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Tilting at Windmills

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August 30, 2006
By: Kevin Drum

THE BEST CARE ANYWHERE....Thanks to innovations introduced during Bill Clinton's administration, VA healthcare is now among the nation's best. It's cheaper than either private healthcare or Medicare, the quality is top notch, and it operates according to strict performance standards. Sounds like a great model, doesn't it? So how about saving the feds money by allowing vets on Medicare to switch over to the VA? Time magazine says it's no dice:

Conservatives fear such an arrangement would be a Trojan horse, setting up an even larger national health-care program and taking more business from the private sector. Congress has no plans to enlarge the scope of veterans' health care much less consider it a model for, say, a government-run system serving nonvets. But it's becoming more and more "ideologically inconvenient for some to have such a stellar health-delivery system being run by the government," says Margaret O'Kane, president of the National Committee for Quality Assurance, which rates health plans for businesses and individuals. If VA health care continues to be the industry leader, it may become more difficult to argue that the market can do better.

It might indeed become difficult. But not impossible! Give 'em time and I imagine that Bush will do the same thing to the VA that he did to FEMA, another Clinton bureaucratic success story.

It turns out that the reasons for the VA's success are pretty straightforward: there are inherent advantages to managing all of a patient's healthcare needs over a long period, something that simply doesn't happen in the pseudo-private market that most of us deal with. Phil Longman wrote about the VA miracle for the Washington Monthly last year and explained the problem with our current healthcare model this way:

As Lawrence P. Casalino, a professor of public health at the University of Chicago, puts it, The U.S. medical market as presently constituted simply does not provide a strong business case for quality.

....Suppose a private managed-care plan follows the VHA example and invests in a computer program to identify diabetics and keep track of whether they are getting appropriate follow-up care. The costs are all upfront, but the benefits may take 20 years to materialize. And by then, unlike in the VHA system, the patient will likely have moved on to some new health-care plan. As the chief financial officer of one health plan told Casalino: Why should I spend our money to save money for our competitors?

....For health-care providers outside the VHA system, improving quality rarely makes financial sense....Investing in any technology that ultimately serves to reduce hospital admissions, like an electronic medical record system that enables more effective disease management and reduces medical errors, is likely to take money straight from the bottom line. The business case for safetyremains inadequate[for] the task, concludes Robert Wachter, M.D., in a recent study for Health Affairs in which he surveyed quality control efforts across the U.S. health-care system.

As it happens, the VA model isn't the one I'd choose if I were inventing a national healthcare system for the United States. But it would probably be one component of it. And it demonstrates pretty conclusively that even in an older, sicker population, a national healthcare system can provide low-cost, high-quality service. We could do the same for every person in the country if we only had the will.

Kevin Drum 12:21 PM Permalink | Trackbacks | Comments (79)

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Give 'em time and I imagine that Bush will do the same thing to the VA that he did to FEMA, another Clinton bureaucratic success story.

You're probably right. Look at all these right-wing blowhards talking about how the Katrina failures "proved that big government doesn't work" when in reality, those government agencies run and staffed by professionals, such as the Coast Guard and the Postal Service, functioned brilliantly. It was just the agencies run by right-wing hacks, like FEMA, that failed miserably. Same with the VA. To the extent that it's run by professionals, it's working. They'll have to break it, and if they screw the vets who rely on it that's just too bad.

Why do these vets hate America?

Posted by: mister pedantic on August 30, 2006 at 12:28 PM | PERMALINK

But...but...Canada! Traffic jams full of Canadians streaming across our border looking for hip replacements!! The m-m-market! SOCIALIZED MEDICINE, DAMN YOU!!!

Posted by: Wonderin on August 30, 2006 at 12:35 PM | PERMALINK

Any thoughts on the California single-payer bill that just passed?

California Assembly approves universal health care.

I've been surprised how little discussion it's received.

Posted by: ferg on August 30, 2006 at 12:36 PM | PERMALINK

Ferg

It hasn't passed yet, although it is expected to get through the Senate. But the proof of the pudding, in this case, is in the funding, and Sheila Kuehl's bill doesn't take care of that. It's expected to be funded through income and payroll taxes -- so far so good by my lights -- but, um, there is some way to go yet. I hope it is done, and done well. Can't happen too soon.

Posted by: Wendy on August 30, 2006 at 12:41 PM | PERMALINK

there are inherent advantages to managing all of a patient's healthcare needs over a long period

This was, of course, the argument for group practices like HMOs made by Alain Enthoven in the late 70s. The idea was a large private organization like Kaiser Permanente was a more efficient health care delivery vehicle,because the organization had an incentive for providing cheap preventitive care rather than expensive hospitalization. The fee for service system at the time was in fact being abused--unnecessary operations like hysterectomies were common.

But the theoretical HMO model got hijacked by insurance companies, who, in principle, should have become obsolete under an HMO system.

It looks like the private sector simply doesn't belong in the health care arena.

Posted by: JayAckroyd on August 30, 2006 at 12:42 PM | PERMALINK

Sounds like a great model, doesn't it? So how about saving the feds money by allowing vets on Medicare to switch over to the VA?

CLICK THE LINK. ALWAYS CLICK THE LINK. Kevin CONVENIENTLY doesn't point out the long waiting periods of 30 days or more just to get the first appointment.

Link

"Vets still gripe about wading through red tape for treatment. Some 11,000 have been waiting 30 days or more for their first appointment."

Posted by: Al on August 30, 2006 at 12:45 PM | PERMALINK

"We could do the same for every person in the country if we only had the will."

This is the important question do we have the will. We need to protest and demand a national healthcare system so everybody, not just the rich, can have access to quality healthcare. If you can't afford it, you will die anyways.

