Editore"s Note
Tilting at Windmills

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February 14, 2008
By: Kevin Drum

CANADIAN HEALTHCARE....Ezra Klein recommends "Ten Myths About Canadian Healthcare," by Sara Robinson, and it is indeed very good (and very fair). My personal favorite is #2, in which Robinson notes that although Canadian doctors are paid less than their U.S. counterparts, there are also upsides to practicing in Canada:

First, as noted, they don't have to charge higher fees to cover the salary of a full-time staffer to deal with over a hundred different insurers, all of whom are bent on denying care whenever possible. In fact, most Canadian doctors get by quite nicely with just one assistant, who cheerfully handles the phones, mail, scheduling, patient reception, stocking, filing, and billing all by herself in the course of a standard workday.

Second, they don't have to spend several hours every day on the phone cajoling insurance company bean counters into doing the right thing by their patients. My doctor in California worked a 70-hour week: 35 hours seeing patients, and another 35 hours on the phone arguing with insurance companies. My Canadian doctor, on the other hand, works a 35-hour week, period. She files her invoices online, and the vast majority are simply paid — quietly, quickly, and without hassle. There is no runaround. There are no fights. Appointments aren't interrupted by vexing phone calls. Care is seldom denied (because everybody knows the rules). She gets her checks on time, sees her patients on schedule, takes Thursdays off, and gets home in time for dinner.

One unsurprising side effect of all this is that the doctors I see here are, to a person, more focused, more relaxed, more generous with their time, more up-to-date in their specialties, and overall much less distracted from the real work of doctoring. You don't realize how much stress the American doctor-insurer fights put on the day-to-day quality of care until you see doctors who don't operate under that stress, because they never have to fight those battles at all. Amazingly: they seem to enjoy their jobs.

I have watched office clerks brought practically to tears trying to deal with a waiting room full of patients while simultaneously fighting over authorizations with five different insurance companies with five different sets of very complex rules. There have been times when I've seen offices practically grind to a halt because of it. It's a continuing wonder to me that U.S. doctors haven't long since rebelled against this insane system.

Kevin Drum 11:38 AM Permalink | Trackbacks | Comments (68)

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I've seen this here in the US as well. Two of our doctors have "opted out" of the insurance world and only take direct payments. They don't deal with insurance companies at all, and as a result both match the description of the Canadian doctors to a tee. They're relaxed, generous with their time, have very small staffs (one assistant for the first guy and two for the other one).

Posted by: Jeff Hebert on February 14, 2008 at 11:45 AM | PERMALINK

Funny, I just got off the phone with my insurance company. They were charging me the $250 deductable for an emergency room visit, even though it was supposed to be covered. When I questioned them, the rep told me that it was billed as an office visit, which is why it had the deductable. Funny, the service title was "EMERGENCY DEPT VISIT" but it was billed as an office visit? I called the ER billing, who told me it was billed correctly. I called back the insurance company and got a better agent who sent it back for review. The first agent had told me I'd have to send a letter for any appeals.

This has been happening for about 8 different bills from that ER visit.

Posted by: DR on February 14, 2008 at 11:46 AM | PERMALINK

http://www.fee.org/publications/the-freeman/article.asp?aid=3092

Posted by: NC Fan on February 14, 2008 at 11:55 AM | PERMALINK

My experience with insurance companies - both in doctor and hospital visits - hasn't been so bad, but it's hard not to notice the three to four staffers maintaining the mountains of paperwork, with each company having it's own extensive, unique system. Nutty doesn't begin to cover it.

Posted by: rhinoman on February 14, 2008 at 11:56 AM | PERMALINK

"It's a continuing wonder to me that U.S. doctors haven't long since rebelled against this insane system."

Because it's the hand that feeds them.. I don't mean that in an unkind way, just that it's pretty much their only source of revenue.

Posted by: IanY77 on February 14, 2008 at 11:59 AM | PERMALINK

B-b-b-but, that's socialized medicine, Kevin! You don't want socialized medicine... d-d-do you?

I hope to god we get universal healthcare from our next president, but I can't help but think that we're somehow going to fuck it all up, and it's not going to work nearly as well as the French, Canadian, or British systems.

Posted by: carl on February 14, 2008 at 12:00 PM | PERMALINK

It's a continuing wonder to me that U.S. doctors haven't long since rebelled against this insane system.

Based upon my anecdotal conversations with various physicians, they are instead more concerned with the following items:

  • The relatively lower pay received by Canadian physicians.
  • Blaming "the lawyers" for all their woes.
  • Belief in the "free enterprise system."
  • Dislike of taxes

Note: it can logically be quite possible to favor such pro-doctor items as tort reform and public finance of education (including medical schools), and still regard the forgoing concerns as irrational and motivated by greed.

In other words, with respect to the hoary "doctors vs. lawyers" quarrel, it is quite possible to wish "a curse on both their houses."

