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Tilting at Windmills

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April 18, 2006
By: Kevin Drum

A DOCTOR ON SINGLE-PAYER....In the Wall Street Journal today, Dr. Benjamin Brewer writes that he's finally come around to the idea that America would be better off with a single-payer national healthcare system:

Doctors in private practice fear a loss of autonomy with a single-payer system. After being in the private practice of family medicine for 8 1/2 years, I see that autonomy is largely an illusion. Through Medicare and Medicaid, the government is already writing its own rules for 45% of the patients I see.

The rest are privately insured under 301 different insurance products (my staff and I counted). The companies set the fees and the contracts are largely non-negotiable by individual doctors.

....My practice requires two full-time staff members for billing. My two secretaries spend about half their time collecting insurance information. Plus, there's $9,000 in computer expenses yearly to handle the insurance information and billing follow up. I suspect I could go from four people in the paper chase to one with a single-payer system.

Read the rest. He makes a good case from a ground level that both doctors and patients would be better off if we swept away our current "maze of deductibles, provider networks, out-of-network costs, exclusions, policy riders, ER surcharges, etc." He's right.

Kevin Drum 2:41 AM Permalink | Trackbacks | Comments (82)

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Comments

You jump in bed with the insurance "industry" and you just now notice you got fucked?
Oh docktor!

Posted by: jay boilswater on April 18, 2006 at 3:09 AM | PERMALINK

I've lived in America on both sides of it and some of my family live there today. Here in Oz we have a clearly superior single payer system. Did I tell you my Mom's a nurse? The argument over single payer is a non-starter the real argument is how to sell common sense to a nation that barely believes in evolution.
I think it can be done but not by the present Donkee party. A new refreshed party that is already coming up within the shell of the old will overthrow the old guard Vichy Dems ( so long Drum- don't let the door hit yr butt )and they will sell the superior plan as part of a larger plan to DOWNSIZE THE STATE. This is critical because smaller statism and less taxes is a key election winning meme for the lunar right Repugnant party.
The new Dems will follow on from the late great Martin Luther King and they will cut down the pork at the pentagon. There are already financial black holes there that must be plugged if it takes another plane landing on it.

In answer to the rhetorical question of when will you noisy civil righters ever be satisfied King thundered out a lightening string of never's - Never as long as police brutality, disenfranchisement, housing and lodging discrimination, ghettoization and routine attacks on black self esteem exist and spread. Never, he shouted quoting the prophet Amos till..."Justice rolls down like waters and righteousness like a mighty stream..."
" Should unjust conditions for anarchists prevail the call for them to be non-violent is a demand for them to submit to injustice. Nothing in the theory of non-violence counsels this suicidal course."

King on non-violence and it's inextricable link with justice.( he may have mentioned Negro's there, not anarchists, me bad.)

Martin Luther King jnr also described " AGGRESSIVE non-violence, MASSIVE non-violence and non-violent SABOTAGE " this post 67 King also spoke of the new campaigns " DISRUPTIVE DIMENSIONS."
Only such campaigns would be "POWERFUL" and "DRAMATIC" enough to bring essential change.

" Non-violence must be adapted to urban conditions and urban moods. Non-violent protest must now mature to a new level, to correspond to heightened black impatience and stiffened white resistance. This high level is MASS CIVIL DISOBEDIENCE. There must be more than a statement to the larger society, there must be a force that interrupts its functioning at some key point...to dislocate the functioning of a city without destroying it can be more effective than a riot because it can be longer lasting, costly to the larger society, but not wantonly destructive. It is a device of of social action that is more difficult for a government to quell by superior force...it is militant and defiant not destructive."

Round this time MLK also said he wanted to "go for broke", was willing to accept longer jail time and said..." In a sense you could say we were engaged in the class struggle," and also called for ..." a redistribution of economic power. We are now making demands that will cost the nation something...you are messing with folk then. Your messing with the captains of industry...and this all means that we're in dangerous waters because it really means that we're saying something's wrong with capitalism...there must be a better distribution of wealth and maybe America must move toward a democratic socialism."

Posted by: professor rat on April 18, 2006 at 3:34 AM | PERMALINK

Doctors in private practice fear a loss of autonomy with a single-payer system.

For good reason. Look at what's happening in the UK with their single-payer system.

Link

"Patients are being denied appointments with consultants in a systematic attempt to ration care and save the NHS money, The Times has learnt.

Leaked documents passed to The Times show that while ministers promise patients choice, a series of barriers are being erected limiting GPs rights to refer people to consultants.

Consultant-to-consultant referrals are also being limited, in many cases denying patients a second opinion."

Also another link on the UK single payer system.

Link

"Op death rates 'far higher' in UK surgery

Three million operations are carried out in the UK each year
Patients undergoing major surgery in the UK are four times as likely to die as those in the US, researchers have found."

A single payer system would result in tens of thousands more deaths than under our current system.

Posted by: Al on April 18, 2006 at 3:38 AM | PERMALINK

I feel a little bad for the billing managers that would all be unemployed. But at least they would still have health insurance.

Posted by: Occulize on April 18, 2006 at 3:52 AM | PERMALINK

I suspect I could go from four people in the paper chase to one with a single-payer system.

But then THREE PEOPLE WOULD BE OUT OF A JOB! HEARTLESS!!! NO SINGLE PAYER!!!

/channeling some troll

Posted by: MNPundit on April 18, 2006 at 4:02 AM | PERMALINK

Kevin: "[Dr. Benjamin Brewer] makes a good case from a ground level that both doctors and patients would be better off if we swept away our current 'maze of deductibles, provider networks, out-of-network costs, exclusions, policy riders, ER surcharges, etc.' He's right."

Dr. Brewer has apparently also perfected the art of re-stating the painfully obvious to us, the choir. He needs to repeat this argument over and over again to the insurance company-indoctrinated American masses, whose misguided notion of the very concept of socialized medicine seems curiously akin to Omar Sharif's trials and tribulations in Dr. Zhivago.

Doctors and patients won't be the only ones who benefit. Probably the biggest single cost to American employers today is mandated employee and retiree-related health care coverage.