Posted by: dee on August 30, 2006 at 12:51 PM | PERMALINK

But it would probably be one component of it. And it demonstrates pretty conclusively that even in an older, sicker population, a national healthcare system can provide low-cost, high-quality service.

Building on a thread from yesterday, does the existence of this high quality medical care constitute an improvement in the wealth of this segment of the US, or a diminishment of the wealth of theis segment? I would say that this system is one example of the increased wealth of poor people in the US since the early 50s.

That's a separate question from the question of how health care can be optimally delivered.

Looking at healthcare in the aggregate, the improvement of healthcare in the US since the early 50s constitutes and increase in the wealth of the US since the 50s (otherwise no one would work or spend money to get it). Many people work harder, or more married couples have both spouses working, in order to pay the people who provide the healthcare, but the improved healthcare definitely constitutes increased wealth.

A few examples: in the early 50s, about 45,000 people died per year in auto accidents; now the figure is about 35,000, with more drivers and many more miles driven.

In the early 50s about 45,000 people per year contracted paralytic polio, but now the number is 0. the increased lives are increased wealth for America and for those who lived.

In the early 50s there were no relible cures for any cancer, or even agents that prolonged life somewhat. Now plenty of cases of cancer are cured, and many lives are prolonged by surgery and chemotherapy.

There haave been three serious setbacks since then.

The increased tobacco use of the 40s and 50s led to many shortened lives in the following years, but that epidemic is abating.

The VietNam war dramatically reduced the wealth of the US and the lives and wealth of many particular Americans.

The invention of HIV by mother nature and its introduction into the US have led to enormous expenditures that might have been directed elsewhere, and to the loss of life and health by millions of Americans.

But back to the main point. Do you think that the growth of the VA medical system since the early 50s constitutes an increase in the wealth of the poor and elderly vets? I think so, even though the wealth requires extra work to achieve it, and even though the health care system in the aggregate requires some repair.

Posted by: republicrat on August 30, 2006 at 12:57 PM | PERMALINK

Sorry Al, but waiting times of 60 days or more are routine for my private health-care provider.

Posted by: Steve on August 30, 2006 at 12:57 PM | PERMALINK

Of course the VA's software system is available as open source (and has been for years) for any plan that would like to implement it.

Posted by: jjj on August 30, 2006 at 12:58 PM | PERMALINK

Traffic jams full of Canadians streaming across our border looking for hip replacements!!

Well, those too. But the larger migration is among doctors and nurses and other medical technicians.

Posted by: republicrat on August 30, 2006 at 12:59 PM | PERMALINK

Hey, Al, who covers you? Because I just had to wait 5 weeks to get in to see my primary care physician to get a referral to a dermatologist, for whom I had to wait 4 weeks, to get help with a case of cellulosis. Not a huge problem, but it took me 9 weeks to get treated. And this is with a Primary Care Physician with whom I, in theory, already have a relationship.

This, of course, is after a case last year of walking pneumonia that I suffered with for over 5 weeks because I could not get in to see her. Welcome to my world.

First appointments in my health care system take 5-8 weeks. And this costs significantly more than the VA system for each person enrolled.

Click the link. I agree. But let me know what you pay and with whom you have insurance, please, because 30 days, though annoying, sounds pretty good to me. It's certainly better than Blue Shield CareFirst Open Access.

Posted by: Ron on August 30, 2006 at 1:01 PM | PERMALINK

The front desk at my primary care doctor's office offered me an appointment a month away when I called in and said I had a severe cold with a severe sore throat (I could barely speak at that time). I asked if there was another doctor available, or a physician's assistant. Nope, she helpfully replied, not until the end of the next week. I ended up going to the urgent care facility in the nearest hospital so that I could get antibiotics for my severe sinus infection.

The private sector can beat the public sector at incompetence any day, due to the desire to hire the cheapest labor possible in order to maximize profits.

Posted by: Carol on August 30, 2006 at 1:03 PM | PERMALINK

I have been using the VA for five years -- since I lost my job and private medical benefits.

In that time the local Akron, Ohio VA clinic moved from a run down, overcrowded inner city site to a new stand alone building with amenities of a well-run HMO.

The local people are caring and competent. Major tests and high specialties (kidney dialysis, etc.) require going to Cleveland (40 miles away).

The kidney services are so overloaded that it takes 6-months to see a specialist for a new patient. Other high-end specialties have similar waits.

The VA distributes a blood glucose analyzer for free to diabetics and gives free test supplies. A great benefit, equivalent to Medicare.

But the VA unit, though recently upgraded, is slow, takes more blood to work, and has some flaky components that break. It is not quality-equivalent to the units used in the private sector (and is not sold publicly).

The VA pharmacopia is limited and does not offer the "latest and greatest" drugs available in the private sector. Even when they offer them they push the use of older generics first. Only if you have an adverse reaction to the old stuff do you get to the premium drugs.

In sum, I think the VA service shines in routine care. For high-end stuff you should look elsewhere.

Posted by: Mike on August 30, 2006 at 1:08 PM | PERMALINK

it's already happened. the VA is dreadfully overburdened, underfunded, and teetering on the precipice...just like the everything else that Bush has touched.,

Posted by: susan on August 30, 2006 at 1:09 PM | PERMALINK

The VA used to be the place where incompetent doctors went to commit malpractice, but since Clinton started his reforms, the VA has dramatically improved its medical staff. Now they are often among the best and the brightest. Why, well in the VA system they are allowed to spend more time with each patient. They feel they can spend time looking at long term care issues, something they could never do in their insurance driven private practices. While the gross pay is adequate, the net pay is superior, especially since they are permitted to practice the kind of medicine they love.

Posted by: Ron Byers on August 30, 2006 at 1:14 PM | PERMALINK

Hey, Al, who covers you?

Who do you think?