But don't expect to make headway with that simple point. There's too much money at stake.

Posted by: Duncan Kinder on February 14, 2008 at 12:28 PM | PERMALINK

I also read that series, Kevin, and what struck me was the difference between how much it costs to go to medical school in the U.S. vs. medical school in Canada. I am in the pharmaceutical research business and see more and more physicians with MDs from other countries. Not because they couldn't hack it in U.S. med schools and certainly not because foreign schools are in any way inferior. Just because it was much cheaper to go to med school outside the U.S. (University of Mumbai is widely considered the best med school in the world), then come back and take the long gauntlet of qualification exams to practice in the U.S.

Posted by: Constance Reader on February 14, 2008 at 12:33 PM | PERMALINK

Robinson notes that although Canadian doctors are paid less than their U.S. counterparts

There is no "although". Please understand that Americans want to be paid high salaries. If the office workers have to take grief from the insurance companies, so be it.

I have yet to hear a reasonable explanation from those advocating cheaper universal healthcare in the Canadian model (or France, or whereever) how they intend to get doctors to take enormous pay cuts.

Posted by: Jack on February 14, 2008 at 12:36 PM | PERMALINK

Jack, I think Sara Robinson's note about how much cheaper medical school is in Canada at least partially answers that question. Doctors probably wouldn't demand such high salaries if they weren't graduating from med school with student loan debt of well over $100k.

Posted by: Constance Reader on February 14, 2008 at 12:43 PM | PERMALINK

I compared health care costs with family members in Canada. The increase in income tax that I would pay in Canada is just about a wash with the insurance premiums, co-pays and deductible I pay in the US. (Although I a fortunate to have a health care plan offered employees of a state government.) None of my relatives in the Toronto area have had to wait for care in an emergency, although one had to wait a few months for tests for an elective procedure - with no serious complaint.

Posted by: Monzie on February 14, 2008 at 12:46 PM | PERMALINK
"It's a continuing wonder to me that U.S. doctors haven't long since rebelled against this insane system."

Because the average doctor makes more than $150K a year here in the U.S. ... ?

With a single payer (or other) system -- just so long as it doesn't include insurance co.s -- the loss in income could be made up by having less staff that handles these issues.

(On a side note, Ms. Robinson must have had the bestest doctor in America -- I know nearly two dozen doctores on a personal level, have talked with all of them about the current issues, and I guarandamntee not a single one of them has ever talked to an insurance company on behalf of a patient. I'm impressed.)

With a single payer (or other) system -- just so long as it doesn't include insurance co.s -- the loss in income could be made up by having less sstaf

Posted by: Mark D on February 14, 2008 at 12:48 PM | PERMALINK

Bear in mind that even if we have a new President who supports universal health care that this insanity will continue for another generation. There is no way to get any meaningful change past the corporate lobbyists, IMO.

A new societal trend will be a new generation of ex-pats (mostly aging baby boomers) in other countries whose main motivation is to escape the cost and hassle of health care in the U.S., to a long list of countries that truly have universal health care (i.e., not even a question about pre-existing conditions on the application).

Posted by: CB on February 14, 2008 at 12:49 PM | PERMALINK

Whoops ... that last graf in my 12:48 post was supposed to be deleted. Guess I didn't scroll down far enough.

Preview is my friend. Preview is my friend. Preview is my friend. Preview is my friend ...

Posted by: Mark D on February 14, 2008 at 12:50 PM | PERMALINK

One of my current frustrations with US healthcare is the outsourcing of labwork to non-network providers. My family coverage through my employer states that certain preventive procedures are to be covered 100%. This makes economic sense: encourage people to get PSA's or mammograms regularly and catch cancers early when treatment is more effective and much cheaper. So why, when my wife gets her mammogram done at the local hospital - the only in-network provider in our part of the state that has the equipment - do they send the films to a radiologist halfway across the state to read them? He is not in our network, so we get billed.

Anybody else have similar experiences?

Posted by: Mike (who seldom comments) on February 14, 2008 at 12:50 PM | PERMALINK

Doctors don't like the current system. Businesses don't like the current system. Citizens don't like the current system. It costs more, covers too few and doesn't deliver quality health outcomes. We all live with healthcare-related anxiety and stress. So, yes, good question: why does it continue?

Posted by: PTate in MN on February 14, 2008 at 1:10 PM | PERMALINK

T there are an awful lot of VERY expensive cars parked in American healthcare parking lots, and I'm thinking it's probably not the nurses driving them.

Posted by: ferd on February 14, 2008 at 1:25 PM | PERMALINK

"We all live with healthcare-related anxiety and stress. So, yes, good question: why does it continue?

Posted by: PTate in MN"

In a word: lobbyists (from the insurance companies).

Posted by: slanted tom on February 14, 2008 at 1:27 PM | PERMALINK

"It's a continuing wonder to me that U.S. doctors haven't long since rebelled against this insane system."