All you pro-business free-market advocates want to give American business a great big economic shot in the arm? Then support single payer coverage in this country, and free American business to compete on relatively equal footing with the rest of the western world.

The biggest legalized fleecing in America today is perpetrated by the insurance industry. To do nothing to address this pervasive and unindicted corporate RICO activity is obviously counterproductive to our country's best interests.

Posted by: Donald from Hawaii on April 18, 2006 at 4:56 AM | PERMALINK

What makes him think single payer systems don't have paperwork on what is and what is not paid for?

Posted by: McA on April 18, 2006 at 5:40 AM | PERMALINK

Kevin: "[Dr. Benjamin Brewer] makes a good case from a ground level that both doctors and patients would be better off if we swept away our current 'maze of deductibles, provider networks, out-of-network costs, exclusions, policy riders, ER surcharges, etc.' He's right."

Donald from Hawaii: "Dr. Brewer has apparently also perfected the art of re-stating the painfully obvious to us, the choir. He needs to repeat this argument over and over again to the insurance company-indoctrinated American masses, whose misguided notion of the very concept of socialized medicine seems curiously akin to Omar Sharif's trials and tribulations in Dr. Zhivago."

Donald, Dr. Brewer's article appeared in the Wall Street Journal. I would not exactly call that the choir.

I do agree with the rest of your points and I do see some encouraging signs that a few Fortune 500 CEO's and health care providers are starting to come around.

At the moment, the slow rate at which these converts are appearing, the lack of any real support for single-payer in the Democratic party and the lack of a strong lobbying effort in favor of it are a bit discouraging but at least there are some signs of hope.

Posted by: tanj on April 18, 2006 at 5:41 AM | PERMALINK

At a sixth of GDP, one would think this was a discussion worth having. Not yet, apparently.
I'd also like hear about how the current arrangement relates to iatrogenic injury and death.

Posted by: Knate on April 18, 2006 at 5:45 AM | PERMALINK

What makes him think single payer systems don't have paperwork on what is and what is not paid for?

Posted by: McA on April 18, 2006 at 5:40 AM

Of course there will be paperwork under a single-payer system. But not 301 different insurance products! Each of which has its own particular combination of billing and procedure codes, covered and uncovered procedures, deductibles, co-pays and other terms that the health care provider and/or the patient must keep track of.

Every single-payer system has much lower overhead costs than the current system in the U.S. The VA health care system and Medicare also spend much more of their dollars on patient care and less on administrative costs than private programs in this country.

Posted by: tanj on April 18, 2006 at 5:50 AM | PERMALINK

Which silly Al just called the UK a single-payer system? The problem with the UK (which many agree delivers excellent health care) is that it's National Health, and care providers are generally state employees. In Canada or France, the usual examples of single payer health care, private practitioners are reimbursed by one agency. Zero overhead.

Oh, and they spend less per person than we do. Shhh. Don't tell anyone; they're not permitted to believe that America isn't the best in every way.

Of course doctors are terminally P.O.'ed by the cost of the overhead involved with reimbursement by insurance companies. On the other end of the deal, employers are in exactly the same situation. Year after year the cost goes up and the coverage goes down.

It's always good to find a physician who isn't frightened to death by the specter of "socialized medicine", when the facts in front of us strongly suggest that it's the only sane approach.

Posted by: bad Jim on April 18, 2006 at 5:53 AM | PERMALINK

What's impressive is that this is in the WSJ. They don't usually give voice to opinions they're strongly opposed to, and their readership ain't the choir.

Posted by: RT on April 18, 2006 at 6:25 AM | PERMALINK

My practice requires two full-time staff members for billing. My two secretaries spend about half their time collecting insurance information. Plus, there's $9,000 in computer expenses yearly to handle the insurance information and billing follow up. I suspect I could go from four people in the paper chase to one with a single-payer system.

Advocates of the American system tout the efficiency of our system, citing no evidence to support this except the fact that their freshman economics textbook says that the "market" solution has to be the most efficient. Meanwhile we are paying between 20 and 30% of our private health care expenses to cover administrative overhead while over on the other side of the lake the NHS spends less than 2% of its budget on admin costs and Medicare also spends a comparable fraction on admin expenses.

I don't understand how people think our system is efficient with all the haggling and confusion over insurance reimbursement that goes on every time they visit their doctor. When I went to my NHS GP there were no forms and no confusion and the only thing the office staff was there for was to keep records and make appointments. When we got referred to a specialist, again there were no forms and no insurance confusion.

The truly annoying thing is that a big chunk of that 20-30% goes to profits for the insurance companies, if not directly then as part of their investment machinery. I don't mind spending money on health care, but I don't want to be paying money to a middleman who provides very little added value.

Posted by: Jay on April 18, 2006 at 7:08 AM | PERMALINK

The problem with the UK (which many agree delivers excellent health care) is that it's National Health, and care providers are generally state employees.

Nonsense. The NHS physicians are not state employees and they have the option of accapting private insurance if they like. And private insurance does exist in the UK. It gives the wealthy the option to "jump the queue" on elective procedures or obtain procedures that their particular district doesn't cover. (For example, not all districts cover fertility treatment as part of the NHS.)

If we went to single payer, I imagine that a few people would retain their private insurance. It would just be the case that the largest health paying cartel would probably be the government, just as it is today (medicare).

Posted by: Jay on April 18, 2006 at 7:13 AM | PERMALINK

It's a mystery to me why liberals would want a single-payer medical care system run by President George W. Bush.

Posted by: anonymous on April 18, 2006 at 7:34 AM | PERMALINK

Well, I guess we've reached one milestone in insanity- rightwing trolls arguing that this could never work because George Bush is in office.

That's their real version of "Mission Accomplished".

What a long strange trip it's been.

Posted by: serial catowner on April 18, 2006 at 8:01 AM | PERMALINK

As a physician, I can unequivocally state that our current system is broken. As hinted at in some of the above posts, the ONLY segment of our society that benefits from the current structure is the insurance industry. I wish my colleagues would see that as the real problem, but, for some bizarre reason, they've focused on the trial lawyers/malpractice as the root of all evil. The insurance people laugh all the way to the bank.