His mommy: either through direct intervention (putting a band-aid on his ouchies) or through her health-care plan (for his bed sores from sitting in bed and trolling blogs on his laptop).

Posted by: NSA Mole on August 30, 2006 at 1:14 PM | PERMALINK

Even when they offer them they push the use of older generics first. Only if you have an adverse reaction to the old stuff do you get to the premium drugs.

This is exactly what health care providers should be doing anyway! There's no need to use the latest and greatest if the old, much cheaper stuff works anyway.

Posted by: Milind on August 30, 2006 at 1:15 PM | PERMALINK

Anecdotes are like assholes--everbody's got one, but nobody really wants to look at the other guy's.

We could do some less-than-socialistic things with our current healthcare while maintaining our precious overpriced private insurance system. For example, why not a national medical record/patient management system, to which hospitals, doctors and pharmacies are required to subscribe if they want any reimbursement from Medicare? Would also handle Medicare billing directly, and other billing by subscription. That would solve most of the patient record and prescription error problems. Probably couldn't do it under this administration and congress, because they're so incompetent at contract oversight. Long-term, we're going to need a national single-payer system, or maybe 50 state single-payer systems just to make sure we keep IBM, EDS et. al. at full employment, but without a national patient information system, we still have the patient record problems that cause so much inefficiency and error today.

Posted by: me2i81 on August 30, 2006 at 1:26 PM | PERMALINK

Kenneth Kizer's "Vision for Change," his original presentation for reform, is here.

Kizer didn't seek renomination for his position in 1999, meeting the fate of many visionaries in government who try to cut costs and spending.

Posted by: Ein on August 30, 2006 at 1:27 PM | PERMALINK

Fine, if you like the VA, sign up and join the military. I'll keep seeing a doctor immediaely when I need to, instead of waiting 30 days. Advantage: Free market. My PPO kicks ass.

Posted by: American Hawk on August 30, 2006 at 1:28 PM | PERMALINK

For health-care providers outside the VHA system, improving quality rarely makes financial sense....Investing in any technology that ultimately serves to reduce hospital admissions, like an electronic medical record system that enables more effective disease management and reduces medical errors, is likely to take money straight from the bottom line.

I think that is the a insight. People other than Vets frequently object to having their medical information shared. HIPAA is supposed to facilitate the sharing of information among all health professionals by providing safeguards to privacy. Health care professionals have wanted for a long time to build an integrated national database of health information, like but more complex than the national database of financial information that you use when you buy gasoline with a credit card or ATM card. With HIPAA and other legalistic recognitions of privacy rights, such a database may yet be constructed.

Posted by: republicrat on August 30, 2006 at 1:28 PM | PERMALINK

I'm a vet with many years experience with the VA. I have few complaints and can offer only anecdotal assurances that it's better now than it ever was. George The First made some demoralizing cuts, but Clinton restored and expanded the program; the irony, of course, being that the war hero apparently didn't give a damn for vets, whereas the draft dodger was the soul of compassion.

Posted by: buddy66 on August 30, 2006 at 1:34 PM | PERMALINK

This, of course, is after a case last year of walking pneumonia that I suffered with for over 5 weeks because I could not get in to see her.

For this you can go to urgent care (at the emergency room) and get same-day treatment. You just need to be sure that they notify your primary care physician. you have to wait while auto accident victims and 105F fevers are treated, but you'll get care.

I did that when I had scabies a few years back. I got immediate effective treatment, and a follow-up appointment in a (quite busy) dermatology clinic just a week later.

Posted by: republicrat on August 30, 2006 at 1:37 PM | PERMALINK

I understand that some people are always going to be on the fringes--those who believe in libertarian and socialist ideas, for instance--but most people, even the very conservative and very liberal voters don't seem to pretend their beliefs are entirely without fault. So why, if government involvement in health care is indeed better, is it impossible for conservatives to admit this? Do they really feel this is one step in the direction of nationalizing car production and housing construction? If so, I don't understand why, because I don't know of many people under the impression a goverment-run construction company would do any better than the private sector.

Posted by: Brian on August 30, 2006 at 1:44 PM | PERMALINK

> For example, why not a national medical
> record/patient management system, to which
> hospitals, doctors and pharmacies are required
> to subscribe if they want any reimbursement
> from Medicare?

Since the VA did their database on the quiet, they were able to use Open Source tools and techniques (in fact I think their software has a GPL license). Were that to be done nationwide by law, there would have to be bidding. And guess who would win that bid? Can you say "large boondoggle contractors"? I thought you could. Cf the FBI case management system.

Cranky

Posted by: Cranky Observer on August 30, 2006 at 1:51 PM | PERMALINK

"Fine, if you like the VA, sign up and join the military. I'll keep seeing a doctor immediaely when I need to, instead of waiting 30 days. Advantage: Free market. My PPO kicks ass."

Once again Republicrat and the Hawk are missing the point. Your PPO kicks ass because you, or your employer, are paying a ridiculous amount for it. I elect for the HMO Family at my work and it costs a total of $930 a month of which I thankfully pay only $110. The PPO options are all quite a bit more. We are getting ripped off! If you were in a nationalized and integrated system (like the VA), and you worked for a benevolent employer who passed the savings on to you, you'd be taking home a few extra dollars a month, the whole nation would be insured, and your long-term
health would improve.

My theory with conservatives is that they use up all their imagination wondering what some other skinned person is trying to kill them or steal from them, leaving no imaginative capacity to make their world a better place to live in. It must suck being scared all the time while stuck in the past.

Posted by: kj on August 30, 2006 at 1:51 PM | PERMALINK

Sometimes I wonder - Have the conservatives who complain about waiting lists for appointments in national healthcare systems ever made an appointment for a doctor in our system?