What do you expect them to do? Go out on strike?

Posted by: s9 on February 14, 2008 at 1:27 PM | PERMALINK

Even with a private-insurance focused VOUCHERS and mandates system (when will Kevin start talking about vouchers in a non-single payer system?) the idea of standardized paperwork is a no-brainer.

A federal department of insurance regulators is needed right now, and would be de rigeur in a VOUCHER and mandate private-based national healthcare system.

Posted by: SocraticGadfly on February 14, 2008 at 1:30 PM | PERMALINK

But the hips

What about the hips?

Months & months of waiting for hip replacement surgery.

Long lines of deperate, hip-damaged Canadians waiting patiently for surgery in the snow for months.

Don't forget about the hips is what I say.

Posted by: Asciutto on February 14, 2008 at 1:31 PM | PERMALINK

NC Fan: The post-Soviet Union Russia of 1994 is NOTHING like modern Canada, UK, etc. Take your nutbar lies and stick 'em.

Posted by: SocraticGadfly on February 14, 2008 at 1:34 PM | PERMALINK

The province does charge a small monthly premium (ours is $108/month for a family of four) for the basic coverage.

I wonder how the Canadian Medicare deals with the self-employed? Any Canucks know? I'd like to know what a self-employed Canadian has to pay for a premium every month.

Posted by: Doc at the Radar Station on February 14, 2008 at 1:44 PM | PERMALINK

I can't speak to the differences in insurance and all that, but I do know that were I a part of the American society I would already be dead because I would be uncoverable. I had a genetic blood disorder start causing me problems when I was 20, although it was undiagnosable for a decade so (thank you human genome project, otherwise I still wouldn't know why) for the first decade I was throwing deep veined blood clots without warning, family history of such or any explanation. Under the American system unless I and my family were independently wealthy I would have died already. That is something I can never forget when I hear about how much better the US system is.

I hear Americans talk about how in Canada backlogs are so bad/severe, how you have to wait forever for treatment (which to be fair does happen a fair bit in non-critical procedures, especially in orthopedic procedures like hip replacements) etc. Well, I have a recent example regarding cardiac care (which is another heavily strained element of our system) I can cite to show why I will take our system over yours anyday. I started having arrhythmias, my GP saw me within 2 days of my calling for an emergency appointment, got my bloodwork panels done that day, an EKG the next day and she had the results checked with a cardiologist within two hours and then called me to let me know what was the score, and that I was being moved into the urgent/priority lane for further examination. I today just got the call (exactly seven days from when I saw my GP)from the clinic for those tests, and I am waiting on the final time being set, but should be no later than early next week. I am a well below the poverty line person, yet I am getting quality rapid care as if I were able to pay out of pocket were I in the US system (since I am uninsurable in US terms) and able to be here annoying people with my long-windedness.

I'll take my system over yours anyday of the week, at least I know I have a far better chance of surviving than I would in yours. If your values are such that you think human life is more important than profit I can't see how one could go any other way than universal coverage. I also see our country gaining significant economic advantages because we fund it through taxes instead thereby reducing the benefits costs many employers are finding they can no longer maintain. It has always baffled me how all of this is so debatable in the USA, in this area I find my American cousins extremely hard to understand.

Posted by: Scotian on February 14, 2008 at 1:45 PM | PERMALINK
"It's a continuing wonder to me that U.S. doctors haven't long since rebelled against this insane system."

What do you expect them to do? Go out on strike?

Perhaps they should try "smart sanctions" and only refused to treat insurance executives and lobbyists.

"Oh, got a chest pain, Mr. HugeHealthInsCo CEO? I'll put you down for an appointment. But it may be a while, since first we have to clean up a huge mess of billing paperwork. Have a nice day!"

Posted by: Snarki, child of Loki on February 14, 2008 at 1:50 PM | PERMALINK

A few comments based on the above: Doctors can't strike without being brought up for treble damages under the antitrust laws; reimbursement is a major concern, right up there with tort reform; I've parked in doctors' parking lots and there are many beat-up old cars amidst the BMWs and Lexi; the extra staffperson for insurance problems is a common story; I've known many physicians who were on the phone with the carriers, sometimes in tears, for patients.

Posted by: sj on February 14, 2008 at 1:51 PM | PERMALINK

so: What do you expect them to do? Go out on strike?

That actually happened in Wheeling, WV. Here's the Washington Monthly article about this very strike.

This strike was over malpractice insurance and not over medical insurance, however.

Posted by: Duncan Kinder on February 14, 2008 at 2:05 PM | PERMALINK

Kevin,

I suspect that more docs than you know have "protested" by leaving private practice. I myself closed my practice 10 years ago and now work ER as in independent contractor.

No only am I mandated by law to see all patients in provide "an appropriate screening exam" as well as care that the exam suggests [the infamous COBRA], but while someone is fighting with insurance companies, it's not I. I also know several doctors who have gone the cash only route: letting the patient deal with their insurers.

