So I went to VA1 this morning. Now I had no appointment (my pain only became unmanageable in the last week) so I had to go through the walk-in clinic. My preferred clinic is Women Health and their walk in hours are only on Mondays and Thursdays so when I got there at 11:20 today I was totally prepared to wait. And I did. For about 25 minutes. I spent the time explaining computers to a very nice fellow vet with a brand new Gateway and no clue how to use it. Eventually a nurse came to get me. She checked my vitals, asked for my primary complaint, and asked all the standard questions about the rest of my health. I explained my problem and she got me set up with the Nurse Practitioner. She kept me waiting for a few more minutes while she read through my electronic medical records and familiarized herself with my case.
There was some more discussion of my complaint and an exam and then the NP set me up with a laundry list of appointments (a full physical, my next mammogram, physical therapy, podiatry, and an orthopedic consult) and I did spend some time in there getting a lecture on my lifestyle and my arthritis. Because she wanted to impress upon me that my condition is progressive and my tendency to overwork myself is a bad idea. Those of you picturing a frustrated medical professional contemplating hitting me with a hammer? That picture is pretty close to correct. Bonus points if you imagined me edging toward the door blathering about the errands I needed to run. She finished her lecture and prescribed me a drug with a name like a Transformer before sending me downstairs to make sure that my prescription coverage eligibility was in the system.
I stopped at the pharmacy to get a number before I went to the eligibility desk. That took longer than expected (20 minutes) so by the time I got back to the pharmacy I had to get a new number. There was some more waiting to get my med consult (they explain the dosage instructions and all the possible side effects to you) and get my actual meds. At 1:30 I was on my way. My appointment list is pretty long because I haven’t been seen in over a year, but that’s my fault since I generally don’t go to the doctor unless I’m sick. Now I’m home again, I’ve taken the medication and for the first time in several days I am feeling no pain. Total cost? 0 dollars. That was government run healthcare from start to finish. If I wasn’t eligible for the prescription coverage? My medication would have been $8 for a 90 day supply.
If you’re thinking that I earned this because I was in the Army? Nice sentiment, but completely and totally ridiculous. I paid taxes before I was ever in the Army, and really no one should have to spend days in pain with no hope of affording treatment. Now, near as I can tell the medicine I was prescribed runs right around $1 per pill for a 90 day supply. Not insanely expensive, but not cheap either. And I’m sure there are people out there with osteoarthritis that are struggling to afford the pills, never mind trips to a podiatrist, physical therapy, or consulting with a orthopedic specialist. I want people in pain to have access to the exact same treatment I enjoyed today. My tax dollars are in the same pool as everyone else’s and if I can benefit from yours? I want you to benefit from mine.
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Footnotes
- Veterans Affairs Hospital. I am a service connected disabled veteran of the US Army and as such I am entitled to healthcare through this government agency. This is a good thing because most private insurance won’t touch me. I have the dreaded pre-existing condition of osteoarthritis along with some other chronic health issues
I am happy to pay the taxes to pay for your subsidized care in the VA system, precisely because you are a veteran.
I am not willing to pay the same taxes to pay for your sister’s care, the one who ran off to Vermont to become a hippie or to NYC to become a high-powered corporate lawyer.
So, Robert…..civilians don’t also serve their country? Including civilians who are not physically eligible for military service? Interesting.
My appointment list is pretty long because I haven’t been seen in over a year, but that’s my fault since I generally don’t go to the doctor unless I’m sick.
Dammit, I’m getting an e-hammer and beating you with it! You* need regular checkups. If you got them there’d be some chance that you wouldn’t end up at the VA without an appointment and in pain so often. And your (hopefully never existent) breast cancer/hypertension/diabetes/etc would be found at an earlier and more treatable stage. Plus you’d be at lower risk for hammer related injury.
*And just about everyone else with the possible exception of (some) men under 40.
I believe the idea of incentives/rewards for particularly dangerous, harrowing, or valuable service is pretty self-explanatory, La Lubu, and has nothing to do with disdaining the people who aren’t entitled to the reward.
Ability to live without pain (or just flat out live) = reward. Okay, that’s interesting.
So, basically you just want people to suffer if you don’t approve of choices they make.
I believe that Robert is going by the philosophy espoused in Heinlein’s Starship Troopers, among other of his novels.
No. “Free medical care for life” = reward. Which many people are willing to pay taxes for. Many people are willing to pay taxes to pay for free health care for elderly people (~$450 billion or so), free health care for the very poor and/or helpless (~$300 billion), and free health care for (disabled) vets (~$40 billion). That’s not because we hate young people, rich people, and peaceniks/vets who didn’t get disabled on duty.
What many people are not willing to do is to pay taxes to provide free health care to everyone. That isn’t because we hate everyone, it’s because we think that subsidies need to go first to the elderly, the poor, and to the people who put their lives on the line for the country – and although we’re able to put out some ~$800 billion annually in subsidies, amounting to a $2300 contribution from every man, woman, and child to this subset of the population, we don’t think we can put out the extra trillions each year to give EVERYBODY the same thing we can give to our old, our poor, and our heroes.
We don’t have $4600 or $6900 per capita to give away. People need that money for their own health care, for their own mortgages, for their own living expenses.
What many people are not willing to do is to pay taxes to provide free health care to everyone.
Why not? It’d probably be cheaper in the long run than our current system which encourages very inefficient care, often at taxpayers expense. And unless you’re willing to say that it’s ok to let people die in the ER because they can’t prove that they can pay then you’re (um…generic you, as in you the taxpayer, not Robert in particular) stuck with paying for emergency care.
Before you say, ok, fine, let’s go to the Chinese system remember that means that if you got hurt at a time when you didn’t happen to have your proof of insurance card on you, that means that it’d be you dying in front of an ER, no matter how rich and/or insured you really are.
I’m medically unfit to serve and my Facebook profile identifies me as a Communist, so there you go, La Lubu.
Why not? It’d probably be cheaper in the long run than our current system which encourages very inefficient care, often at taxpayers expense.
Cheaper is not an absolute trump. It would be cheaper to make everyone eat and live in a government dorm; it would just be anathema to our values of individual choice and liberty.
Robert,
You seem to be laboring under the impression that private insurance is somehow different from paying into a tax pool to cover healthcare. For that matter you seem to think that uninsured = not paying taxes. Both ideas are based on some very faulty groundwork. The working poor (an ever larger group) are paying taxes, but they make too much to qualify for federally subsidized medical cards under the current system. Many of them have served their country, (after all unless they have a service connected disability they do not qualify for the care I received today) and they are suffering from being underemployed/uninsurable because of their service.