I have a typical employer provided insurance plan - the classic American system. I've routinely had to wait to see doctors. It took me 6 weeks to see a dermatologist to look at a birthmark; and when I made the appointment the secretary said I was lucky because someone had just canceled. Waiting lists aren't nearly this bad in wealthy countries (e.g. France) that run an efficient national health.

Posted by: keptsimple on August 30, 2006 at 1:55 PM | PERMALINK

Al nails it!

If we let government work, people would like government! Much better to just take taxpayer dollars and give it to Republican donors!

Posted by: Freedom Phukher on August 30, 2006 at 1:55 PM | PERMALINK

I work hard. I studied hard in school. I went into engineering partly for the pay and security and believe me a ba in history at U-Party would have been a lot more fun. I thinnk more people should work harder. I pay a lot in taxes and I'm okay with that. Government is prety good here. But i really do think that if you need surgery and it costs a lot of money and it takes you years to pay of the hospital, thats okay.

Posted by: joe on August 30, 2006 at 1:59 PM | PERMALINK

American Hawk:
"I'll keep seeing a doctor immediaely when I need to, instead of waiting 30 days."

Do you have a personal doctor on call 24 hours a day?

I'm not aware of anyone who can waltz into their doctor's office and say, "I need to see the doctor now". You need to make an appointment.

And I live in Chapel Hill, NC - just a few miles from two major university hospitals. The doctor to citizen ratio here is one of the highest in the US.

Posted by: keptsimple on August 30, 2006 at 2:00 PM | PERMALINK

Fine, if you like the VA, sign up and join the military. I'll keep seeing a doctor immediaely when I need to, instead of waiting 30 days. Advantage: Free market. My PPO kicks ass.

There are so many things wrong with this I don't know where to begin.

"if you like the VA, sign up and join the military"

There are numerous healthcare conditions that will keep you out of the service yet require ongoing preventative care. Type I Diabetes, for instance.

Pleanty of people also need good healthcare, but are too old, too young, or too gay for the military. What do they do?

"I'll keep seeing a doctor immediaely when I need to, instead of waiting 30 days."

How often do you need to? If you only see a doctor for urgent care once or twice every couple of years, you are not a real user of the healthcare system and are not getting a good picture.

If you live in a very small town where you can just waltz in to a doctor's office, great. Here in NYC you need to book a routine checkup 5-8 weeks in advance. And we have more doctors per capita than perhaps anywhere else in the world.

I would gladly wait 30 days for an appointment, it's an improvement.

"Advantage: Free market."

It's not a free market, as economists understand the term. You are not the purchaser, your insurance company is. Therefore, the end user and the purchaser are not the same, a huge market inefficiency. You are making decisions on healthcare without regard to price, but the insurance company is not.

Did you know some doctors can't take cash for services? I learned this the hard way. They literally will not see you if you want to pay cash because of insurance company regulations. If you have Insurance X, and Doctor Y accepts it, you can't pay him cash (say you just want service now and don't want to deal with paperwork or insurance hassles), or the insurance company throws a fit. I want to pay them. They want the money. It costs the insurer nothing. Explain to me again how that is a free market.

"My PPO kicks ass."

That's great! I used to have a PPO, it was very convenient. Unfortunately, my employer does not offer that option any longer. Most employers do not offer that option.

So, as a relatively healthy person who rarely goes to the doctor and has a great, no-hassle insurance plan, you think the healthcare system is great. Thanks for your input.

Posted by: Alderaan on August 30, 2006 at 2:00 PM | PERMALINK

"So why, if government involvement in health care is indeed better, is it impossible for conservatives to admit this?" Brian


In a word money. Years ago we allowed insurance companies, organizations designed to deal with acts of God, carwrecks and shipwrecks, to handle health care reembursements. They have applied all the same tools developed to handle car and shipwreck risk sharing to what is really a different task. Unlike injuries sustained in a car wreck, most disease related medical care involves long time frames, and multiple activities. The best way to avoid disease is throught prevention. Prevention has nothing to do with an episodic reimbursement. As a result your health care insurer will pay millions for diabetes care, but not a dime for diabetes prevention. The resultant "system" is inherently inefficient, expensive, impersonal, inflexible and a pain in the ass. Knowing what we know now, nobody would employ the insurance model to pay for health care delivery. Unfortunately, those insurance companies have money, and lots of it. Like bureaucracies everywhere the top priority on their corporate agenda is survival. To achieve that priority they are willing to spend every dime of that money on politicians and opinion makers to make sure no changes are made to their gravy train.

Posted by: Ron Byers on August 30, 2006 at 2:05 PM | PERMALINK

I elect for the HMO Family at my work and it costs a total of $930 a month of which I thankfully pay only $110. The PPO options are all quite a bit more. We are getting ripped off!

Yes you are getting royally ripped off. $12,000 a year for health insurance?!? I earn a decent middle class income in Canada (and have a very good life thank you very much) and I don't pay that amount in total taxes to the government that provides my health insurance (along with roads, schools, police, etc.). And the Canadian government has been running surpluses and paying down the national debt for a while now too.

Posted by: Yukoner on August 30, 2006 at 2:07 PM | PERMALINK

Re the California legislation, the Democratic candidate for governor apparently does not support it. I've no idea why, as running against the Governator he needs all the bright ideas and distinguishing positions he can get.

Could be PharMa contributions, I suppose.

Posted by: Cal Gal on August 30, 2006 at 2:09 PM | PERMALINK

Oh, Brian, I didn't mention that conservative politicians are major receipients of insurance company money.

Posted by: Ron Byers on August 30, 2006 at 2:11 PM | PERMALINK

Traffic jams full of Canadians streaming across our border looking for hip replacements!!

Well, those too. But the larger migration is among doctors and nurses and other medical technicians.