Posted by: eekfive on April 18, 2006 at 8:02 AM | PERMALINK

As my own GP doctor recently told me, he works six days a week, but only see patients on four of those days. The other two are spent filling out forms and following up billing through insurance companies. Not Medicaid/Medicare--insurance companies. And this with a relatively small "country" practice and four full-time administrative assistants.

He doesn't accept new patients, and there's no such thing as getting in to see him for an emergency. You want an appointment? Figure two to four months before he can see you.

So c'mon, trolls: Tell me again about how single-payer means I'll have to wait months for healthcare. Explain to me some more about how faceless bureaucrats will dictate my options and tie up my doctor with paperwork.

Posted by: Derelict on April 18, 2006 at 9:05 AM | PERMALINK

Nonsense.
Everyone wants a government check, why is he different? Is it because he sees big bucks in the 4 billion immigrants Kevin has invited to LA?

Posted by: Matt on April 18, 2006 at 9:07 AM | PERMALINK

RT: What's impressive is that this is in the WSJ

It may be what makes it unique, but it's not at all impressive for the WSJ to finally notice what doctors have been saying, and enduring, for years. It will have zero effect on their editorial content, and even less on the Wall St. cupidity they are shills for.

Speaking of which, it always helps to bear in mind why we have the insurance system we do:

Winner, in the category of 2002 Annual Compensation, Exclusive of Unexercised Stock Options is...

Norman C. Payson, M.D. Oxford Health Plans $ 76,010,825

That's about $38,000 per/hour for Norman. But he pales next to William W. McGuire, M.D. of United Health whose $529,986,971 in unexercised stock options topped the list in 2002.

Isn't it grand that they are so amply rewarded for giving us the best 37th-place health system in the whole world?

(My apologies for repeating this yet again but for an interesting report on Healthcare CEOs "compensation" for just one year see this pdf file.)

Posted by: R.Porrofatto on April 18, 2006 at 9:17 AM | PERMALINK

"Everyone wants a government check, why is he different?"

Just because you're on welfare doesn't mean the rest of us envy you, Matt.

Posted by: Joel on April 18, 2006 at 9:18 AM | PERMALINK

Or just hire a billing service.

Posted by: Matt on April 18, 2006 at 9:20 AM | PERMALINK

Plainly there is no debate. The only reason we do not have a single payor system, is the insurance industry and its ability to lobby (bribe) politicians and its ability to influence public opinion through public relations (scare tactics) campaigns.

Posted by: terry on April 18, 2006 at 9:21 AM | PERMALINK

I've come aorund on single payer. I had to get stitches while out in MT recently. The process of getting my insurance to pay for them was about one thousand times more painful than the stitches. Don't ask about kids getting hurt or wife getting sick while traveling.

And in general I have great insurance too.

Posted by: Red State Mike on April 18, 2006 at 9:28 AM | PERMALINK

. . . the contracts are largely non-negotiable by individual doctors.

So much for the free market principles that conservatives with shameful mendaciously say they support.

Posted by: Advocate for God on April 18, 2006 at 9:28 AM | PERMALINK

Having hundreds of different plans benefits Big Pharma most of all, thanks to the lack of economies of scale. Nice little racket they've got going between them.

Posted by: ahem on April 18, 2006 at 9:37 AM | PERMALINK

Al is LYING to you. Click his link. You must always click his link.

Nowhere in his link is it ever proven that the single payer system has been scientifically proven to cause the higher death rate in medical procedures.

Correlation is not causation, Alistair.

Posted by: NSA Mole on April 18, 2006 at 9:46 AM | PERMALINK

Yah Know whut? Whut yew say. These Doctors are Hypocratic Oathers, yupp, how so?
lemme splain a few things, the Drug Makers, Pfizer Etc offer free drugs to people if they qualify under the drug makers poverty guidlines,,,
SO this company, we start it, we help people get the drugs from the mfg. Paperwork is horrendoous. but thats not what Im gonna beeatch bout.

These Doctors, many of them, refuse to do the paperwork to get their Patients free drugs, The paperwork is less than what insurance requires, yet they are so busy with other patients billing, they refuse to do the non insured FREE DRUG paperwrok!!!
Many of the people we help have to switch doctors just so thy can get free drugs!!
These kind of 'Hypocritc Oath' Doctors exist today. many of the patients had to change Doctors JUST so they COULD get the prescriptions filled for FREE! thru PAP providers. [PAP is Patience Assistance Programs]

Money Money Money.
What happened to Life Life Life?
The Hypocratic Oath is Dead.

Posted by: one eye buck tooth [X^B on April 18, 2006 at 9:59 AM | PERMALINK

Don't need no damn Stitches, you people are a bunch of damn girlie men, many a time have I laid open my skin, deeply so, upon a sharp piece of metal jutting out from the interior of the aircraft skin, and many a time has super glue been used to glue the loose skin back into position, the flow of blood staunches immediately and the Glue stays flexible for the rest of the day, Stitches are but for Wussies and overpaid hypocrit doctors, and thats the truth.

Posted by: one eye buck tooth [X^B on April 18, 2006 at 10:07 AM | PERMALINK

one eye buck tooth...
Don't need no damn Stitches...many a time has super glue been used to glue the loose skin back into position

I suppose you carry super glue in your purse, next to your SPF 30 lip balm?

Posted by: Red State Mike on April 18, 2006 at 10:13 AM | PERMALINK

Well, I guess we've reached one milestone in insanity- rightwing trolls arguing that this could never work because George Bush is in office.

That would send us through the looking glass big-time - but, frankly, serial catowner, it's unfair of you to call anonymous a "rightwing troll" simply because he/she referred to "liberals." His/her brief, single statement is not nearly enough for you to presume that.

Posted by: Alek Hidell on April 18, 2006 at 10:14 AM | PERMALINK

"What makes him think single payer systems don't have paperwork on what is and what is not paid for?"
Posted by: McA

Yeah, Imagine a gov't program with NO paperwork.