Are you saying that they don’t deserve healthcare? Somehow I suspect you think that they should also have access to treatment. Well so should their spouses and children and friends. Because they’re contributing and sacrificing too. There’s more than one way to serve a country after all.
Every month that you don’t use the insurance that you mention paying for? You’re paying for someone else’s healthcare. So, what’s the difference between paying a company and the government for someone else’s healthcare (even as someone else is paying for yours) and simply paying the government so that everyone is covered?
I don’t think dying, living in pain, and living in massive debt is really within our values of liberty and freedom, really.
(I’ll leave aside individual choice, because I’m unsure of how much we actually have after taking advertising, sociology, political science, and psychology).
I’m currently in grad school and on a student health insurance plan, which is crap compared to other private plans, but at least it’s something. I’ve also got a genetic condition that, among other things, causes chronic pain. One of the people that Obama spotlighted at one of the meetings as someone who can’t get private insurance because of a preexisting condition was someone who has the same condition that I do. Lots of universities lately have been saving money by hiring professors as adjuncts rather than actually hiring them onto the faculty, which, depending on the school, can mean no benefits, and thus no job-provided medical insurance. I have no idea what I will do after I graduate if I can’t find a job that comes with health insurance, because I’ve got regular doctors appointments, physical therapy, medications, and periodic x-rays and MRIs, and I know that I can’t afford that on an adjunct professor’s salary. And without all that stuff, I’m in so much pain that I really can’t work.
I don’t think dying, living in pain, and living in massive debt is really within our values of liberty and freedom, really.
Neither is having our healthcare decisions made by politicians, or having our wealth taxed away for the benefit of able-bodied people.
If you don’t pay, broadly, for your own health care expenses, then who is going to do it? Assume you’re an ordinary person making an ordinary living, neither wealthy nor destitute. There are only three possibilities for who pays, if you don’t:
A) People who make more than you will pay for it.
B) People who make less than you will pay for it.
C) People who make the same as you will pay for it.
C) is basic socialism – spread the expenses, spread the wealth, even things out; not much wrong with that in theory, but it isn’t what most Americans want, so it isn’t on the table.
B) is morally repugnant.
A) sounds great – but the supply of rich people is limited, and we are already (as noted) tapping them for the sweet part of a trillion dollars a year in order to pay for the truly poor. We can tap them for more, perhaps, and improve those systems (which do need improving) – but we cannot tap them to pay everyone’s costs. They don’t have enough, in the first place, and they won’t put up with it, in the second.
There are many things wrong with our current system (foremost of which is our reliance on insurance as the default financial model, which is frankly stupid) but we won’t improve things by declaring ourselves all entitled to above-average care.
The original poster (forgive me, I can’t remember your name, and if I scroll up the posting software eats my comment whole for some reason) would like everyone to have VA-level care. So would I. Heck, we’d both like everyone to have super-VA care, “Star Trek” level care. The difference is not what we want, it’s that I know we can’t afford to provide everyone with VA-level care. The last figures I saw guesstimated that the VA spends two or three times as much per capita as Medicaid/Medicare – both of which are going broke slowly.
Cheaper is not an absolute trump. It would be cheaper to make everyone eat and live in a government dorm; it would just be anathema to our values of individual choice and liberty.
Bad analogy, if what we are discussing is having the government fund all care (Medicare for All), rather than directly provide all care (NHS without the option of “topping up” private insurance, which most of the Brits I know get through their employers anyway).
Also, if you really don’t grasp the difference between daily needs (food, shelter) and occasional needs that lend themselves to risk pools (more-than-primary-healthcare, fire in one’s home, etc.), then this is a futile discussion.
C) is basic socialism – spread the expenses, spread the wealth, even things out; not much wrong with that in theory, but it isn’t what most Americans want, so it isn’t on the table.
That’s pretty much what Britain has, since their tax rates are much flatter than ours. I.e. they have only two brackets: 20% for non-investment income of £0 – £37,400; 40% for non-investment income over £37,400.
Also, what karnythia said in the comment below that seems to have gotten messed up in the software on this site.
Ruchama, people like you are in a terrible bind because we’ve focused our health care system on insuring that people won’t have to cover their bills for major procedures, because those bills are so high.
But insurance is not a good method of equitably distributing expenses or allocating resources; insurance is a bet between the insurer (who is hoping you’ll pay a lot in premiums and collect nothing in benefits) and yourself (who are probably hoping the same thing because you’d rather stay healthy, but as an acceptable outcome, will take “pay a lot in premiums and then collect a lot in benefits”).
The trouble for people like yourself is that there’s no bet. The insurer knows they can’t make a profit on your bet; there is no bet because it’s a certainty that you’ll run up big bills. That being understood, it is fruitless for you to seek out an insurer just as it is fruitless to attempt to place a bet on a horse race that has already been run. You can’t get insurance because there’s nothing to insure.
So what we need is a system, not where we require someone to “insure” you – like demanding that bookies take post-event bets from certain clients, that will just destroy the insurance system which does work for people where there is risk to be arbitraged, but rather a system whereby you can get the health care you need at a price you can afford, and where you can get access to the resources you need when you CAN’T afford to pay anything.
The market can provide services at the best price, when it isn’t distorted by regulatory requirements that demand people pretend they don’t know the horses have already run. So if you’re earning a good living, you can pay for your own care. In the case where you aren’t earning a good living, the most obvious method would be for the government to back a consortium of private lenders who would loan you the money. A backup system, for people who just cannot be expected to repay such a debt, would be a public health system for the indigent which you could access.
Yes, that might end up piling a lot of debt on your head, and making it hard or impossible for you to enjoy some things like home ownership that people without such health problems can enjoy. I am sympathetic to the situation, but I believe that intellectual coherence requires us to assign costs to the people who incur them. I have a huge debt because I have a house and an education that I went into hock to pay for; why should I not pay that debt back? You may have a huge debt because you have used a huge chunk of expensive and hard-to-produce medical talent and resources. I enjoy the use of my house; you enjoy the use of your continued life. TANSTAAFL.
We can make the lunch cheap for the people who really can’t pay; we can decide that certain groups should get a free lunch and put it on our tab; we cannot justifiably decide that all lunch should be free, and expect to find the lunch counters open over the predictable future.
Also, if you really don’t grasp the difference between daily needs (food, shelter) and occasional needs that lend themselves to risk pools (more-than-primary-healthcare, fire in one’s home, etc.), then this is a futile discussion.
People who genuinely have occasional needs for health care are well-served by private insurers. It is people who are obviously going to incur expenses who are not well-served, because their need is no longer occasional; it is chronic.