Posted by: republicrat

This might have been the case a years back...it is no longer the case. In fact, Canada has seen many of its citizens move back to Canada in the last 5 years, as the US is no longer a better deal for anyone but the top 2-3 percent of income earners.

Posted by: Dismayed Liberal on August 30, 2006 at 2:15 PM | PERMALINK

republicrat >"...Health care professionals have wanted for a long time to build an integrated national database of health information, like but more complex than the national database of financial information that you use when you buy gasoline with a credit card or ATM card..."

Exactly

If the pseudo "private sector" can run a credit rating database system (yes, I know somewhat badly) that actually functions then someone (hello EDS, Oracle, SAP) could do the same for medical records.

As Kevin said "...if we only had the will..."

Apparently "We the people..." DON`T have the will

(of course some enterprising open source advocates could take it upon themselves to just go ahead and start down this road, HELLO OSDL etc...)

"Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist." - John Maynard Keynes

Posted by: daCascadian on August 30, 2006 at 2:16 PM | PERMALINK

Yukoner >"...And the Canadian government has been running surpluses and paying down the national debt for a while now too."

Well of course they are

You folks haven`t had to support Jack Abramoff & all his golf junkets (tho Mr. Harper does seem to be trying to correct that specific imbalance)

Come on, put down those hockey sticks & get with the program

"All successful revolutions are the kicking in of a rotten door." - John Kenneth Galbraith

Posted by: daCascadian on August 30, 2006 at 2:27 PM | PERMALINK

daCascadian,

You will have to pry my hockey stick out of my cold, dead hands!

Posted by: Yukoner on August 30, 2006 at 2:45 PM | PERMALINK

IMHO there is one fundamental problem: let's say we create Kevin's perfect health care system, and it contains some government sponsored/managed/controlled elements. It is set up and running well.

How do you stop this system from being Grover-ized somewhere down the line? Particularly if as Kevin says the natural tendency of US politics is to swing between rational and Radical, how do we prevent the Radicals from destroying the system in such a way that it cannot be fixed (as they are doing right now throughout the federal gov't)?

Cranky

Posted by: Cranky Observer on August 30, 2006 at 2:51 PM | PERMALINK

Or Yukoner, your country could go start a long term, pre-emptive war with somebody.

Posted by: slanted tom on August 30, 2006 at 3:03 PM | PERMALINK

I work for a large university and have the internal health plan - i.e. you use the student infirmary and the teaching hospital. They have all our health records online and accessible at all times. I think if people got a chance to see how well this works and how it improves the care you receive, they will worry less about the privacy issues.

My husband had a seizure disorder, and for every doctor who sees him throughout the system to have his complete medical history (and he has only one that everyone updates) helps enormously. When he ended up at a small town emergency room in the middle of the night, they were able to call a doctor at the clinic and have him talk them through his treatment routine. (He was not able to help.) The emergency room doctors didn't have to contact our primary care doctor (who wouldn't have the records at home anyway), all they had to do was talk to the clinician on duty. When he got back home, the neurologist had the complete record of what happened that night, as reported by the emergency room doctor to the clinician.

I think the people who are really going to not like this are the hypochondriacs, who by some estimates eat up 10-15% of medical costs. (Note: I think hypochondria is a real problem, that we need to find a treatment for.) The endless rounds of seeing doctor after doctor, none of whom find any physical basis for the complaints will be far more obvious.

It frees up the doctor-patient relationship in many ways, because when you bring something up, they can look up your history with the problem, the actual dosages you used the last time, and your reported success/failure with the treatment. They know the anti-biotic that made you throw up and the cream that didn't help your rash. And they can give you print outs if you want your own record.

Posted by: Maureen Hay on August 30, 2006 at 3:05 PM | PERMALINK

No way would I give up Medicare for VA-care. If the VA continues to have success, be sure that our campaign-cash hungry politicos will start putting up the road blocks to insure the VA fails. Repubs cannot afford to have a successful government porgram.

Posted by: GIBilly on August 30, 2006 at 3:06 PM | PERMALINK

Dismayed Liberal: In fact, Canada has seen many of its citizens move back to Canada in the last 5 years, as the US is no longer a better deal for anyone but the top 2-3 percent of income earners.

A good point that I'll be alert to as I read about this. I think the net migration of health care professionals is in this direction, but I'll certainly remember to read more carefull.

Posted by: republicrat on August 30, 2006 at 3:09 PM | PERMALINK

Cranky, there is an analog that might provide some insights into this question: Social Security. People like it, and they like it just the way it is. At the same time, SS is anathema to Grover and his ideological brethren. The GOP has controlled Congress and the White House for about six years now and despite a sincere effort to privatize, i.e.: destroy, SS they didn't get anywhere. They could try again this year and I still don't think they would get anywhere.

Over time, a similar dynamic could evolve with an effective and well-managed universal insurance plan.

Posted by: joe bob on August 30, 2006 at 3:13 PM | PERMALINK

Even if it's cheaper and better, we can't have national health care.

If we did, then I'd have to pay for abortions and sex change operations for lazy fat unemployed black welfare queens!

Let's instead spend our time and effort debating over how our current system is better than communism, any "facts" you have to the contrary notwithstanding.

Posted by: Gallons Of Poop on August 30, 2006 at 3:17 PM | PERMALINK

Ron
Hey, Al, who covers you? Because I just had to wait 5 weeks to get in to see my primary care physician to get a referral to a dermatologist, for whom I had to wait 4 weeks, to get help with a case of cellulosis. Not a huge problem, but it took me 9 weeks to get treated. And this is with a Primary Care Physician with whom I, in theory, already have a relationship.

That blows. I can usually see my doctor in a day or two. Standard family practice. Covered by HMO.

Posted by: Red State Mike on August 30, 2006 at 3:22 PM | PERMALINK

slanted tom,

I'd be all for it as long as it is a War on Ice fought by six on a side. Last team with a set of intact teeth between them wins!

