “Less haste, more speed.”
…on hesitating in 1939, or 1929
By “1929” you must be referring to the start of the Depression, which actually goes to my side as doing nothing would be been greatly preferable to what they did do.
Doing nothing in 1939 did lead to disaster. Are you coming around to my view that a bit more distrust of foreigners can’t hurt?
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“They don’t necessarily like any specific plan, but they feel that the current system is a stack of cards, stuck together with duct tape and gum, relying on over-payments to some, and underpayments to others, and a messy dense impenetrable financial accounting system that survives by hiding all these costs from the various users and payers.”
Yes, but there are a lot of different market-based ways to skin that cat, as we’ve discussed previously at great length. The US runs the risk of creating an even larger, and more deeply-flawed program that doesn’t work but that no one can kill or cut. The way that the plans keep mutating is a very bad sign, as is the fact that quite a few members of Congress seem positively proud of the fact that they aren’t reading the legislation.
Regarding mammograms–my mom was diagnosed with breast cancer around age 42. Understandably, I’d like to decide when I get mammograms. I get that there are trade-offs for testing, but the federal government shouldn’t be both on the field and refereeing. The problem is that if the Feds have a financial interest in cost-cutting, the public is going to take their recommendations with a big grain of salt. I would welcome impartial, easy-to-understand ratings for effectiveness of different treatments. We’re also hearing a lot about how insurance companies fail to follow through on promises to customers. It seems to me that if that is true, that’s fraud, and the proper authorities should investigate, etc., and perhaps create or improve rating systems that would allow customers to figure out which companies are most reputable and trustworthy.
And of course I’d like to see interstate markets in insurance, as well as many other market-based solutions. We’re a very diverse country of 300 million. One-size-fits-all solutions are not going to work here, in any field of endeavor. I remember harry b saying recently that social welfare provisions are better in some Scandinavian country (???) than in the UK, and better in the UK than in the US. Interestingly, that tracks with the population size. I think we should be very careful about attempting to introduce systems to the US that were never intended to function on this kind of scale.
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“Are you coming around to my view that a bit more distrust of foreigners can’t hurt?”
No, and, I don’t know if you realize, but I find the point of view just straight offensive. I don’t think “foreigners” are any different (and deserve any less trust than you or me). Nebraskan’s and Texans are pretty foreign to me, but I try to give them the benefit of trusting our common humanity (and extend that to the Chinese and Danes, too).
I think our problem in 1939 was not enough trust of foreigners, particularly those in England and France.
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A woman with a mother who was diagnosed with breast cancer at 42 (assuming a biological relationship) would have a recommendation, under any currently revised guidelines, to get a mammogram earlier rather than later.
I understand the concern about one size fits all solutions, and see it most clearly when we talk about school. But, I still think we should have public schools, and public health plans. I don’t think we should be forbidden from buying private solutions (or private schools). I don’t think the plans currently under consideration do this, nor do I think that we are arbitrarily scaling up systems or copying without thoughts about our own country.
I think the problem with health insurance in this country is its tie to specific employment, that it warps our economy and our health care and our health care spending, and that we have to develop options that does not link it so.
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“I think the problem with health insurance in this country is its tie to specific employment”
And this boils down to differing beliefs about human nature. People are either inherently lazy bad characters or they are self motivated. In broad brush strokes the right believes the former – that uncoupling health care from employment would result in more unemployed at the trough of free health care. And the centre/left believe that people will still find paid work to care for themselves.
Disclosure: I live in a “scary” social democrat-type country like Canada. For me universal health care is in the same bucket as universal education, universal roads & highways, and universal safety regulations. I benefit personally from my fellow citizens being safe and healthy.
And I’d like to know how attractive a filibuster would be to Lieberman if he was uninsured and part of the working poor.
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“Understandably, I’d like to decide when I get mammograms. I get that there are trade-offs for testing”
But you would have a choice. You’d just have to pay for it yourself.
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Well, I’m on the fence about the whole thing.
There are two major issues in this health care overhaul.
#1: universal coverage. I am an unrepentant liberal and believe a certain level of universal coverage is a human right.
#2: cost, a.k.a. perverse incentives driven by the fee-for-service model. I work in the health care industry and see first hand how much waste is built into the system; I know how we compare internationally. I am very frustrated at how little progress we’ve made on fixing this issue.
It scares me to death to consider adding coverage for so many Americans without trimming costs. From what I see, if we move forward with adding giant swathes of our population into Medicare, it will be broke in a couple of years.
But I don’t consider “well then let’s not cover everyone” to be an option. I am then left trying to figure out what it will take to incent people to change the fee for service model and really attack costs? I’m starting to think, you know, maybe this whole thing just needs to crash and burn. (At the office we call this “Letting the plates hit the floor.”) Maybe we collectively can’t make this decision any other way. But I would hate to see it snap back on people with a reversal on the decision to cover all citizens a few years out. I consider that a real possibility.
I really don’t understand why we’re never talking about a tiered system; preventive and basic care free for all, with the option of buying layer-on coverage privately to provide more services.