But as a general principle, we ALL know that we will incur significant health expenses at some point in life, barring statistically rare accidents that cut us off cheaply in our prime. (Start training city bus drivers more poorly, and we can cut our expenses enormously!) Insurance is a very poor model for that type of expense curve, where we don’t know “when” but we have a 90% surety of “what”. That type of expense is much better met with a combination of savings programs and lending programs.
I enjoy the use of my house; you enjoy the use of your continued life.
You can sell your house. I don’t really have that option.
People who genuinely have occasional needs for health care are well-served by private insurers. It is people who are obviously going to incur expenses who are not well-served, because their need is no longer occasional; it is chronic.
I think it would be more accurate to say that private insurers are not well-served by having these people as customers.
Overall, I find the whole argument that “this is not how other types of insurance work” to be completely disingenuous. We have this system. Somewhere along the line, it started to be called “insurance.” Whether the use of that term for the companies that manage our medical bills is consistent with the other uses we make of that term is about the least relevant piece of information I can think of.
And I’ll third Karnythia’s question about why it’s okay to pay into a private insurance pool and have people who need more care get more care but somehow it’s a horror to pay taxes into a pool and have people who need more care get more care.
But as a general principle, we ALL know that we will incur significant health expenses at some point in life, barring statistically rare accidents that cut us off cheaply in our prime. (Start training city bus drivers more poorly, and we can cut our expenses enormously!) Insurance is a very poor model for that type of expense curve, where we don’t know “when” but we have a 90% surety of “what”. That type of expense is much better met with a combination of savings programs and lending programs.
I don’t think that’s necessarily true. I’ve had four family members die in the past 18 months. My aunt died of cancer at 48, after having her first tumor at 24. For her to live long enough to see her only child turn 21 cost millions of dollars in surgeries to remove tumors, chemotherapy, hip replacement, pain medication and end of life care (she spent her last few days on a ventilator).
My maternal great grandmother (mother’s mother’s mother) died in her sleep at 100. Until the last 5 years of her life, she could walk fine, had all her own teeth, and was still mentally with-it. She wore glasses (which were really cheap lenses and gave her eyes a very bizarre appearance) and took two generic medications. She was extremely healthy throughout her life, had seven kids live to adulthood out of eight births, and ruled her husband with an iron fist undisguised by velvet glove. Her total lifetime cost of medical care was probably $5000.
My paternal grandfather died at 79. He had a lifelong problem with alcohol, although he did spend some long stretches without drinking (though those tended to be obnoxiously religious phases), and he was diabetic for the last 15 years. His lifetime medical care, probably about $200k. I can’t say whether getting him proper treatment for the alcoholism would have been a cost saving or not — almost certainly it would have extended his life.
One of my paternal uncles died at 54 in a car wreck. He was in reasonably good health and probably would have lived another 20-30 years in decent shape — he didn’t smoke, didn’t drink excessively, etc. His lifetime medical costs were pretty low as well.
I should note that my family doesn’t believe in going to the doctor when you’re well, even though my dad IS a doctor. I went to the dentist for the first time when I was 11, and only started getting yearly checkups when I started going to the gyno for pap smears.
But anyway, lots of people live a pretty good long time without incurring much in medical costs. Running up a big medical tab isn’t inevitable for everyone. It happens for some people early (like my aunt) and some later (like my grandfather) and some not at all (like my great-grandmother and uncle, albeit with very different number of years lived). It’s partly luck of the draw; partly choices in life (though I have a permanent hatred now of John Mackey for saying that you can avoid cancer and all its expenses if you’d just eat right and exercise — my aunt was a lifelong vegetarian, you stupid fucking hippie).
It is precisely this variation in possible experiences that makes health care appropriate for risk-pooling. I don’t know if I will be like my aunt and have tumors removed before I ever have a child; or like my great-grandmother and outlive my husband, siblings and half my children. Uncertainty about health care needs = insurance coverage for health care.
Maybe not yearly-checkup kind of health care or birth control kind of health care, but certainly oh-crap-I-have-X-unexpected-condition-requiring-regular-MRIs health care. In fact, I’d say anything that involves “Oh crap” probably lends itself toward risk pooling through insurance. “Oh crap someone dented my fender and didn’t leave a note.” “Oh crap we got robbed.” “Oh crap the garage caught fire.” “Oh crap I feel a lump in my breast.” Stuff you actually do know will happen — snow that makes a roof over your head nice; hunger that comes three times a day requiring food — or actually want to have happen (kids get into expensive Ivies) — it doesn’t make sense to insure.
Or perhaps it’s just the difference between the healthy people who look at the less-healthy and say “Heh, sucks to be you!” and the healthy people who look at the less-healthy and say, “There but for the grace of God … so far.” And keep up their insurance coverage.
“People who genuinely have occasional needs for health care are well-served by private insurers.”
No, actually, we’re not. Because our claims can be and often are denied.
You can sell your house. I don’t really have that option.
I acknowledge this. You have it worse than me; I’m luckier than you. Although I do have long-term health concerns of my own, as do nearly all Americans eventually.
And I’ll third Karnythia’s question about why it’s okay to pay into a private insurance pool and have people who need more care get more care but somehow it’s a horror to pay taxes into a pool and have people who need more care get more care.
Both are OK, depending how you do it. We regulate the industry, for good reasons; we have similarly good reason to regulate the government.
The way to get quality health care is not to force people to do things and require people to make certain deals, often unwanted in both ends. That way lies madness. The state obviously must wield some coercive force, but that force is singularly misapplied when it comes to the economic decisions of private people. The Congressional proposals amount to requiring people to walk into a casino and make a certain number of bets, on the grounds that the casino industry has a decent health plan.
The motivation is laudable, but the tool chosen to encourage the desired action is inappropriate.
Instead, the way to get more and better health care is to allow people to make their own decisions regarding their quality of care, whether it be “die in the gutter” or “die in the most expensive cardiac ward in New York City”, but carry a basic presumption that they will be expected to pay for those decisions.
We pay more than $7400 a year, per capita, for our health care system in total. About $2300 of that per year, again per capita, is handled by the government and goes to provide free care to the elderly, to the poor, and to a relatively small number of especially needful veterans. About one-third of our total health care spending is specifically directed to the people who most of us would consider the ones who deserve special treatment and assistance.
It would not be fair or just for elderly people long past working age, or very poor people who can barely afford material sustenance, to be left to die. We find that a terribly distressing prospect, and so we collectively block it. I’m not even going to look up what the charity figure is on top of the government figure; it’s huge, I know. (Tens of billions at minimum.)
Medicaid and Medicare and the VA (and state facilities which are not broken out above) are all good and worthy things, which deserve support and improvement. I would welcome constructive liberal-minded solutions for the problems besetting those institutions from the administration or Congress, but haven’t seen many. But they do exist and we are obviously willing to fund them at pretty hefty levels.