But seriously, I would find it more than a little disturbing to live in a political culture where a substantial proportion of the populace believes that their government and all its works (along with the taxes needed to support those works) is (are) inherently bad, useless, corrupt and even down right evil. Except the military of course, which can do no wrong except when it suceeds in delivering good health care at a reasonable cost.

And the quip that Republicans believe that government cannot do anything right and regularly prove themselves right after getting elected is only funny to the degree that it is accurate. Again, I would find it very disturbing to know (or even have a good basis for believing) that the people I was electing were trying to prove that government does not work. Kind of like selecting a single minded and simplistic environmentalist to be the CEO of a mining or forestry company.

Posted by: Yukoner on August 30, 2006 at 3:27 PM | PERMALINK

If we get universal health care in Calfiornia - I predict JOBS. Lots of jobs.

Who would want to employ workers in say, Arizona, and end up having to pay for health insurance, when they can build their plant in California?

Gov. Enronegger, of course, will probably veto this.

Posted by: Osama_Been_Forgotten on August 30, 2006 at 3:31 PM | PERMALINK

I clicked the link.
Yep, approximately 11,000 have 30+ days for first appointment. 11,000 out of 5.3 million eligible members - 2 per thousand.

What a meaningless number. We don't know what mean or median waits are. We don't know what comparable waits are for non-VA medical service. But I can say it's lower than one of the insurances in my state was reporting a couple of years ago, so I guess it's pretty good.

Posted by: Kirk Spencer on August 30, 2006 at 3:32 PM | PERMALINK

A few examples: in the early 50s, about 45,000 people died per year in auto accidents; now the figure is about 35,000, with more drivers and many more miles driven.

That's an interesting example to choose. With no data at all, I'd say that about 80-90% of that improvement comes from Federal regulations making cars safer, mandating child seats, seatbelts, etc, etc.

It was Ford, meanwhile, that decided it was more "cost-effective" to let its customers die in Pinto explosions than to fix the problem.

I love me that private sector! It's always better at everything, even when it isn't!

Posted by: craigie on August 30, 2006 at 3:33 PM | PERMALINK

Last time I changed insurance (forced-doctor-change) my initial appointment wait was 15 days.

I don't reckon it matters whether I have private or single-payer coverage. Most doctors in my region are booked solid all the time. Market ain't workin with private insurance. I don't expect single-payer to fix that. I don't expect anything to fix that. It's just a fact of life. The only solution is: many, many, many more doctors offices.

Posted by: Osama_Been_Forgotten on August 30, 2006 at 3:43 PM | PERMALINK

Since the VA did their database on the quiet, they were able to use Open Source tools and techniques (in fact I think their software has a GPL license). Were that to be done nationwide by law, there would have to be bidding. And guess who would win that bid? Can you say "large boondoggle contractors"? I thought you could. Cf the FBI case management system.

No doubt this is true right now, under the current administration, where contract oversight means making sure George's friends get the contracts. Nothing useful is going to happen on the healthcare front while this administration and congress are still in power.

However, taking that stance forever is just a demonstration of Grover et. al.'s success in spreading the "always incompetent government" idea. It's not impossible to have a competent and more-or-less honest government, it's just that we don't have one.

Posted by: me2i81 on August 30, 2006 at 3:49 PM | PERMALINK

BusinessWeek ran a very similar article back in July.

Posted by: klaus on August 30, 2006 at 3:52 PM | PERMALINK

> Social Security. People like it, and they
> like it just the way it is.

joe bob,
I hope you are right. But if the Radicals keep control of either house of Congress in November I think they are going to have another go at Social Security (and even if they don't). And as the 4th generation warfare people say, the insurgents only have to win once - the defenders have to win every time.

Cranky

Posted by: Cranky Observer on August 30, 2006 at 3:53 PM | PERMALINK

Why should I spend our money to save money for our competitors?

Don't forget it works the other way too - saving money now to increase spending for my competition later.

Not that it results in better health care, though.

Posted by: pebird on August 30, 2006 at 4:03 PM | PERMALINK

craigie: With no data at all, I'd say that about 80-90% of that improvement comes from Federal regulations making cars safer, mandating child seats, seatbelts, etc, etc.

I agree. In other posts I have mentioned that almost everything that works in the U.S. results from a public/private cooperation (or, in this case, tension.) The market does many creative things, but it sometimes benefits from voter mandates as well as customer choice.

There is also better drivers' education available.

Posted by: republicrat on August 30, 2006 at 4:32 PM | PERMALINK

Once again Republicrat and the Hawk are missing the point.

good grief, have my comments not been at least a little supportive of the VA? I claimed that the health care provided by the VA was a part of national wealth, and I applauded Kevin's idea of making a national database of medical information.

Posted by: republicrat on August 30, 2006 at 4:37 PM | PERMALINK

A few examples: in the early 50s, about 45,000 people died per year in auto accidents; now the figure is about 35,000, with more drivers and many more miles driven.

Wrong. The figure now is about 43k.

Posted by: Disputo on August 30, 2006 at 4:39 PM | PERMALINK

daCascadian on August 30, 2006 at 2:16 PM

I am glad we agree on some things, even if we don't agree on all things.

Posted by: republicrat on August 30, 2006 at 4:41 PM | PERMALINK

Re: the TIME article. Ken Kizer gets all the wet kisses in any VA piece, but let it be stated publicly that my father Harry E. Marshall (VACO, retired 1999), known to Republicans far and wide as a "faceless bureaucrat" played no small part in VA's success as the non-doc head of rehabilitation medicine during those years. A young kid took Kennedy's words to heart, "Ask not what your country can do for you..." and he made a difference that endures years past his retirement and truly affects veterans lives. That's what you do when you love your country, not buy a magnetic ribbon and slap it on your damn Hummer.