"Nowhere in his link is it ever proven that the single payer system has been scientifically proven to cause the higher death rate in medical procedures."

I read it. It makes it's case pretty well. No it doesn't mention the phrase "single payer system" but it does say,
"The most seriously ill NHS patients are seven times more likely to die than American patients who are as sick.".
NHS-single payer system. Six of one half dozen of the other.

Posted by: Lurker42 on April 18, 2006 at 10:14 AM | PERMALINK

Advocate for God
conservatives with shameful mendaciously...

Whaaa?

Heh. You write your own replies.

Posted by: Red State Mike on April 18, 2006 at 10:16 AM | PERMALINK

What the doctor describes sounds very much like what my wife observed when she worked as a receptionist for a doctor who had a small practice (one doctor office) in New England. Every insurance company had a different set of paperwork, different diagnostic codes, different allowed treatments, different submission and appeals procedures.

Oh yeah - and the companies would reject correctly filled out claims regularly, requiring the use of the appeals procedure with lengthy extra documentation, only to be told: "Gee, you shouldn't have had to appeal that, we cover the treatment."

Of course, this tended to mean that many payments were months in arrears. Medicare and Medicaid were the only plans that paid predictably.

He also had a fair number of customers who had no coverage and he would work out payment or barter schedules. So to those who say other countries ration health care - so does the US. We just have a different rationing system.

Posted by: Butch on April 18, 2006 at 10:26 AM | PERMALINK

"What makes him think single payer systems don't have paperwork on what is and what is not paid for?"
Posted by: McA

Yeah, Imagine a gov't program with NO paperwork.

The US spends between 6 and 7% of its GNP on healthcare paperwork. AFAIK, no other country spends in excess of 1%. Thems the facts. Spin away, Lurker.


(seriously, you look like an idiot to us non-Merkans listening in)

Posted by: snicker-snack on April 18, 2006 at 10:36 AM | PERMALINK

Al: your argumetns are not meaningful. We currently have rationing in the United States: many insurances limit specialist access, and many (most, if not all) limit medications. As a doctor, I am daily, hourly, confronted with what science says is best, but denied by insurances, becasue they tend to lag in adjusting payouts. The kicker for me is that a good proportion of my patients are uninsured altogether. They stop taking their diabetes medicines, and then visit the Emergency Department when they have their stroke or heart attack. Guess who pays that? you got it, the government, which means, the bulk of legal immigrants who actually pay their taxes. The right is whitewashing this, and the left is too loony to really approach this, but we already have governmental health care. it is jsut too disorganized and too little too late when patients arrive in the ER.

Posted by: Chris on April 18, 2006 at 10:38 AM | PERMALINK

I suppose you carry super glue in your purse, next to your SPF 30 lip balm?

Geez, you say that like it's a bad thing. Next you'll be ranking on my Epilady-as-self-defense-tool (snaps to Sparkle Hayter, and I wish I'd had it last week).

Posted by: shortstop on April 18, 2006 at 10:42 AM | PERMALINK

snick: (seriously, you look like an idiot to us non-Merkans listening in)

Just to non-Merkans? Hey! Leave us in this!

Posted by: shortstop on April 18, 2006 at 10:44 AM | PERMALINK

Just to non-Merkans? Hey! Leave us in this!

sorry, shortstop. You're in of course!

I just meant that there is no consituency anywhere, anywhere for a move to a US-style system (doesn't this ever give them pause?) and to anyone who's experienced healthcare outside the States this whole argument just seems weirdly surreal.

Posted by: snicker-snack on April 18, 2006 at 10:52 AM | PERMALINK

I knew what you meant, snick. I was just funnin' with you. This whole argument is also weirdly surreal to the U.S. citizens who are actually awake.

Posted by: shortstop on April 18, 2006 at 10:53 AM | PERMALINK

I would to say a heartfelt thanks to the Tom Brosz wing of the Veteran's Hospital in Portland, OR - Thanks, Tom, for all of your tax support - They provide excellent care for various maladies - The vets love your Darth Vader photo in the lobby.

Keep your money flowing, Tom.

Posted by: thethirdPaul on April 18, 2006 at 11:05 AM | PERMALINK

The largest obstacle to single payer is rhetoric like that of professor rat. Most Americans know that socialism doesn't work.

A single payer health program would, or should, be more like a public utility or police and fire service. Physicians feared the loss of autonomy but found it was worse in managed care. The insurance companies and especially the for-profit HMOs have had the power of size over doctors for years due to FTC rules about doctors forming associations to negotiate for fees. Some call those unions. The medical associations lost that fight years ago.

The best chance we had was a case called "Broadcast Music" in which songwriters retained the right to collectively negotiate for residuals on music they had written. The Maricopa County Medical Association tried to use that precedent in the 80s and lost to a liberal supreme court.

I have a history of national medical care systems in my book and Jay above is correct about the NHS. The Thatcher reforms actually fixed a lot of the problems with the NHS. They allowed private care and about 25% of souteast England (London and suburbs) have private insurance.

Canada made a big mistake when they banned private care. They wanted to be egalitarian but they caused a lot of the best doctors to emigrate and wound up with periodic scandals like CT scanners being used by vetinarians after hours for dog and cat scans (pun intended) when patients were waiting 6 months for a CT scan. The Canadians decided to emphasize general practice and penalize specialty care like surgery. Medicare is doing the same thing. Vascular surgery fees are down 75% in 10 years.

Most physicians, and almost all medical students, now support single payer. The problem is the rhetoric that comes from the left. We could end up with another Canadian system. I predict that Republicans and big business will be the ones to establish a single payer system. Not Bush as he seems to be too closely tied to big pharmacy, but the next Republican president may give it serious consideration. I think that will be McCain or Giuliani.

Posted by: Mike K on April 18, 2006 at 11:05 AM | PERMALINK

but I don't want to be paying money to a middleman who provides very little added value.~Jay

Jay shows again how dumb he is, even about arguments for the dark side. The "added value" of insurance coverage is that covered illnesses are paid for, up to policy limits, regardless of the amount paid in premiums by the insured. It's why it's called Jay. Or maybe you don't think it's a "value" to have your child's cancer treatments paid for even though you've only been paying health premiums for a few years?