This doesn't help patients pay the bills. They are still dunned by the hospital for co-pays, uninsured treatments, etc., or end up paying out of pocket, which is one thing for an office visit and quite another for major surgery, ICU care or trauma. The patient does get, as noted above, a doctor who is more focused on medicine and patient care, which is worth something.

Random thoughts:
- before insurers decided to concentrate on providing profits to stockholders rather than insurance to policy holders my father ran a huge, and I mean huge, primary care practice with 2 front office workers and an RN in the back. When he added a partner they had to expand to another RN and a half-time billing clerk cum transcriptionist.

-Mark D: I used to enjoy fighting with insurers. Won with one letter almost all the time; occasionally had to call someone. I considered it relaxation on par with baiting drug detail people. But it did add significant time to my work week.

Posted by: caduceus on February 14, 2008 at 2:13 PM | PERMALINK

Just FYI, Sara's second installment on Mythbusting Canadian Healthcare is here.

Posted by: idlemind on February 14, 2008 at 2:30 PM | PERMALINK

Any writer, anywhere on earth, who would claim, as Robinson does, that it is "false" that health care is rationed, is either a dunce or a dishonest hack. Strangely enough, earlier in the piece, Robinson explicitly acknowledges that health care is rationed. Just what the hell does Robinson think is happening when the Canadian system ends up with fewer MRI machines?

As far as which country is a better place to practice medicine, one way to get a handle on it is to see how many American doctors try to relocate to Canada after they pay off their student debt, compared to how many Canadian doctors try to relocate to the U.S..

Posted by: Will Allen on February 14, 2008 at 2:36 PM | PERMALINK

I think this post is missing one critical piece of information that could very effectively drive the point home:

How much time do office clerks have to spend arguing with Medicare and/or Medicaid over whether a payment or procedure is authorized?

Posted by: Drew P on February 14, 2008 at 2:38 PM | PERMALINK

I counsel people dealing with a specific disease, some of whom are in Canada. Yes, their care is free and the wait times are a pain (but not the end of the world.)

The real issue is that their doctors are 10 years behind the US and UK in adopting new surgical procedures. Canadian surgeons don't do anything that isn't in "the book" and they won't even consider newer treatments. I have to tell Canadian patients to try and find a way to get to the USA and pay privately for cutting edge surgeries. I have a woman presently who is near suicidal because she needs a surgery that she can't get in Canada.

That just sucks.

Posted by: arteclectic on February 14, 2008 at 2:48 PM | PERMALINK

"I wonder how the Canadian Medicare deals with the self-employed?"

Each province decides.
Most provinces don't charge a premium at all
Alberta still charges $44 per month - though a premium phase-out plan was just announced.


From the governmant website:

Albertans receive full coverage for medically necessary physician and hospital services, as well as specific oral surgical services
[and] limited coverage for services provided by allied health practitioners, such a podiatrists and chiropractors.
[and] palliative care, physical therapy, immunization programs and air ambulance services.

With the exception of seniors, premiums are charged
All residents of Alberta and their dependents are eligible to join the Plan; no eligible Albertan is denied coverage.
Families with children will not pay full premiums until their taxable income exceeds $39,250.
Of every dollar in health funding:

08 cents come from premiums,
15 cents come from federal transfer payments,
74 cents come from Alberta’s general revenues; and
03 cents come from lottery and other revenues.

Posted by: Asciutto on February 14, 2008 at 3:05 PM | PERMALINK

I know a few doctors, and the reason they don't rebel is that doctors, like soldiers, are specifically trained to never rebel. The fall-in-line attitude does them well in some areas of their practice, but insurance is one area where the attitude screws them.

Posted by: tom veil on February 14, 2008 at 3:05 PM | PERMALINK

Doc at the Radar Station
I wonder how the Canadian Medicare deals with the self-employed? Any Canucks know? I'd like to know what a self-employed Canadian has to pay for a premium every month.

Doc, I am self-employed and pay no premium at all. But then, the Yukon does not charge anyone a health care premium. Last I saw, BC, Alberta and Ontario charge a monthly premium (that includes the self-employed) of about $50.00 per month per person. Everywhere else medical care is paid for entirely out of the general tax pool.

Posted by: Yukoner on February 14, 2008 at 3:09 PM | PERMALINK

BTW,
I understand that in the US, someone in my situation (self-employed with a wife and 3 children) would have to pay around $10 to $12 thousand per year to get basic medical coverage for the family.

That is just insane.

Posted by: Yukoner on February 14, 2008 at 3:30 PM | PERMALINK

Yukoner: That is just insane.

Previously I would have said that people who choose to live amongst polar bears are crazy. On further reflection though, you're right - we're the crazy ones.

P.S. That number you cite for the US is just about right. That's total cost for a plan under a small company - to buy it as an individual would be higher.