Posted by: wombat on August 30, 2006 at 4:50 PM | PERMALINK

Kevin,

If your facts and figures are correct, I'm impressed. I have used the VA for my medical care for the last few years and think it provides excellent service. When I was first discharged in the early '80's I had tried the VA and it was like Dante's Inferno. I returned to the system about five years ago I was knocked out by the improvement; if Clinton deserves the credit, I'd be glad to acknowledge it. I am curious, though, why you don't think this would be a good nucleus to build a national system around?

Posted by: minion of rove on August 30, 2006 at 5:18 PM | PERMALINK

Yukoner >"...Last team with a set of intact teeth between them wins!..."

Yea but youse guys have to drink your own beer, no Mericun microbrews allowed

Yukoner >"...the people I was electing were trying to prove that government does not work..."

Well, most of us realize we haven`t actually been electing these ReThuglicans but that is a whole nother rant which I`ll spare you at the moment...

republicrat >"...I am glad we agree on some things, even if we don't agree on all things."

Always happy to acknowledge good ideas grounded in reality

Now if only all those open source folks would get on this case & start the ball rollin (HELLO OSDL etc)

"There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things." - Niccol Machiavelli (The Prince, 1532)

Posted by: daCascadian on August 30, 2006 at 6:10 PM | PERMALINK

AH: Fine, if you like the VA, sign up and join the military. I'll keep seeing a doctor immediaely when I need to, instead of waiting 30 days. Advantage: Free market. My PPO kicks ass.

Typical Republican. 'I've got good health care, so the fact that millions of US citizens don't, including children, fails to trigger caring in me.' This is the party of 'values'? I value families that don't break up under the strain of illness. I value entrepenuers that can start new businesses without exposing themselves and their familes to life without health insurance. I value the lives and happiness saved when people can worry about things that are actually important in life instead of about premiums and portability.

American Hawk shows no sign of valuing any of these things.

Posted by: NBarnes on August 30, 2006 at 6:17 PM | PERMALINK

Osama, Enronegger is from Austria, they do have good national healthcare, also he is ambitious and wants to be remembered well in the history book. Maybe it will contribute to his decission.

Why does the Democrate oppose a single payer plan, what does he object to? Is he bought by the insurance industry?

In Iraq the private sector is one biiiig black hole wher Billions of $$$$$ have disappeared, I just whish our Bozo in Chief and his entourage would disappear in the same black hole, now not later. He has done enough damage.

Posted by: Renate on August 30, 2006 at 7:14 PM | PERMALINK

Yes you are getting royally ripped off. $12,000 a year for health insurance?!? I earn a decent middle class income in Canada (and have a very good life thank you very much) and I don't pay that amount in total taxes to the government that provides my health insurance (along with roads, schools, police, etc.).

If kj makes only a "decent middle class income" then he probably doesn't pay that amount in total taxes to the government, either. In fact, if his income is comparable to yours, he probably pays much less in taxes than you do.

And he doesn't pay anything close to $12,000 a year for health insurance, either. He said he pays $110 a month for a family plan. That's $1,300 a year. And he and his family won't have to wait weeks or months to see a specialist or get routine surgery like you Canadians do.

Posted by: GOP on August 30, 2006 at 7:43 PM | PERMALINK

osama,

If we get universal health care in Calfiornia - I predict JOBS. Lots of jobs.

I predict rationing, budget deficits, and angry voters. Lots of angry voters. Single-payer advocates in California tried to get single-payer health care in 1994 through ballot initiative. It was overwhelmingly defeated, by a 3-to-1 margin.

Who would want to employ workers in say, Arizona, and end up having to pay for health insurance, when they can build their plant in California?

Anyone who doesn't want to pay the exorbitant new taxes that would be required to fund single-payer health care.

Posted by: GOP on August 30, 2006 at 7:52 PM | PERMALINK

craigie,

With no data at all, I'd say that about 80-90% of that improvement comes from Federal regulations making cars safer, mandating child seats, seatbelts, etc, etc.

I'd say you're very probably wrong. The effects of seat belt legislation on rates of injury and death, for example, seems very unclear. It may not have any significant effect at all.

Posted by: GOP on August 30, 2006 at 8:07 PM | PERMALINK

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Posted by: 联通铃声下载 on August 30, 2006 at 9:58 PM | PERMALINK

Hospital stays are expensive.
Prescription drugs are expensive.
Long-term health care is expensive.
Sustaining life with disabilities is expensive.
The unfettered free-market health care system the rich right-wing and their ignorant dupe followers long for is designed to cut costs as much as possible to increase profits as much as possible.
Death is the ultimate cost cutter.


Posted by: secularhuman on August 31, 2006 at 1:12 AM | PERMALINK

Republicrat, Sorry to lump you in with American Hawk, but I was responding to this post.

"Building on a thread from yesterday, does the existence of this high quality medical care constitute an improvement in the wealth of this segment of the US, or a diminishment of the wealth of theis segment? I would say that this system is one example of the increased wealth of poor people in the US since the early 50s."

You continue your crusade to prove that the poor are well off. That's why you seemed to miss the point. The point is about effeciency and actual access. Health care costs so much that the poor are often not insured meaning they don't have access except in emergencies. That is highly ineffecient and probably immoral considering our nation's wealth.

Posted by: kj on August 31, 2006 at 2:21 AM | PERMALINK

I want to comment on the contrast between private market care and the VA system. I have been served by some of the best HMO's in the county, by private doctors, and in the last five years, by the VA. Of the three, the VA has given me the best attention.