Posted by: Ace Franze on April 18, 2006 at 11:21 AM | PERMALINK

Canada made a big mistake when they banned private care.

Canada banned private care? In which alternate universe did this happen?

Oh wait, no -- it's just another of the drunken moron Mike K's many lies.

Posted by: Stefan on April 18, 2006 at 11:23 AM | PERMALINK

Which, by the way, is why anyone who prefers "health savings accounts" or whatever they call them to insurance is an idiot.

Posted by: Ace Franze on April 18, 2006 at 11:24 AM | PERMALINK

"Thems the facts. Spin away, Lurker.


(seriously, you look like an idiot to us non-Merkans listening in)"
Posted by: snicker-snack

Um, that was supposed to be humorous. No spin intended.
Don't be-little yourself with useless name calling. It speaks poorly of your intelligence and your maturity.

Posted by: Lurker42 on April 18, 2006 at 11:27 AM | PERMALINK

"Canada banned private care? In which alternate universe did this happen?

Oh wait, no -- it's just another of the drunken moron Mike K's many lies.

Posted by: Stefan "

Stefan, you are more knowledgeable than many here but this time you don't know what you are talking about.

And thank you for showing how serious you are in an attempt to discuss a matter in which I have a lot of information. Maybe you should read my book. And, by the way, how are your books doing ? Haven't written any ? Oh.

Physicians in Canada are not allowed to bill the patient and cannot even practice if they do not have a billing number from the government plan. All services must be paid through the government plan and billing numbers have been rationed to control the number of physicians. To provide services to a patient and ask for payment on a private basis is a crime, if you have a government billing number.

I believe it is possible to open an office and offer medical care without a government number now but the number of patients who would choose this is tiny. If one did attempt this, however, you could not apply for a billing number. It would have to be all cash and there is no private insurance.

Medicare has a similar rule and a young woman physician who was offering additional services to geriatric patients not allowed by Medicare is being prosecuted, last I heard. This sort of behavior by the US government is responsible for the lack of enthusiasm for single payer.

The Canadian government has also reduced the number of positions in medical schools and nursing schools. When criticized for this they have responded that any deficiency will be filled with foreign graduates. Canadian kids are applying to US medical schools. Ironically, the situation has reduced the number of applicants to Canadian medical schools and they are now easier to get into than US schools.

Posted by: Mike K on April 18, 2006 at 11:39 AM | PERMALINK

The solution is simple, I've said it over and over again.

Each state should buy a controling stake in a health insurance provider. Using the plenary police power of the state, grant that provider with mandatory monopoly status inside its borders. Thus you have a single payer, universal semi-private health care insurance provider.

Competing health care providers could sell their policies within that state to the monopoly under eminent domain doctrine.

Alternatively, state could choose a strategy of merger with competing health care companies where it makes sense.

Regulate the monopoly.

In essence this is the telecom model circa 1979, a single payer, universal coverage by a private (though in this case, semi private) company overseen by a regulatory board.

The regulatory board would consist of representatives from the various interest groups: Doctors, Nurses, Consumers, Unions, Business People, Drug Companies, Hospitals, Education Providers, etc....

Then run the Regulatory commission the way you run the telecom regulatory commission.

A couple of things the regulatory commission could do right away is increase the number of doctors by increasing the number of seats in Medical schools. The number of Medical Seats has not chaned appreciatively since the 1950s, but the population has more than doubled. In conjunction, create schemes to alleviate budding doctors of high tuition debt.

This would allow for more doctors and better health care.

This could be done now by some enterprising "blue" state.

Remember, the state has pleniary police power within its boarders, and the power of eminent domain.

Posted by: E Publius on April 18, 2006 at 11:39 AM | PERMALINK

Canada banned private care? In which alternate universe did this happen?

Yeah, Canada did. And it happened in this alternate universe.

And a provincial high court found that the resulting care was so bad that it violated Canadians' human rights.

Sounds like that's exactly what the left wing wants for us.

Posted by: Al on April 18, 2006 at 11:44 AM | PERMALINK

I want to see someone propose something solid. Most of this discussion has been somewhat vague, particularly on how a transition would be made.

Most of the non-government health care money comes from companies who pay for insurance, now. One assumes that, if we don't want to stick the average citizen (currently thinking their employer-paid insurance is "free") with a huge tax hike, the money is still going to have to flow from employers. Is it going to be a balance with what they were paying for health insurance before? If so, or if single-payer comes off better, you've got something to sell. But someone needs to do the numbers.

Before looking to other countries, remember that they have a wide variety of systems. A good overview can be found at Ezra Klein's site. Some of these systems, in their current forms, haven't been in place that long.

I see England is no longer a shining example for liberals to show how well government health care works. I remember when it used to be.

***

NSA Mole:

Nowhere in his link is it ever proven that the single payer system has been scientifically proven to cause the higher death rate in medical procedures.

Correlation is not causation, Alistair.

True enough. Can we keep in mind that this also applies to statistics like life expectancy, infant mortality, and others?

***

Jay:

...citing no evidence to support this except the fact that their freshman economics textbook says that the "market" solution has to be the most efficient.

Overall, market solutions work better than centralized ones. "Most efficient" depends on your goals. A wide variety of choices is not necessarily "efficient" in terms of simplicity or use of resources. Obviously, if we only had one brand of car being manufactured in the U.S., it would use far fewer resources and time than dozens of different brands do. But is that what we want?

This example doesn't apply directly to single-payer medical care, which could still, if properly done, have all-important competition among providers (think "medical voucher,") but is intended to address your general point.

Posted by: tbrosz on April 18, 2006 at 11:44 AM | PERMALINK

(My apologies for repeating this yet again but for an interesting report on Healthcare CEOs "compensation" for just one year see this pdf file.)

Don't apologize.

For the slower amongst us repetition is the only way...