Posted by: alex on February 14, 2008 at 4:54 PM | PERMALINK

Will Allen: As far as which country is a better place to practice medicine, one way to get a handle on it is to see how many American doctors try to relocate to Canada after they pay off their student debt, compared to how many Canadian doctors try to relocate to the U.S..

And a good way to get a handle on which country has better medical care is to see how many Americans want the Canadian health care system, compared to how many Canadians want the American system.

Posted by: alex on February 14, 2008 at 4:57 PM | PERMALINK

No, alex, it would be actually better to see how many Canadians travel to the U.S. to receive health care, compared to how many U.S. citizens travel to Canada to receive health care.

Posted by: Will Allen on February 14, 2008 at 5:10 PM | PERMALINK

Artecletic: Simply not true.

Nearly 20 years ago, my dad went to Toronto for hernia surgery precisely because it was a procedure U.S. hospitals didn't do.

Try again.

Posted by: SocraticGadfly on February 14, 2008 at 5:19 PM | PERMALINK

Will Allen: No, alex, it would be actually better to see how many Canadians travel to the U.S. to receive health care, compared to how many U.S. citizens travel to Canada to receive health care.

Why would that be better?

Posted by: alex on February 14, 2008 at 5:25 PM | PERMALINK

Because that would reveal a true preference, Alex. It's one thing to say you want x, but it is quite a bit more indicative when you actually go out and get x.

Posted by: Will Allen on February 14, 2008 at 5:32 PM | PERMALINK

No, alex, it would be actually better to see how many Canadians travel to the U.S. to receive health care, compared to how many U.S. citizens travel to Canada to receive health care.
---------------

Perhaps it would be better to see how many Canadians have no health coverage compared to how many Americans have no health coverage.

Posted by: pylon on February 14, 2008 at 5:38 PM | PERMALINK

Will Allen: Because that would reveal a true preference

A true preference that's immaterial to what I was talking about, unless you want to consider a fantasyland of unlimited resources (which seems an odd tack for a libertarian). I said the Canadian health care system, which includes how things get paid for.

It's one thing to say you want x, but it is quite a bit more indicative when you actually go out and get x.

Where possible, experiment is always better than survey. So here's a simple experiment to determine whether we should switch to the Canadian system:

Take people on both sides of the border and offer the Americans the opportunity to use the Canadian system and pay for it as Canadians do. Then offer the Canadians the chance to use the American system, also paying for it as Americans do.

Any bets on whether the Northbound or Southbound traffic will be heavier?

Posted by: alex on February 14, 2008 at 5:43 PM | PERMALINK

alex:
Previously I would have said that people who choose to live amongst polar bears are crazy

I haven't seen any polar bears around lately, maybe they've gone extinct or something.

That number you cite for the US is just about right. That's total cost for a plan under a small company - to buy it as an individual would be higher.

I just cannot get over this. I make a decent living and support a family of 5. Last year I paid a total of $11,500 in federal and territorial income tax. Of course I also pay the sales, excise and property taxes but still, almost my entire tax bill (in this supposedly wildly overtaxed country!) would barely cover the cost of medical insurance in the US. Crazy stuff.

Posted by: Yukoner on February 14, 2008 at 5:48 PM | PERMALINK

alex, the nonpoor old people would definitely prefer the U.S., and the nonrich young people would likely prefer Canada. Since nonpoor old people have the greatest electoral power in the U.S. the system you advocate is most unlikely to be instituted in the U.S.

Posted by: Will Allen on February 14, 2008 at 5:55 PM | PERMALINK

Will Allen: the nonpoor old people would definitely prefer the U.S.

In other words they'd think that the American government's UHC system for the elderly is better than the Canadian one? Maybe so - we have shorter waiting times for hip replacements.

Since nonpoor old people have the greatest electoral power in the U.S. the system you advocate is most unlikely to be instituted in the U.S.

So you think that representative government is alive and well in America? I hope you're right.

Posted by: alex on February 14, 2008 at 6:02 PM | PERMALINK

Oh, absolutely, alex. Nonpoor old people in the U.S. face less rationing than just about any large demographic on the planet, assuming we don't call the mega-wealthy a large demographic, and nonpoor old people have their care heavily subsidized by young healthy people. Any change to the systems that Kein and you presumably favor is going to entail more rationing for nonpoor old people. Given that that the Democratic Party has spent 40-plus years teaching this group that health care rationing is mostly for other folks, and given that this demographic is the the most fought over by politicians in elections, what Kevin and you presumably favor simply isn't going to happen.

Posted by: Will Allen on February 14, 2008 at 6:10 PM | PERMALINK

I have watched office clerks brought practically to tears trying to deal with a waiting room full of patients ... Big deal. Many employers can drive employees to tears while living the good life themselves.

I recall years back I got to the office, watched my co-workers file in and out of the office, and became so depressed that I had to work at that company with these assholes I started weeping and ran back home for the day.