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Um. I’m German, so go ahead and mistrust me…
I’m married to a US American and have been on his health plan for five years. Then his company fired him, so we went on COBRA. Four months in, the company went bankrupt, canceled all health plans for all employees and thus kicked us out of COBRA; then they went ahead and installed a new health plan for current employees. Economically, that made sense. Ethically, that just sucked. (I’m looking at you, BearingPoint.)
My husband is now working as a free-lance contractor and we live in our vacation home in Germany. The money is okay when there is a job but there is not always a job. Influx is not reliable enough to shell out in excess of $1,000 for a private health plan for our family (we’re six people). We can’t get back into the German system without even higher payments — because I opted out years ago, our payments would be excessive with no employer to carry a share.
So we have no health insurance. Nada, none. We’re not lazy, we’re motivated, my husband works hard. We never thought we’d find ourselves in such a situation. We simply can’t afford health care because we don’t have the reliable income to pay off the mortgage and put food on the table.
Our decision to stay in Germany is partly based on the fact that medical bills are much, much, much lower here than in the US. If you have to pay for all of it out of pocket, that matters big time.
Yes, I want universal healthcare, I want affordable healthcare. Ourselves, we need more than just “basic” care — we have four kids, one needs speech therapy, the other has ADHD and is on medication, and need continuous therapy and consultations. It’s still less than a private health plan, though.
Jen, I think the problem with “basic” care and private add-on option is this: People don’t anticipate problems of a specific kind. Heart problems, cancer, diabetes – people don’t expect to get this, so they wouldn’t buy coverage for it. But the moment they get diabetes, any health care provider would deny coverage for it…
Yes, I lie awake at night, worrying. Why do you ask?
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The tie between employment and health insurance isn’t a left-right or Dem/Rep issue in the U.S. Given that being very unhealthy usually means not working, anybody without employeer-based coverage is pooled with the costliest to cover groups.
I think the bigger problem is that nobody wants to pay anything out of pocket. High deductable plans are a good way to cover more people, but politically they are apparently a non-starter. I don’t see why (other than public opinion) we can’t have a base catastrophic plan with a high deductable. That’s how the self-employed middle class used to insure itself (including my family when I was growing up). It just doesn’t exist anymore.
(P.S. I only worry about Germans in the aggregrate.)
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Claudia, I find it really interesting that you assume basic coverage would not include treatment for things like diabetes. It really shows how much variance there is in such definitions. I think of basic coverage as excluding things like infertility, orthopedic surgery where less costly treatments would also work, ultrasounds on every visit for OB care, etc.
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“We can’t get back into the German system without even higher payments — because I opted out years ago, our payments would be excessive with no employer to carry a share. ”
This is interesting Claudia. Tell us more. I’ve always imagined that my European friends can just move back to their home countries and fall on that safety net if things didn’t work out here in the US. What is the “opt out” system in Germany, and how would it affect people who travel elsewhere (the US, UK, another Schengen country, . . .) for education or work for a period of time?
Jen I agree with you — and I’ve said something similar about schools, that demanding the “best” (gold-plated coverage, tiny class sizes, etc.) for a publicly provided good is a road to disaster. You’re talking specifically about the pay/service model, but, what it really interacts with is people’s desire to consume health care. What I do not know, and this is an issue that the right brings up, and that needs to be considered, is how much the “basic care” model drives out alternative models. Take the mammogram example: I would like to see a system where mammograms are available after 50, as the current scientific evidence suggests, and then allow private payments earlier, if a woman wants them. But, would allowing such a system either 1) prevent the 50 year old from getting her mammogram, because the radiologist would opt to serve the paying 40 year old first or 2) prevent the 40 year old from getting her mammogram, because the government would drive out the private provider? I don’t know.
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“The tie between employment and health insurance isn’t a left-right or Dem/Rep issue in the U.S.”
Quite right. There is a long, long wishlist of right-wing health reforms, but they don’t seem to overlap very much with the left-wing wishlist. Nobody who thinks about this stuff is thrilled with the status quo.
“I think the bigger problem is that nobody wants to pay anything out of pocket. High deductable plans are a good way to cover more people, but politically they are apparently a non-starter. I don’t see why (other than public opinion) we can’t have a base catastrophic plan with a high deductable. That’s how the self-employed middle class used to insure itself (including my family when I was growing up). It just doesn’t exist anymore.”
Amen. On the other hand, when you look at how much employer-based insurance actually costs, it wouldn’t necessarily be such a bad deal to move to a more out-of-pocket model, if you could get your hands on the money that your employer currently pays for insurance. If you could put all of that in your HSA, you’d be extremely secure within just a few healthy years and might not even need much of a catastrophic policy (except for something truly huge).
Speaking of health care, I was just talking to my dad about my parents’ uninsured medical arrangements. They usually go to Dr. Cash (not his real name) as their family doctor, which costs around $50 per visit. I’m not sure Dr. Cash even takes insurance. Dr. Cash is an excellent physician. My dad has to see a specialist regularly. That’s also cash, and it costs $85 per visit (including a shot). That’s plumbers’ wages, really. I’d hate to be trying to clear $200,000 of medical school debt $50 at a time. Anyway, regular medical expenses and minor surgeries are well within my parents’ means as middle-income empty nesters, but I think they’d have to sell off land to pay for anything really big (heart surgery, hip replacement, etc.). That’s what they would need catastrophic insurance for.
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