Posted by: obscure on April 18, 2006 at 12:04 PM | PERMALINK

Really, it comes down to this:
Is health care something that you believe all citizens should have access to, like clean water? Or is it a consumer good, like DVD players?

Answer that, and you assign yourself a position on the merits of single-payer vs the current American fiasco (whoops, I tipped my hand).

Posted by: craigie on April 18, 2006 at 12:21 PM | PERMALINK

The Thatcher reforms actually fixed a lot of the problems with the NHS. They allowed private care

Private medicine has existed alongside the NHS since the NHS was founded. The Thatcher "reforms" didn't make the NHS better, Blair's government had to do a lot to get it back to where it was before her... (he is now ruining it again).

Posted by: jayann on April 18, 2006 at 12:22 PM | PERMALINK

Really, it comes down to this:
Is health care something that you believe all citizens should have access to, like clean water? Or is it a consumer good, like DVD players?

Yes.

Posted by: Red State Mike on April 18, 2006 at 12:36 PM | PERMALINK

Single payer is a good idea but its primary objective should not be to make the life of a doctor easier.

Medical practice is a business, and of course you have to employ people to collect bills.

How many people does Microsoft employ to collect payments from the customers? How many does Boeing? Dr. Brewer hs the right solution, but for the wrong problem.

Posted by: lib on April 18, 2006 at 12:48 PM | PERMALINK

"The Canadian government has also reduced the number of positions in medical schools and nursing schools."

Actually , it's the privately run medical associations that have the most control over the numbers of doctors in this country.

It is true, however, that most of the problems (an dyes, there are problems, nothing is perfect) in the Canadian system right now stem from a lack of support from the Federal government. But that's very different from being the result of a single payer system. The British examples are a good illustration of what happens when a good single payer system is watered down with privatization and "market solutions".

It amazes how the same people who are so frightened of giving up autonomy to a single payer system operated by a democratically elected government which is answerable to the people and audited publicly have no problem ceding even more of their autonomy to a host of privately run insuarance companies who answer only to the bottom line.

People are not well served by treating their health like a commodity. When I or my loved ones need medical treatment we go to the doctor we choose and decide with him/her what treatment options are best and then proceed. Medical decisions are made on the basis of medical need, not on the basis of some pencil pusher's actuarial tables. We don't need to get approval from an HMO or our insurance agent, no bills are sent, no one has to mortgage their home to pay for the surgery, no one has to worry about their premiums increasing...and it costs Canadian taxpayers less per capita than the allegedly private system in the US.

Posted by: A Hermit on April 18, 2006 at 12:48 PM | PERMALINK

craigie asked: Is health care something that you believe all citizens should have access to, like clean water? Or is it a consumer good, like DVD players?

There are those who believe that clean water is not something that all citizens should have access to, but a "consumer good" like DVD players.

Why should you get clean air and clean water without paying for it? That's communism.

Posted by: SecularAnimist on April 18, 2006 at 1:20 PM | PERMALINK

Lurker42: Don't be-little yourself with useless name calling. It speaks poorly of your intelligence and your maturity.

Look in the mirror.

Mike K: I have a lot of information.

GIGO.

Posted by: Advocate for God on April 18, 2006 at 1:28 PM | PERMALINK

A form of socialized medicine already is running rampant in cities like Los Angeles, where many low-income people, a high percentage of them illegal immigrants, receive treatment they don't pay for. Consequently, quite a few emergency room in such cities are shutting down. That's in spite of voters in LA County, as one example, two years ago approving an increase in property taxes to pay for such services.

Posted by: Tim on April 18, 2006 at 2:00 PM | PERMALINK

Well the answer there is obvious. We just give some property to low-income people, and then when they pay taxes on it, there's plenty of money!

Sheesh, some people are so negative...

Posted by: craigie on April 18, 2006 at 2:33 PM | PERMALINK

SecularAnimist:

Why should you get clean air and clean water without paying for it? That's communism.

Somebody has to pay for anything that requires human effort and skill to deliver. Where the arguments come in is who pays, and what choices they have in the matter.

Posted by: tbrosz on April 18, 2006 at 2:38 PM | PERMALINK


Applause for you, Craigie. You've hit it precisely on the head. As long as private industry has control of the healthcare system, healthcare gets treated like a business product. What do businesses care about? Profits. That's it. At the end of the day, all they care about is profits. They don't care about providing you the best care or making sure everyone has access. They're just concerned, deep down, about how to make money. Hence the denial of perfeclty legit claims (I've experienced that one personally) and all sorts of nonsense rules about what drugs and procedures are "approved" and which are not. If you want your health, your LIFE, to actually be in the hands of a trusted physician rather than some guy in a suit running after profits, then you should be screaming for a single-payer system. If you want to be able to choose your doctor instead of being restricted to the all-powerful "Network", you should be screaming for a single-payer system. If you want to sleep soundly at night knowing that you and your loved ones will get the care they need no matter WHAT should happen, for better or for worse and in sickness and in health, you should be screaming for a single-payer system.

Posted by: brainchild on April 18, 2006 at 3:01 PM | PERMALINK

"The Thatcher reforms actually fixed a lot of the problems with the NHS. They allowed private care

Private medicine has existed alongside the NHS since the NHS was founded. "

The unions in about 1975 began to refuse to care for private patients in NHS hospitals. Before that it had been tolerated. The specialists moved their private practices to Belgium. There was a small scandal when a Labour minister of health had her GYN surgery in Belgium.


"The Thatcher "reforms" didn't make the NHS better,"

Well, let's say more efficient, which may be a characteristic that does not appeal to you. I was one of the American physicians who went over to the West Riding of Yorkshire to help them adapt to the reforms. The principle one was called "fund holding" and it gave a lot more power to the GPs who had been ignored by district hospitals for years. The GP was given the power to send his patients to other hospitals and to require specialists to communicate with him (or her) if they wanted referrals.

"Blair's government had to do a lot to get it back to where it was before her... (he is now ruining it again)."

Blair kept much of the Thatcher changes but renamed them to make socialists, like you, happier. If you want to know more, you'll have to read my book.