In my tennis bum days I used to play with a lot of doctors at the club, since they seemed to be the only ones besides us bums to have the time to hang around the club during the day. One anasthesiologist I played with all the time only worked on Saturdays for 30 times my hourly rate in those days. Don't know that they're all suffering drudges.

Posted by: Luther on February 14, 2008 at 6:31 PM | PERMALINK

Will Allen: Nonpoor old people in the U.S. face less rationing than just about any large demographic on the planet

To the extent that "nonpoor" old people who are face less rationing than poor old people, it's because they can afford supplemental insurance or pay out-of-pocket, as in say, Canada or France.

nonpoor old people have their care heavily subsidized by young healthy people

And poor old people don't?

Cheer up, if you eat your spinach and look both ways before crossing the street, someday you too can become an evil parasitic old geezer sapping the finances of America's youth to pay for your profligate health care!

Any change to the systems that Kein [sic] and you presumably favor is going to entail more rationing for nonpoor old people.

But not more rationing for poor old people? Why?

Given that that the Democratic Party has spent 40-plus years teaching this group that health care rationing is mostly for other folks

How have they done that? By providing them with a health insurance system that has vastly lower overhead and lower rates of inflation than our "free market" (yuk, yuk) private health insurance. Oh, those evil Democratic politicians!

Posted by: alex on February 14, 2008 at 6:40 PM | PERMALINK

No, alex, by providing them less rationed health care than nonpoor old people anywhere else on the planet. Old poor people don't vote nearly as much as nonpoor old people, and nonpoor old people greatly outnumber them, so, no, nobody much cares if old poor people endure a lot more rationing. That's how democracy works, which you seem to think is a fine thing.

By the way, were you just munching on straw, or did I ever make any reference to a "free market" in health care?

Posted by: Will Allen on February 14, 2008 at 6:48 PM | PERMALINK

Will Allen: by providing them less rationed health care than nonpoor old people anywhere else on the planet. Old poor people don't vote nearly as much as nonpoor old people, and nonpoor old people greatly outnumber them, so, no, nobody much cares if old poor people endure a lot more rationing.

You still haven't explained how the government rations health care for poor old people more than it does for "nonpoor" old people.

If you meant rationing by factors other than government, then obviously the greater funds of the nonpoor mean that they'll be less rationed because they can supplement their government funded care by non-government funded care. But that seems such a trivially obvious point that, absent your assertion to the contrary, I'll assume you weren't bothering to make it.

That's how democracy works

One person, one vote? Ideally, yes. Do you have a better suggestion? Perhaps our current one (million) dollars, one vote system is better? Would poor old people fare better under such a system?

Of course we could instead have a purely market driven paradise. I'm sure that poor old people would fare much better under that system.

did I ever make any reference to a "free market" in health care?

Did I say that you did?

Posted by: alex on February 14, 2008 at 7:07 PM | PERMALINK

I think Americans are starting to focus on good things, like wear and tear on pysches. I like the Canadian system just fine. I don't worry, and indeed don't even think about physical complaints in money terms. If Americans had that peace of mind, I do think they would be happier. Best wishes.

Posted by: Bob M on February 14, 2008 at 8:33 PM | PERMALINK

Alex, yes, the nonpoor elderly have an easier time with Part B premiums, something that Medicaid bridges for the poor imperfectly, and of course they can pay for private coverage, so the poor elderly do face more rationing. That isn't the end of it, however. The fee structure Medicare imposes on providers results in cost shifting to young people which benefits, in the form of less rationing, non-poor old people, which poor old people do not fully benefit from. Believe it or not, "private" medigap policy premiums do not reflect the true cost of what is being provided.

One of the pillars of the Democratic Party's electoral strategy for the past 40 years has been to allow nonpoor old people to shift their medical expenses onto young people, many of them poor young people. If the young poor people have been lucky enough to get old enough to start being the beneficiaries of such cost shifting, it has sometimes worked out for them, assuming they didn't desperately need the money they were spending to cover such cost shifting for other purposes along the way. If they did need that money desperately for other purposes, or if they had the bad judgement to die before becoming Medicare eligible, well, they got screwed.


Also, please name a citizen who gets to enter the voting booth, and casts more than one vote.

Finally, you may not be aware of it, but when you use quotation marks, it is very frequently interpreted that you are quoting someone.

Posted by: Will Allen on February 14, 2008 at 8:39 PM | PERMALINK

As it happens, here's an article which appeared today which nicely sums up what the primary function of our national government has become; transferring wealth from poorer, younger, people, to wealthier old people.

http://www.usatoday.com/printedition/news/20080214/1a_lede14_dom.art.htm

Posted by: Will Allen on February 14, 2008 at 9:08 PM | PERMALINK

SocraticGadfy - dude, that was 20 years ago. Today they are waaay behind. When I can point someone to 42 surgeons in the US doing a particular procedure and can't come up with a SINGLE ONE in Canada doing that procedure, something is fucked up.