The rest of us have to pay our own way. If we want to finance that in collective fashion, through co-ops and insurance systems and such, that is absolutely fine (as long as it is voluntary) – such spontaneous organization is very socially beneficial. Let a thousand health-care co-ops flower. But the principal responsibility for funding health care is just like the principal responsibility for funding food, shelter, fun, and frolics – the individual who wants to enjoy the good.
Critics of this rightly decry that individuals will often founder on necessities far outweighing their resources. Most advocates of a liberty-focused approach accept the justness of this complaint. But the solution is to make contingency resources available, at a sufficient cost to the recipient to eliminate moral hazard from subsidy, so that the care can be provided while the responsibility remains with the beneficiary.
To finance such care, the government could readily create credit markets for healthcare loans with reasonable interest rates, using its enforcement power somewhere where it is appropriate to do so – to uphold a contract, and thus make it a negotiable instrument. People will loan you $100,000 for a new kidney, if they are pretty sure they’re going to get it back with interest. The government is actually good at guaranteeing “pretty sure”.
Some illnesses incur expenses so large that even a high-earning middle class professional is going to have trouble making the bill. Cancers can run into the millions of dollars. (Many others fortunately or unfortunately don’t, of course.) Again, non-coercive means can mitigate, if not altogether blunt, this negative consequence of freedom. People can collect and give money. They can even do this through their governments, if they wish to.
And you’d still be free to buy or sell whatever private insurance you could arrange within the law, just as today. (Though the laws should be greatly liberalized so that people can offer more and different kinds of insurance.)
Such a system makes care near-universally available – and near-universal is pretty damn good. If we as a society decide that the outcomes from such a system are too harsh (I suspect they would in fact be significantly superior overall to what we enjoy today) it would be relatively simple to apply some form of incremental taxation to income, presumably hitting the richer people harder, to do direct transfers at whatever magnitude the polity feels appropriate. That would be unhappy-making for libertarians, but the minimally intrusive way of accomplishing the social good.
But it requires giving up a great deal of control, and that is a very hard thing for people to do.
The way to get quality health care is not to force people to do things and require people to make certain deals, often unwanted in both ends. That way lies madness. The state obviously must wield some coercive force, but that force is singularly misapplied when it comes to the economic decisions of private people. The Congressional proposals amount to requiring people to walk into a casino and make a certain number of bets, on the grounds that the casino industry has a decent health plan.
Why doesn’t all of this apply equally well to Medicare? FICA taxes are coercive — I don’t get an option on whether I want to contribute to Medicare and Social Security. Perhaps I’m planning to off myself at 65 to avoid the indignities of aging, and I’ll never get to enjoy what a chunk of every paycheck was supposed to buy me at the end. Medicare and SS, after all, are not means-tested programs; they aren’t “welfare” in the traditional sense of “aid only to the poor.” They are the third rails of American politics precisely because they are enjoyed by everyone in the most consistent voting bloc in America.
Is it just that you’ve resigned yourself to Medicare as the status quo, or do you actually have a principled distinction between all of us paying in taxes to have a shared insurance pool for our senior years (that being the theory behind FICA taxes, if not the reality) and all of us paying in taxes to have a share insurance pool for all of the years of our lives?
The way to get quality health care is not to force people to do things and require people to make certain deals, often unwanted in both ends. That way lies madness. The state obviously must wield some coercive force, but that force is singularly misapplied when it comes to the economic decisions of private people. The Congressional proposals amount to requiring people to walk into a casino and make a certain number of bets, on the grounds that the casino industry has a decent health plan.
Why doesn’t all of this apply equally well to Medicare? FICA taxes are coercive — I don’t get an option on whether I want to contribute to Medicare and Social Security. Perhaps I’m planning to off myself at 65 to avoid the indignities of aging, and I’ll never get to enjoy what a chunk of every paycheck was supposed to buy me at the end. Medicare and SS, after all, are not means-tested programs; they aren’t “welfare” in the traditional sense of “aid only to the poor.” They are the third rails of American politics precisely because they are enjoyed by everyone in the most consistent voting bloc in America.
Is it just that you’ve resigned yourself to Medicare as the status quo, or do you actually have a principled distinction between all of us paying in taxes to have a shared insurance pool for our senior years (that being the theory behind FICA taxes, if not the reality) and all of us paying in taxes to have a share insurance pool for all of the years of our lives?
Not true.
In 2006 dollars, medicare cost an average of $8,304 per enrollee. (This varied regionally, from a high of $16,351 in Miami to a low of $5,311 in Honolulu.) (Source.)
In contrast, the cost per VA patient is about $5000. So VA care is actually cheaper than Medicare. (Source.)
Medicaid costs about $4,500 per patient — but provides lousy care compared to either the VA or even Medicare.
And as for “going broke” — the VA is superior in that regard, as well. From a CBO report:
VA care appears much more affordable over the long term than Medicaid, Medicare, or private health care.
This article in the Washington Monthly points out that a lot of it comes down to incentives. Most medical systems in the US are set up to render you a single service and charge you for it. This creates an incentive to concentrate on doing lots and lots of individual treatments, without paying much attention to the patient’s long-term health.
In the VA, in contrast, incentives reward keeping patients well. In the long run, that’s both cheaper and better.
Cheaper is not an absolute trump. It would be cheaper to make everyone eat and live in a government dorm; it would just be anathema to our values of individual choice and liberty.
I don’t see how giving people an additional choice (government sponsored health insurance) is taking away liberty and individual choice.
And as for the cost, no country on earth spends as much per capita on health care as the US. So, either US-Americans are uniquely sick or uniquely stupid and unable to make a system that has been successful in every other developed country in the world work. Tsk. So unpatriotic these Republicans-implying that US-Americans aren’t as smart as people in other countries.
Just to confuse the issue further, this abstract suggests that patients with medicare may be getting better care than other patients in some circumstances (specifically, non-Hogkin lymphoma). So much for government death panels: you’re better off with government insurance than with private. At least in this limited example.
PG – Basically resigned to it; people want it, so there it is. My personal view is that such a program is eminently desirable for the elderly poor, unjustifiable for the elderly rich, who should be asked to use their resources to pay for their own care. Medicare for the elderly wealthy is basically a “you can still leave your grandchildren millions” program, and even as a grandchild slated for millions, I think it would be better for them to pull their own weight while they can.
Amp – Thank you for the additional data. It was late; what I was muzzily saying (and got badly wrong) was that the VA spends two or three times more than is being proposed to spend as the median subsidy to average-joes in the Congressional plan. I don’t know why I said Medicare/Medicaid, other than that it was all getting jumbled up together in my head.