As Kevin notes, the VA's care is forward looking and preventative. In that, is bears a marked similarity to the good care I received from Kaiser Permanente. But unique to the VA in my experience is the amount of time my primary physicians have been willing to give me. They don't seem to be in all that much of a hurry to rush me through their treadmill. They listen to what I have to say respectfully and respond to me instead of appearing to know mysteriously what is wrong the moment they walk into the office. As a result, they have had a thorough grounding in my particular maladies and needs and have kept track.

During my life I saw another thing Kevin mentions: during the Reagon years, I visited a VA hospital at the request of the VA to add my experiences to the Agent Orange Data Base. The VA hospital I visited was a cess pool and the attitude of the workers toward vets was demeaning. Four years after Clinton took office, I returned to the VA and found the system completely restored, with the staff cheerful and respectful toward the vets--even those who didn't deserve it from their behavior. It's amazing how it helps to have people in charge of the government who believe in government!

Sadly, under Bush the system has come under great stress--Katrina again and again. The staff still gives the best care they can, but they are having to knock themselves out to do it as their resources dwindle while the number of men and women they have to treat expands. They are making a good fight of it but it is really tough for those who haven't made it into the system. The lines for entry are long, a fact that has been previously reported but not received the attention it deserves. This is a rationing of our responsibility, whereby the veteran is asked again and again to sacrifice so the rest of the country can enjoy their tax breaks.

It is ironic, isn't it, that the party that sells itself as the patriotic party, has such contempt for the fighting men and women on whom our country relies for its defense. I could get lost in talking about chicken hawks, but that story has been told and I assume that would be preaching to the choir.

A last plea: support the VA. They deserve it. And don't be reluctant to emulate the system they have developed.

Posted by: frank logan on August 31, 2006 at 2:23 AM | PERMALINK

If kj makes only a "decent middle class income" then he probably doesn't pay that amount in total taxes to the government, either. In fact, if his income is comparable to yours, he probably pays much less in taxes than you do.

And he doesn't pay anything close to $12,000 a year for health insurance, either. He said he pays $110 a month for a family plan. That's $1,300 a year. And he and his family won't have to wait weeks or months to see a specialist or get routine surgery like you Canadians do.

Brilliant GOP. I may pay 1300 but my employer chips in an extra 11 grand. That's basically a tax on me, you dumbass. If my employer didn't have to shell out $900 a month in health insurance, I would probably see most of that in my paycheck.

So do the math. If the feds could raise my taxes by $500 a month and cover my health insurance, I would have more money to buy plasma TVs at the end of the year and I'd have better health care.

And stop it with the waiting lines in Canada. Talk about an ignorant GOP talking point. Waiting lines are for elective procedures, most of which are a waste of money or are hardly urgent. I lived near the Canadian border a while ago and Canadians would come to our hospital for cardio work placing shunts in arteries and stuff like that. Turns out the the procedures were a complete waste of money as studies later showed that they didn't improve quality of life or life expectancy at the risk level these patients were getting it done at. The Doctors in the U.S. sure liked to sell the procedure to the Canadians though. Easy money.

Posted by: kj on August 31, 2006 at 2:36 AM | PERMALINK

Note: I think hypochondria is a real problem, that we need to find a treatment for.)

Was that intended to be hysterically funny? Because it was.

On topic, however, whether it's the VA or a single-payer scheme, the major gain comes from removing the incentive to try and shift health costs to someone else.

How much of the expense of private health insurance is eaten up in trying to avoid payment? It's not insignificant, as anyone that has had to deal with the flurry of paperwork after a hospital stay can tell you. This is what happens when you let the accountants run the health-care "system".

First off, we hang all the bean-counters.

Posted by: Satan luvvs Repugs on August 31, 2006 at 11:38 AM | PERMALINK

What's this about VA offering top notch medical services? That's just nuts. I know a lot of med students and doctors and they all say VA hospitals are among the worst. Also, when my grandfather had to get his arteries cleaned up, my Dad begged him to avoid the VA hospital. Grandpa stuck with the VA, they had an 'event', and gramps hasn't been himself since. I'm not saying VA hospitals are cess pools, I'm just saying we shouldn't be arguing that they're models of quality health care.

Posted by: j_flo on August 31, 2006 at 11:57 AM | PERMALINK

GOP;
I see that kj has already replied to you but I think that this point needs to be emphasised.

If a family plan health insurance costs $12k then it costs $12k and it doesn't matter how the cost is shared between the employer and worker. And what really gets me is that I guess if kj tried to buy that same insurance as an individual it would cost even more (assuming that the employer greats a pool of risk and therefore pays less).

You. Are. Being. Ripped. Off.

How curious that some (many?, most?)in the US just don't understand that basic fact.

Posted by: Yukoner on August 31, 2006 at 12:51 PM | PERMALINK

Brilliant GOP. I may pay 1300 but my employer chips in an extra 11 grand. That's basically a tax on me, you dumbass.

No, it isn't, fuckface. It's a cost your employer chooses to pay as part of your employment compensation. The fact remains that the cost to the employee in this case is about $1,300 a year, not $12,000.

If my employer didn't have to shell out $900 a month in health insurance, I would probably see most of that in my paycheck.

And you wouldn't have health insurance. You are perfectly free to go work for an employer who doesn't offer health insurance. Most large employers also give their employees the option of declining health insurance and receiving a higher salary in its place.

So do the math. If the feds could raise my taxes by $500 a month and cover my health insurance,

The feds could not do that.

And stop it with the waiting lines in Canada.

No.

Talk about an ignorant GOP talking point. Waiting lines are for elective procedures, most of which are a waste of money or are hardly urgent.

Nonsense. Waiting lists apply to both elective and required procedures. There is clear evidence that Canadians are denied vital health care services because of waiting lists, and that in some cases patients die as a result of these waits.


Posted by: GOP on August 31, 2006 at 1:40 PM | PERMALINK




 

 

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