Posted by: arteclectic on February 14, 2008 at 9:09 PM | PERMALINK

Will Allen: the nonpoor elderly have an easier time with Part B premiums, something that Medicaid bridges for the poor imperfectly

So you would suggest better bridging? I agree.

The fee structure Medicare imposes on providers results in cost shifting to young people which benefits

Just because providers make more money on young people with benefits, doesn't mean they don't make money on Medicare patients.

allow nonpoor old people to shift their medical expenses onto young people

Those parasitic old coots.

many of them poor young people

A problem. Certainly that was lessened by lifting the salary cap on the Medicare tax (another act of the Democratic conspirators). Perhaps you would suggest that we eliminate the flat payroll tax though, and replace it with a progressive income tax? I agree.

please name a citizen who gets to enter the voting booth, and casts more than one vote

We could play the game where you act obtuse, but I'm not in the mood. Alternatively you might believe that campaign spending doesn't strongly affect election results, but that would strain credibility.

you may not be aware of it, but when you use quotation marks, it is very frequently interpreted that you are quoting someone

No I wasn't aware - thanks for the punctuation lesson.

Allow me to return the favor. Perhaps you weren't aware that when a single term is quoted without attribution it simply implies that the term is often used that way, but the writer doesn't agree with that usage. Alternatively it may indicate metaphorical or ironical usage by the writer.

Posted by: alex on February 14, 2008 at 9:30 PM | PERMALINK

arteclectic: The real issue is that [Canadian] doctors are 10 years behind the US and UK in adopting new surgical procedures.

Why? Clearly it isn't UHC, or even single payer, as the UK isn't so far behind (and spends less of its GDP on health care than Canada).

Posted by: alex on February 14, 2008 at 9:35 PM | PERMALINK

Alex, something has happened in your brain to cause you to believe that the phrase "cost shifting to young people..." has relevance to the phrase "does not mean they don't make money on Medicare patients", in terms of whether nonpoor old people benefit significantly from less rationing due to such cost shifting. It doesn't. Now, if your point is that providers charge too much for non-Medicare patients, yes, you could impose the same fee structure for them, which would mean more rationing for everyone, including the nonpoor elderly, which, of course is politically impossible, because the Democratic Party has spent 40 years telling the nonpoor elderly that they should not have to endure the same rationing that the nonpoor elderly endure everywhere else.

Perhaps I could suggest that we eliminate Medicare taxes on the first $30,000 in income, and replace it with a no-deduction 100% estate tax, payable until all medicare benefits paid are recovered. I'm sure you'll agree

The alternative is that you think it is the civic duty for much younger, much poorer people, to give their income to much richer, much older people. I disagree.

Posted by: Will Allen on February 14, 2008 at 9:54 PM | PERMALINK

Also, you might also believe that no matter what money is spent on campaigns, it doesn't do anything to prevent a citizen from casting the ballot for the candidate he or she supports. If Bill Gates and Warren Buffett combined their fortunes tomorrow, with the goal of electing politicians who would institute the Canadian system in the U.S., all they would accomplish is the distribution of 100 billion dollars, without even coming close to accomplishing their goal.

Posted by: Will Allen on February 14, 2008 at 10:00 PM | PERMALINK

Will, methinks you doth protest too much.

Posted by: Bob M on February 14, 2008 at 10:06 PM | PERMALINK

Golly, Bob, I didn't know I was protesting anything.

Posted by: Will Allen on February 14, 2008 at 10:29 PM | PERMALINK

Will Allen: "cost shifting to young people..." has relevance to the phrase "does not mean they don't make money on Medicare patients"

So if sell a car to person A, priced such that I make a profit of X, and then sell an identical car to B, priced so that I make a 2X profit, I'm "cost shifting"? Health care providers certainly have interesting accounting terminology.

Perhaps I could suggest that we eliminate Medicare taxes on the first $30,000 in income, and replace it with a no-deduction 100% estate tax, payable until all medicare benefits paid are recovered. I'm sure you'll agree

Hmmm, kind of like saying that since I'm not a fascist, I must be a communist.

Alternatively, in my non-boolean world, we could exempt the first $30k in income, and then apply a single rate tax on income above that. Certainly an income tax would be an improvement on what we have now - a payroll tax. Or do you believe that poor young people should subsidize people collecting lots of capital gains? (as they do now, given the capital gains rates in the income tax).

you might also believe that no matter what money is spent on campaigns, it doesn't do anything to prevent a citizen from casting the ballot for the candidate he or she supports

Ok, we'll play the obtuse game.

It doesn't "prevent" them from voting for whoever they support, but the aggregate affect is to affect who they're likely to support.

Alternatively, you believe that campaign spending never influences people, and hence is entirely wasted. If so, then I've got a bridge to sell you.