And as for the cost, no country on earth spends as much per capita on health care as the US. So, either US-Americans are uniquely sick or uniquely stupid and unable to make a system that has been successful in every other developed country in the world work.
There are reasons that we spend the most per capita, and they have little to do with either sickness or stupidity.
Major factor one, we spend far more on end-of-life care than do most nations with nationalized systems, for the fairly obvious reason that here most end-of-life care decisions are made by patients and their families. The NHS says “sorry, you’re too old for procedure [x]”, while we pay for it. We don’t get much for those dollars.
Major factor two, we spend far more in private dollars than users of those nationalized systems do.
It isn’t so much that Europe spends their health care dollars wisely and we spend them poorly; we both spend them wisely at the bottom 70%, and then the US goes ahead and spends another 30% that Europe doesn’t.
I believe the idea of incentives/rewards for particularly dangerous, harrowing, or valuable service is pretty self-explanatory, La Lubu,
Oh cool! So you are completely on board with the government making COBRA payments for unemployed construction workers! All right! (didn’t know you were so generous!)
You know, what strikes me in the whole conservative uproar against government healthcare (as long as it doesn’t remove the already-existing forms of government healthcare, like the VA system that takes care of karnythia, or the Medicare system that takes care of elders in the U.S.) is the vitriol directed at the working poor and lower-middle/working class people struggling in a shit economy. Because let’s face it—desperately poor people can get access to Medicaid. Working poor people (baristas, waitstaff, dry cleaning staff, grocery checkers/baggers, janitorial crew, etc.)—those people do not have access to healthcare because they do not earn enough money to either pay for care or pay for insurance, but they earn “too much” to get any form of assistance. Working-class and lower middle class people who are in-and-out of work (happening a lot these days!) get separated from their insurance, and can’t afford COBRA. Unemployment benefits aren’t much, but they’re enough to put you out of reach of Medicaid. (it’s probably also worth mentioning that some of those people lost their job because of health issues; not all employers are understanding about cancer).
So, the people who are “doing the right thing”, keeping up their end of the social contract by having (or seeking) a job, getting an education, paying their bills and taxes and such—those are the people who are getting the big middle finger in all this.
Here are the problems:
*insurance is connected to employment (for most people)
*people who have to get on the “free market system” pay up the wazoo, have extraordinarily high deductables to the point where they might as well not have insurance, and any health problem they already have (high blood pressure? pregnancy? carpal tunnel? bad back?) isn’t covered.
*people who have had a previous serious health problem are disqualified from obtaining any health insurance
*the cost of healthcare without insurance is out of reach of the average U.S. wage.
I just read an article in the Atlantic from some moron whose “solution” to the healthcare crisis in the U.S. is simply to have people pay for healthcare themselves, along with a “catastrophic” fund that would kick in if the cost went over $50,000 (he thought that the average person should be able to come up with $50,000). BWAhahahahaha!!! For the average person, $5000 is going to be a catastrophic disaster. 50 grand? you gotta be kidding me. I borrowed $50,000 to buy my house. It’s going to take me thirty years to pay that off. If I didn’t have insurance and I had that much in medical costs, I wouldn’t pass “go”, I’d go straight to bankruptcy court. Bankruptcy only lasts ten years. I can’t afford two houses; what makes this moron think I could afford paying for the equivalent of another house?
Bottom line: the social contract doesn’t exist. There is no respect for the common person. Human value in the United States consists solely in terms of how much money one earns. That some of those people protesting at townhall meetings are among the abandoned doesn’t negate that.
Robert, co-cops aren’t a viable solution. The population base isn’t high enough. And as soon as some member has a catastrophic health issue, the co-op folds. Rich folks who earn over $100,000 or so might be able to fund their own care; the rest of us, not so much. Being working class means not having (or not having much of) a safety net.
And that’s what we’re talking about here—healthcare being a safety net for survival. And who is worth saving.
C) is basic socialism – spread the expenses, spread the wealth, even things out; not much wrong with that in theory, but it isn’t what most Americans want, so it isn’t on the table.
And yet, we have socialized roads, socialized libraries, socialized schools, socialized police forces, socialized courts, socialized fire departments, etc.
Ampersand or Rachel, can you move these comments to the other thread? for some reason, Karnythia’s article ‘ported here three times. Maybe combo and remove the extras?
Most of those things are public goods, Lubu, not private goods. It makes sense to “socialize” items which can’t really be privately enjoyed, or that pay society major dividends above the cost of providing the good. Your education makes me richer because you’re more able to transact with me; it might make sense for me to help pay you to get educated. Your health care, however, benefits primarily you.
If the average person can’t pay for their own healthcare, then how is it to be paid for? There is no free money. Resources are not created because we need them, but from work. We cannot subsidize “the average person” – we can subsidize the poor. People richer than the poor must pay their own way.
Or do you seriously expect the top 2% of the population to carry the medical expenses for 100% of the population?
Karnythia:
You seem to be laboring under the impression that private insurance is somehow different from paying into a tax pool to cover healthcare.
Obviously, it IS different. I have to pay taxes. I do not have to place a bet with an insurer.
For that matter you seem to think that uninsured = not paying taxes.
Not sure why you think so, but no, I don’t.
The working poor (an ever larger group) are paying taxes, but they make too much to qualify for federally subsidized medical cards under the current system. Many of them have served their country, (after all unless they have a service connected disability they do not qualify for the care I received today) and they are suffering from being underemployed/uninsurable because of their service.
I am not disputing suffering.
Are you saying that they don’t deserve healthcare?
What people “deserve” is rarely material to discussions of this type. You deserve to live in a mansion, to drive a beautiful car, to have all the education you can handle, to have a career doing something you love, etc. You deserve all these things because you’re one of God’s beautiful and unique creatures.
What you deserve, and what society can afford to pay for, are two separate questions.
Every month that you don’t use the insurance that you mention paying for? You’re paying for someone else’s healthcare.
Or the health company’s costs (including return to capital) for providing risk arbitrage.
So, what’s the difference between paying a company and the government for someone else’s healthcare (even as someone else is paying for yours) and simply paying the government so that everyone is covered?
Freedom and choice, and the incentives provided to our citizens.
I’m an occasional user of healthcare services and the insurance industry has not served me well at ALL. I recently went to the dentist for the first time in 10 years, and otherwise I only go to the doctor about every 2 years. I’ve had a few big medical incidents – most notably 2 pregnancies and one birth – which were more expensive than average (the ectopic pregnancy required both expensive medication and some followup appointments; the birth was horrendously expensive because of prenatal complications and a c-section).