Posted by: Mike K on April 18, 2006 at 3:30 PM | PERMALINK

I'm surprised no one has mentioned (unless I missed it in my scan of the comments) that the front page of today's Wall St J features an article on how the middlemen in the American system (in this case the CEO, United Health) are making out like bandits even as patients and doctors are being forced to cut back. United's ceo is now worth over $1B! Clear evidence of the scale of "friction" costs imposed by the various middlemen responsible for administering insurnace plans, managing risk, etc - imagine how much more efficient it would be to have this $ directed into actual medical care.

Posted by: Aidan on April 18, 2006 at 3:32 PM | PERMALINK

I'm surprised no one has mentioned (unless I missed it in my scan of the comments) that the front page of today's Wall St J features an article on how the middlemen in the American system (in this case the CEO, United Health) are making out like bandits even as patients and doctors are being forced to cut back. United's ceo is now worth over $1B! Clear evidence of the scale of "friction" costs imposed by the various middlemen responsible for administering insurnace plans, managing risk, etc - imagine how much more efficient it would be to have this $ directed into actual medical care.

Posted by: Aidan on April 18, 2006 at 3:33 PM | PERMALINK

One can rave on forever about how "right" it is, but nothing can happen until we clean the cess pool that is Washington , D.C.!! First thing to do when the shit hits the fan, is SHUT OFF THE DAMN FAN!!!!!!

Posted by: Grouchy Cowboy on April 18, 2006 at 3:47 PM | PERMALINK

"A form of socialized medicine already is running rampant in cities like Los Angeles, where many low-income people, a high percentage of them illegal immigrants, receive treatment they don't pay for..."
Posted by: Tim on April 18, 2006 at 2:00 PM | PERMALINK

So should treatment depend on your income? More taxes paid = better care?

Did you know that Americans actually spend more tax money per capita for their allegedly private system than Canadians do for their allegedly "socialist" one? At least we all get something for our money, unlike the 16% of Americans who have no coverage at all.

Posted by: A Hermit on April 18, 2006 at 3:56 PM | PERMALINK

Hmmmmm, a 25% RIF in the Clerical/IT side of the health industry if we go single-payer? Some people might not be too thrilled to hear that....

Posted by: Doozer on April 18, 2006 at 4:19 PM | PERMALINK

I suppose you carry super glue in your purse, next to your SPF 30 lip balm?
Posted by: Red State Mike on April 18, 2006 at 10:13 AM | PERMALINK

I carry it along in my toolbox, I also have some .025 safetywire and some safetywire pliers, and a 32 oz ball peen hammer, I have used them to sew peoples lips back together, would you care to see me perform that, all I need is a volunteer, How about You? After Im done sewing your sissy lips back together, with that wire, I'd like to show you the intake of a Jet Engine whiles it's running at full military takeoff power. You don't know sheeaht office boy, I suggest you climb off that "Fairy" Phobia you got and stop putting your " GAY Imagination" sheeat on me. Cause the only thing I got for another Mans ass is my size 12 workboot..

Posted by: one eye buck tooth [X^B on April 18, 2006 at 4:54 PM | PERMALINK

There's another argument to be made in favor of single payer, regarding costs paid by consumers, whether individuals, small businesses, or corporations.

I'm thinking of a reduction in insurance costs across the board...

Think about it:

How much less will your homeowner's insurance premium be without medical liability for accidents on your property?

How about your car insurance premium, if your car coverage only has to cover property damage, and not medical costs of injuries?

Would a business need to carry any liability coverage at all, other than for property damage?

Would the entire Worker's Compensation policy simply go away? Or would it just have to pay for lost time, but not the medical costs associated with job-related injuries? I can see small business owners around the nation whooping with joy over that one...

I haven't seen this discussed much at all, and admittedly don't know a lot about the insurance industry, but it seems to me like a real single-payer system would substancially reduce ALL insurance premiums and even eliminate a few completely. Any insurance experts out there?

I know a few small business owners who would be willing to pay higher taxes, if it meant eliminating their health care premiums, worker's comp premiums, reducing their other insurance costs, and lightening their own paperwork load.

Insurance costs are a huge load on small businesses, and are often the major hurdle for anyone wanting to start one, or expand one with new hires.

What effect has Canada's system had on the REST of their insurance industry? Have they seen any reduction in non-health premiums for businesses, individuals, car owners, homeowners, etc.? Does anyone have any data on that? How would one find out?

Posted by: RobW on April 18, 2006 at 8:48 PM | PERMALINK

"There's another argument to be made in favor of single payer..."

Yes, the author of the article says something about how you will need to link universal coverage with malpractice reform to sweeten the pot for doctors, but as you point out much of the cost of medical malpractice simply vanishes under universal coverage. When everybody is fully covered there is no need to sue for future medical costs because they are already taken care of. You still have lost wages, pain and suffering, punative damages, etc but health care as a result of a mistake is a big item in malpractice and it can leave the realm of litigation completely.

I presume there are insurance statistics in canada from whoever regulates insurance. A good comparison might be washington state and british colombia, which are similar in many ways. The washington state insurance commissioner's office should have piles of data about insurance rates and awards. Might even be available on the state website.

Posted by: jefff on April 18, 2006 at 9:06 PM | PERMALINK

"much of the cost of medical malpractice simply vanishes"

I mean much of the cost that must be dealt with through malpractice insurance, of course.

Posted by: jefff on April 18, 2006 at 9:07 PM | PERMALINK

The "added value" of insurance coverage is that covered illnesses are paid for, up to policy limits, regardless of the amount paid in premiums by the insured. It's why it's called Jay. Or maybe you don't think it's a "value" to have your child's cancer treatments paid for even though you've only been paying health premiums for a few years?

I understand the value-add of risk pooling. I probably understand it better than you do. But the value-add you get from it is apparently worth about 2% of the overall cost of the health care, because that's what it costs in the UK and France and Germany and here under Medicare ad the VA, and not 20%, which is the premium that we pay for it from private insurance. I want my 18% back.