Posted by: alex on February 14, 2008 at 10:36 PM | PERMALINK

Alex, if you are gojng to draw an analogy, would you please use one that is apt? Yes, if the state sets a cost schedule for certain customers on a car, yielding a profit of x, and every other customer pays a price which yields 2x in profit, the state has cost shfited from one kind of customer to another, functionally reducing the rationing of that car for customer who is paying a price which yields x in profit. Now, if the customers paying the lower price are part of a demographic which is highly sought by politicians, it becomes very unlikely that any reforms will be possible.

Perhaps you could explain what is entailed in an estate tax which recovers benefits paid that is consistent with communism.

Actually, I'd rather not have income or payroll taxes, and would simply prefer to shrink government enough to where a progressive consumption tax would be viable.

Finally, I know you think people aren't capable of making informed decisions in their own interest, without your guidance, hence your desire to prevent some parties from attempting to persuade others. How authoritarian of you.

Posted by: Will Allen on February 14, 2008 at 11:23 PM | PERMALINK

Alex: Why? Clearly it isn't UHC, or even single payer, as the UK isn't so far behind (and spends less of its GDP on health care than Canada).

To be honest, I'm not sure, but if I were a gambling woman I'd be placing my bets on politics. I'm in contact with surgeons across the globe and each system has failures. For example, the NHS in the UK was years ahead of the US in adopting newer wound healing technologies and products like alginates. My suspicion is that UK wound healing professionals had a greater "voice" to push the Drug Tariff to allow alginates to be a covered cost. Patients had to push US insurers pretty hard before they would start covering use of alginates in wound healing even though they had been proven to produce superior results.

I hear from surgeons in the US that the primary reason it is so hard to get new techniques and surgeries adopted comes down to not having an acceptable "billing code" for repayment. The surgeons doing pioneering work are forever having to figure out how to come up with billing codes that pass insurers. I would hazard a guess that is what is wrong with the Canadian system as well but on a much grander scale.

"We've never heard of that and don't know how to code it, so we won't cover it."

In my mind, the danger in any health care system is in who sets the limits and codes on what is "allowed." That person has to be forward thinking and progressive in allowing advances in care and still keeping on budget. When it becomes nothing more than bean counting the advances in medicine suffer -- no matter what country you are in.

Posted by: arteclectic on February 14, 2008 at 11:23 PM | PERMALINK

Will Allen: if the state sets a cost schedule for certain customers on a car, yielding a profit of x, and every other customer pays a price which yields 2x in profit, the state has cost shfited from one kind of customer to another, functionally reducing the rationing of that car for customer who is paying a price which yields x in profit.

Of course you're conveniently neglecting the fact that the state does not, in general, force providers to accept Medicare. Some don't. Some do and cry poverty. Yet they stay in business. Funny, isn't it?

And, in moaning endlessly about the shift in "rationing" that this causes, you're assuming that the slope of the supply curve is such that it's a significant factor compared to all the other market "distorting" factors involved in health care economics.

Most importantly, you're ignoring the overwhelming empirical fact that countries which universally set price caps not only pay less for health care, but ration it less than we do in the US. It seems that the problem isn't that we set price caps for some, but that we don't set them for all.

Perhaps you could explain what is entailed in an estate tax which recovers benefits paid that is consistent with communism.

Methinks it'd be better to explain what a simile is, but there are dictionaries for that.

Actually, I'd rather not have income or payroll taxes, and would simply prefer to shrink government enough to where a progressive consumption tax would be viable.

Having a progressive consumption tax instead of payroll and income taxes has nothing to do with shrinking the government.

I know you think people aren't capable of making informed decisions in their own interest, without your guidance, hence your desire to prevent some parties from attempting to persuade others.

On the contrary, it's you who wants to limit the parties that can persuade others to those parties that can collect enough bribes. I'd prefer that all parties be heard without having to prostitute themselves.

Posted by: alex on February 15, 2008 at 12:09 AM | PERMALINK

No alex, the most politically powerful group in the U.S., nonpoor retirees, endure less rationing than any other large demographic on earth. They are the ones that set the terms of the debate, largely due the Democratic Party's electoral strategy for the last 40 years. They aren't interested in experiencing more rationing than what they now experience. Thus you aren't going to get what you desire.

Alex, a person who claims that the viability of a consumption tax is not related to how much money needs to be raised, and thus how large the government can be, due to the incentive for avoidance, and thus the creation of black markets, is entirely too ignorant to discuss the matter.

Yes, I know you wish to oversee persuasive efforts in this country, given your authoritarian mindset. You really despise the notion of people not behaving in the manner you see fit.

Posted by: Will Allen on February 15, 2008 at 1:31 AM | PERMALINK

from Bob M: "If Americans had that peace of mind, I do think they would be happier."

As an American currently living in the Netherlands, I must agree. It is as amazing relief to know that everything is covered (doctor, hospital, pharmacy, etc), and that there will be no financial costs if a medical problem arises.

Posted by: J on February 15, 2008 at 3:01 AM | PERMALINK




 

 

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