I *would* go more, but because my insurance has changed every year since I gave birth, whenever I get sick I’m finding a new doctor and trying to get in as a new patient. The wait times for this are not conducive to people with acute illness – last time I had an awful flu I spent three hours calling providers who were covered on my plan looking for someone who would see me, then gave up.
As a patient who is pretty much exactly what the industry wants – pays for years and years with no coverage gaps, is rarely ill, has no degenerative or recurrent conditions (I even took care of my birth control with the method that is absolutely cheapest for the insurer – my partner got a vasectomy) I cannot see someone when I am ill unless for some reason I decide I might be dying and go sit in an emergency room. Which I haven’t done since I broke abone as a kid.
Oh, and my premiums go up every year because of other people’s decisions – such as the insurer’s decision to always rake it in if we pay more than we use, but to always raise rates when they pay out more than we pay in.
Your education makes me richer because you’re more able to transact with me; it might make sense for me to help pay you to get educated. Your health care, however, benefits primarily you.
If I don’t get treatment, then I’m in too much pain to work. I cannot afford the treatment that I need. You’re either paying for my health care or you’re paying for my disability benefits.
You paid for your own disability benefits with your (past) productivity.
If your economic productivity is not sufficient that your wage can pay your costs, then it is also not going to be sufficient to (re)pay the system for the investment you would like it to make. Putting a government stamp on the check doesn’t add any zeroes.
Bluntly, either your productivity pays for your needs or it doesn’t. In the former case, hooray – pay your own way, and pay some more to help people worse off than you. In the latter case, you need charity/help – charity/help which most people, me included, think you should be able to get in one form or another. If you’re really poor, we think the government should help you directly. If you’re not so poor that we should pay your bill for you, then (I at least think) we should loan you the money.
But not at the cost of turning the health care system into the Post Office.
“Rich folks who earn over $100,000 or so might be able to fund their own care; the rest of us, not so much.”
$100,000 a year is only rich in places with low costs of living. It’s easy to spend $100,000 a year on necessities in most big cities. The average cost of a house in the city I live in is $400,000. You say you paid $50,000 for your house. That would buy a parking spot downtown, here. I’m not kidding- and this is not an expensive city compared to, say, New York, Boston or San Francisco.
My husband and I have a combined income in the $100,000 range. We save significant money every month, but we live in a rental and we don’t have kids. We don’t feel rich at all. If we had kids and owned a 1500 square foot house in the city, we’d just be meeting expenses. $100,000 a year is a middle class family income here. To be well off, you’d have to have an income of twice that. To be rich, you’d probably need to make half a million or something.
That’s where the $50,000 = doable for a middle class family idea comes from. We could save that much in five years, but it wouldn’t even be a 20% downpayment on an average house.
Oh, and my premiums go up every year because of other people’s decisions – such as the insurer’s decision to always rake it in if we pay more than we use, but to always raise rates when they pay out more than we pay in.
That’s an insurer’s classic. See also the pattern of raising premiums for medical malpractice coverage in the last 20 years. It has very little correlation with the actual payouts in malpractice awards and settlements (which have remained fairly stable over that time), and a whole lot to do with how the stock market is faring, because in order to make really good profits, insurance companies take premiums and invest them. Market up, premiums can stay the same. Market down, premiums go up.
Here are my recent choices, as a free and liberated American:
I was recently unemployed, looking for work, for 6 months after the recession thingie hit. I ‘chose’ to take the first job that was offered to me instead of bankruptcy. After taxes I make $27,000 and I live in NYC. I can barely afford rent, food, basic (basic) bills on this amount, let alone paying off the debt I incurred while I ‘chose’ unemployment.
Fortunately, my employer chooses to offer limited health insurance. I didn’t get to choose my insurer or my plan, but as I don’t have any pre-existing conditions (“that I know of” wink wink nudge nudge), they ‘allowed’ me to enroll.
If the first employer to offer me a job hadn’t offered health insurance, I would have had to take the job anyway, because I had the ‘choice’ of going bankrupt and losing my apartment, or taking the first job I could get.
If my job hadn’t happened to offer health insurance, and my salary was similar, I would have the ‘choice’ to pay for an individual plan instead of rent and lose my housing, or have no insurance.
If I had no insurance but had an accident or developed a dangerous medical condition, I would have had the ‘choice’ to seek emergency care at the ER and go bankrupt when the bills hit, or crawl into my room (if I still had one) and die quietly.
And I am angry, very very angry, that these Public Option and Universal Health Care people are trying to take these God-given, America-approved choices away from me. The very thought of being free from insurance bill worries is an insult to my deeply held patriotism. The Invisible Hand, which I worship much like a God, has guided the Free Market to offer me these choices, and I agree that my most basic human rights would be violated if I were to be able to access affordable government health care that actually met my health needs.
Give me back my freedom to die penniless in the streets from a curable illness!
A fair point in a policy discussion.
But not at the cost of turning the health care system into the Post Office.
God, I am sick of this talking point. I saw it yesterday as “I would rather UPS or FEDEX run my Health Care at least they are efficient and know how to treat there customs and make a profit.”
Of course, unlike the government’s postal service, UPS and FedEx have no obligation to provide their services in every rural outpost of America. Take a zip code where many of my dad’s patients live: 75948 (Hemphill, TX, a town of less than 2000 people).
If you go to the US Postal Service website, you can see that there’s a full-service post office right in Hemphill itself. In contrast, if you go to FedEx’s website and put in that zip code, there’s a single drop-off box in that zip code. If you want so much as a FedEx Authorized ShipCenter, you have to go 20 miles to San Augustine (and even that isn’t an actual FedEx/ Kinkos, but just a company contracting with FedEx). UPS is worse — its nearest drop-box is 28 miles away in Many, Louisiana.
I hope all of the folks who want health care run on the UPS/FedEx model (serve only the areas big enough to make the company a nice big profit) don’t have a grandmother living in a small town like Hemphill, where there aren’t enough residents for companies that care solely about profits to bother providing services.
The United States Postal Service has been subsidizing mail coverage for these areas for decades in order to keep them connected with the rest of America. Maybe they shouldn’t bother; maybe places that small should just dry up and die. But you certainly can’t count on the private sector to show up there.
Funny how certain conservatives like to talk up the values of small towns and how we grow good people there, but often seem ignorant of the realities of living in a speck on a map.
PG, I grew up in a variety of places, but the anchor home was always my grandparent’s place in Shaw, MS, population 2000 on a good day. So please don’t lecture me about how I’m ignorant of small-town life, for heaven’s sake.
That said, I really don’t understand the example you bring to the table. This small rural county has a dropoff box, where you can use the FedEx service if you’re willing to pay for the package with a bank or credit card online. And of course FedEx will DELIVER to you. And if you absolutely must contract with a human being to move your box of whatever it is, then you have to make a 20-minute drive. So what service are they NOT providing?