Posted by: Jay on April 18, 2006 at 10:23 PM | PERMALINK

I agree. I favor going to a single payer system. I've got most of the disadvantages of being a federal employee already. I'd enjoy some of the advantages.

It's easier to appeal an adverse coverage decision from Medicare than from an HMO. You need the patient's home address so you can find his Congressman. If you don't know who the Congressional representative for that address is, call any congressman's office and ask. They'll give you the right representative's name and office phone number.

Telephone that office. Ask for a case worker. Tell him or her the patient's story, starting with, "Your constituent, who's my patient, needs help with Medicare."

I had the gratifying experience of doing just this for a patient within the last month. She was an elderly diabetic who had a toe amputated months ago. The stump was very slow to heal, but with hyperbaric treatments it was finally, clearly, improving. Then the hospital wanted to transfer her from its "skilled nursing facility" (a separate floor that bills Medicare as a nursing home would) back to her long term nursing home. It seemed there was no coverage for the last three weeks of treatments she needed. Some new interpretation of coverage rules left a 'crack' in the coverage, and the patient was about to fall through that crack. Fortunately, an inquiry from her Congressman's office created enough cage-rattling that Medicare, the hospital, and the nursing home came up with some arrangement and agreement on what to do, who'd pay, and who'd punt some billings. It probably wasn't the ideal solution, but now the parties can grope toward that at their leisure, without the added pressure of finger-pointing about who is at fault for the patient losing her whole leg.

Posted by: duvidil on April 19, 2006 at 1:16 AM | PERMALINK

When I or my loved ones need medical treatment we go to the doctor we choose and decide with him/her what treatment options are best and then proceed.

Posted by: A Hermit on April 18, 2006 at 12:48 PM | PERMALINK

That's only possible because there's no private system, in effect the only doctors you have to choose from are those the government provides, who've agreed to work on government rates. Its like a big HMO. You have choice only within the doctor's who've signed up.

Any bright kid, who chooses not to go South and pursue US medical qualifications implicitly signed up for the big All Canadian HMO.

Given that US doctors earn lots, lots more, you have to wonder if Canada will attract the best and brightest to its medical profession.


Posted by: McA on April 19, 2006 at 1:36 AM | PERMALINK

I want my 18% back.

Posted by: Jay on April 18, 2006 at 10:23 PM | PERMALINK

Migrate then. But those countries would only let in young persons with a prospect of good incomes and tax dollars to pay for their future burdens (except for refugees)

Posted by: McA on April 19, 2006 at 1:38 AM | PERMALINK

I agree that a single-payer health care plan similar to what Senator John Kerry had proposed in the 2004 presidential elections would be best: the same health care that the U.S. president, vice president, cabinet, and members of Congress presently use.

What's good for the "employees" (US polticians) would be good for the "employers" (all U.S. citizens) as well without adding an additional bureaucracy.

Posted by: Jesse A. Weissman on April 19, 2006 at 1:59 AM | PERMALINK

one eye buck tooth:

I'd like to show you the intake of a Jet Engine whiles it's running at full military takeoff power.

I found a film clip of you doing this. It explains a lot.

Posted by: tbrosz on April 19, 2006 at 2:16 AM | PERMALINK

Most physicians, and almost all medical students, now support single payer. The problem is the rhetoric that comes from the left.
Posted by: Mike K

This is an unequivocally asinine statement, likely made by someone nowhere near qualified enough to attend a US med school ... and not at all reflective of the local or nationwide sentiment among young MDs or med students when I graduated.

Posted by: Nads on April 19, 2006 at 3:04 AM | PERMALINK

Actually Nads, the docs that I currently work with mostly out-liberal me, but even at my last job the Republican docs were pro-single payer here in Southern California.

I've looked into immigrating to Canada and the "lots more" that I make in the US is actually not that big a difference. Now, if only the spouse weren't such a wimp about cold weather....

Posted by: J Bean on April 19, 2006 at 6:15 AM | PERMALINK

"That's only possible because there's no private system, in effect the only doctors you have to choose from are those the government provides, who've agreed to work on government rates. Its like a big HMO. You have choice only within the doctor's who've signed up..."

Wow.

I mean, WOW!

"the only doctors you have to choose from are those the government provides, who've agreed to work on government rates."

Yeah that would really narrow the choice down to, ummmm, every doctor in the country...

The complete and utter failure to grasp the workings of Canadian health care evident in that comment is truly astounding...

The government doesn't "provide doctors" and they don't "sign up for" anything. They go to school, get their degree and are liscenced by the provincial Medical Association, which is run by THE DOCTORS not THE GOVERNMENT. I go to the doctor I choose, the bill goes to the government which pays out of an insurance fund created with tax dollars according to a fee schedule which is consistent, uniform and based on realistic costs determined, again, by the medical profession itself not on some insurance company's desired profit margin.

There's no HMO, no one to tell me which doctor I can or cannot go to, and my costs don't go up if I get sick.

How do you think this works, McA? You think I have to get approval from the government to see a doctor? It ain't like that. I decide if I need medical advice, I call my doctor (or go to a walk-in clinic if I'm in a real hurry, or the emergency room if it's life threatening) and I see teh doctor I've chosen to see (who makes a very nice living, thank you very much). There are no forms to fill out, no means tests, no on asks "how will you be paying for this", sends me to different hospital or clinic, tells me I have to get a second opinion, or that I can't use the doctor I've chosen.

Oh yeah, it's terrible having my choices limited to...whatever I decide is best for me and my family...and paying less than you do for the priveledge.

LMAO...;-)

Posted by: A Hermit on April 19, 2006 at 12:28 PM | PERMALINK

For the moonbats like Stefan, here is today's New England Journal public article

http://content.nejm.org/cgi/content/full/354/16/1661?query=TOC

Note the absence of private care by physicians. That and the lack of copay were the principle mistakes. The GPs waiting rooms are full of "worried well" and surgery is rationed.

I love how the dopes all include personal snarks like "asinine" when someone is trying to educate them. I'm an advisor to students for a national health plan.

Posted by: Mike K on April 19, 2006 at 6:42 PM | PERMALINK




 

 

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