The health-care analogy would seem to be along the lines that the little farming community would have a tiny clinic, and 20 minutes away there’d be a larger clinic with a full-time staff. I’ll acknowledge that this is not the Mayo or a Chicago trauma ward, but exactly how much health care infrastructure can we sequester among the cornfields? The private sector will go to where there are patients, even if there aren’t very many; it just won’t set up its megaplexes there. How could it?
Nor could a public version; certainly government must maintain a certain infrastructure presence to function, which is why South Bixby, MT gets a post office, but the South Bixby office is a tiny storefront, not a 50,000 square foot sorting plant. Government healthcare in South Bixby is going to be tiny and tripwire, of necessity.
Arguing against the efficacy and costs of single-payer (or any fully funded government run) healthcare plan is going to lose. We have many real world examples of government run healthcare systems that have better outcomes and cost less per person than our current “free-market” healthcare system. Some of those examples of outcomes and costs have been posted on this blog in the past.
If you want to argue the morality of giving every citizen a standard minimum of healthcare, be my guest.
we both spend them wisely at the bottom 70%, and then the US goes ahead and spends another 30% that Europe doesn’t.
Infant mortality in the UK = 4.85/1000 live births (according to the CIA World Book). Infant mortality in the U.S. = 6.25/1000 live births. Stats from WHO: Births by C-section: 23% in US, 17% in UK. Maternal mortality: 14/100k in US; 11/100k in UK. I’d consider prenatal care the “bottom 70%” in terms of fairly easy benefit relative to cost, but we don’t do that well on it.
This small rural county has a dropoff box, where you can use the FedEx service if you’re willing to pay for the package with a bank or credit card online. … And if you absolutely must contract with a human being to move your box of whatever it is, then you have to make a 20-minute drive. So what service are they NOT providing?
(1) I assume you realize this is a much lower level of service than that provided by the much-abused USPS. It’s a lot easier to make a profit and provide extra-nice service in the locations where you bother to staff human beings if, like the private sector carriers but unlike the government, you have no obligation to serve out-of-the-way places.
(2) You have to have internet access and a debit/credit card; you also have to have your own packaging (no shelves with various packaging options). The health care analogy would be having a website that offers diagnostic testing: you package your own bodily fluids, drop them off and someone will pick them up and email your results.
In health care, there is still some sentiment that this isn’t just a business — medicine is a profession, with ethical obligations (and a guild that can keep the unlicensed from practicing). Government subsidization makes it financially possible to do this; my dad goes to Hemphill once a month to see Medicare beneficiaries. If there were no Medicare, most of his current patients probably couldn’t afford medical care, and it would be impractical for him to drive out there with a nurse. (And hey, why bother bringing the nurse when there could be DIY blood-drawing mailed to him?)
However, because so many under-65s don’t have insurance coverage (or have a limited coverage that doesn’t include checkups with a specialist, even if they have specialist-type problems), it’s not worthwhile for people in any non-geriatric specialty. If we had universal coverage, the cost-benefit analysis of serving that rural area changes.
TheCzech,
If the first employer to offer me a job hadn’t offered health insurance, I would have had to take the job anyway, because I had the ‘choice’ of going bankrupt and losing my apartment, or taking the first job I could get.
Yeah, somehow the conservative outcome makes it in a parent’s rational self-interest to stay unemployed and on Medicaid/ CHIP, if the alternative is employment without health benefits and any of her kids have a medical condition requiring steady care. We can’t have universal coverage, because then people might actually be able to maximize their potential instead of having the question “Will I still have coverage?” shadow every decision.
If the average person can’t pay for their own healthcare, then how is it to be paid for? There is no free money. Resources are not created because we need them, but from work.
Exactly. Resources are created from work. So, I ask you again, why should working people, those who are doing their part in the social contract, not inherit the wealth of their labor—the wealth they produce—in the form of healthcare when they need it?
In other words, the average person can’t pay for their own healthcare because the average person’s wages have either remained stagnant relative to their purchasing power (if they’re lucky), or have declined relative to purchasing power. Meanwhile, the amount of wealth they are creating is still growing—it’s just not being shared with them. The past thirty years have seen quite the shift in wealth from the bottom to the top, and it doesn’t have a damn bit to do with “freedom” or the “free market” or any of that nonsense.
Your health care, however, benefits primarily you.
Yeah? Wait till swine flu gets under way, baby! Think about all those folks who are going to go to work with it, because what choice will they have otherwise? As Ruchama said—pay (a small amount) now or pay (a large amount) later. Why shouldn’t police forces be private? Why shouldn’t fire departments be private? Why shouldn’t all roads be toll roads? Why shouldn’t the U.S. have an all-mercenary military? Why do we have public libraries, anyway? Why do we have public schools? Just think of the cost savings of having an uneducated workforce that would be willing to work for bread and water! Why shouldn’t we return to the halcyon days of 80-90% illiteracy?
There is “free money”, Robert. It just isn’t going to the working stiffs of this world; those who create the wealth. It’s going to a bunch of criminals on Wall Street. Why is it that it’s ok for tax dollars to benefit the Ponzi schemes of Wall Street, or war profiteers—-but not for the same tax dollars to benefit the people who are paying them?
By the way, I would be overjoyed for healthcare to resemble the Post Office. Fantastic service, cheaper than the rest, and easily accessible. Score! Sign me up for that!! It would in fact, resemble the care my mother is getting on Medicare. Far from the “hurry up and die” lie that is being passed on by the conservative crowd, its paying for her change in chemo (since the last form didn’t work). Did you hear that? She’s getting more time to live, and without having to argue with an insurance company about whether or not she’s worth it, or having to explain to her family that she’s going to die sooner rather than later, because her insurance company decided she wasn’t worth it.
(Dee…I know a hundred grand doesn’t go far where you live. that was kinda my ill-put point. that even in the godforsaken abandoned rust belt where I live, a person would have to have at least that much to even think about going it alone on healthcare, with just a catastrophic plan that didn’t kick in until over 50 grand. meanwhile, the average person in the U.S. is earning under 40 grand. i’m a single parent; it would take me over twenty years of super-frugal living, along with full employment and excellent health, and just saying “no” to any form of retirement savings, to save up $50,000—and that’s provided I needed no significant healthcare during that time, no vehicle repairs, no home repairs, that sort of thing. and I earn what is considered a good living around here, even though folks in S.F. wouldn’t get out of bed for what I make.)
I gave up at this comment:
That’s exactly what I expect. Further, if the top 2% doesn’t, I expect them to be ostracized, boycotted, or in the case of governmental and other elected posts, voted out.
One of my favorite Ampersand comics is the ‘Concise history of Black-White relations in the USA’. It’s a great reference to whites getting a ‘leg up’ through abusing minorities but then refusing to allow for affirmative action or other programs to bring minorities up to their level. US capitalism/democracy/imperialism does the same thing. Until/unless the top 2% (of course we innately know that we’re talking about income…because that’s all that matters in the US) cares what happens to the bottom 98% we’re never going to be able to solve ‘big’ national issues with similar results to other industrialized nations. The top 2% has a lot to learn from the bottom 98%.
Jon,
The top 2% has a lot to learn from the bottom 98%.
Unless you’re talking about funding health care solely through inheritance (and possibly savings and investment) taxes, why do you assume the top 2% never has been part of the bottom 98%? Most of the people I know who are in the top 2% of earned income have spent part of their lives outside it. Often the people who clawed their way up are the least sympathetic to those who didn’t. It’s not really that far from being born working class, if you then get an education and become a professional, or become a successful small business owner, to make a household income of $250k, particularly if you live in an expensive city or suburb. The Washington Post noted that 1 in 7 D.C.-area families earn over $200k a year.
Major factor one, we spend far more on end-of-life care than do most nations with nationalized systems, for the fairly obvious reason that here most end-of-life care decisions are made by patients and their families. The NHS says “sorry, you’re too old for procedure [x]“, while we pay for it. We don’t get much for those dollars.
The NHS is only one health care system and one that no one is seriously suggesting that the US copy. 80 year olds in Germany (for example) can get dialysis if they need it and desire that route of treatment or even kidney transplants. I’ve read several articles from Europe complaining about how hard it is to get older patients onto chemotherapy trials because doctors are so unwilling to refer patients for anything other than standard of care when they’re older, so I assume that means that older patients get chemotherapy as well. And Stephen Hawkings is doing fine in Britain, whatever the right wing scare mongers claim.
It may be that Britain and/or other European countries “ration” care (i.e. won’t pay for certain procedures after a certain age or degree of illness), but I’ve yet to see any direct evidence of this. Anyone know the British system well enough to say and/or able to find a reference?
I don’t understand this. The system we have does not work. People need healthcare. You want a healthy workforce – those 2% don’t have anyone to “create their wealth” from without it, unless they take those jobs overseas and hey, who cares right? It’s only America.
Granted, the current legislation is fragmented, but let’s not have this nonsense about people needing to earn their healthcare. What a bunch of privileged bullshit. You can talk to me about the current state of healthcare after you haven’t had insurance and almost died of the flu (me.) Or when your mother keeps getting turned away from the emergency room for a month for nose bleeds until you finally get an appointment with a specialist and they find out its cancer (coworker.) Or when they try to drop off your father in an alley after he was beaten up and had his wallet stolen because they think he’s an illegal alien (another coworker.) Or when you’re 59 and can’t find a job because you were laid off due to the economy and you pay more in continuing COBRA than you do for your house taxes for the year (my mother.)
It’s not just poor or lazy people that don’t have insurance. It’s almost everyone I know that got laid off due to the downturn in the economy. Once our economy recovers, we’ll need them to be in good enough shape to come back and be productive citizens, just as La Lubu suggests.
I marvel at the sheer arrogance of anyone who thinks that they will always be covered by health care or insurance. You know how they make money, right?
Your health care, however, benefits primarily you.
Yeah, la lubu’s said this already, but: influenza. SARS. HIV. Multi-drug resistant TB. HPV. And many, many other viruses known and unknown.
But even forgetting about that, what about the loss to society when people die unnecessarily? Suppose karnythia got no health care and was debilitated by her arthritis. We wouldn’t be able to read her stimulating and thought provoking posts (to start with the most trivial point.) Her family and friends would largely lack her company if she were too debilitated to interact (at the very least she’d likely be much grumpier.) Her employer would lack her contribution to his or her organization. Society would lack the taxes she pays. Now, multiply by the 20% of US-Americans who don’t have health insurance. How much better could society be if they all got the care they needed to live their lives as fully as possible?
What if Stephen Hawking were a US-American? He’d almost certainly not have insurance, his insurer, if he had one, having dumped him when he was diagnosed. He probably wouldn’t have the equipment he needs to continue as an active researcher (motorized wheelchair, voice simulator, etc) because it would be too expensive for him to pay for. He’d probably spend his last days in a back ward somewhere, unable to communicate and tell us about Hawking radiation, until he died of sepsis from bed sores.
Finally, we ARE paying for the medical care for the uninsured. Suppose the Strawwelfarequeen notices a lump in her breast. She doesn’t have insurance so she ignores it and hopes it goes away. It doesn’t. It grows to the point that she can’t stand the pain or it starts to necrose and stink*, or she breaks a hip due to metastatic disease. Then she finally goes to the ER, probably in a publically paid for ambulance, gets admitted to the hospital, where various expensive tests confirm that she has metastatic breast cancer. She gets various expensive treatments and maybe lives for years, but ultimately metastatic breast cancer is not curable and she dies, leaving a huge bill that the hospital has to eat. They pass the cost on to the insured and the government. Wouldn’t it be better for all concerned as well as cheaper if the SWQ had gotten a mammogram 3 years before, had the lump removed when it was a 1 cm tumor that hadn’t spread, gotten a little adjuvant treatment and gone on to live 30 more years. Maybe the brush with death would inspire her to return to school, get a job, become a breast cancer advocate, etc.
The alternative is to simply say that any person who can not prove that they can pay for medical care doesn’t get any. That’d be cheaper, sure, but do you really want to take the risk that you’ll be left to die someday because you forgot to take your insurance card with you when you went for a jog? And do you really want to live in a society where people just step over someone bleeding to death in the street?
PG @ 49
I don’t make that assumption at all, though frankly funding health care largely through inheritance and excessive capital gains sounds like a great start to me.
Good for them! I’m sure they will extend their good fortune and success to those less fortunate.
I don’t make a distinction to people who claw up and those that were born into money, but can we agree that it is extremely likely that those ‘clawing up’ were disproportionately male & white? I don’t want to cloud my argument too much with an extension into POC and white privilege, but frankly I find a ‘but some of the top 2% worked hard to get there’ to be a disingenuous argument. Either you care about people or you don’t. When you’re part of a disproportional 2% either you are willing to help or you don’t. I don’t want a system where clawing up is rewarded with the ability to join the privileged class where one (and their kin) can look down on the lower 98%. The American Dream of new money growing up and joining old money to look down at the peons with less is not the American Dream that I support.
The fact that this is DC really makes me wonder about the race & sex of that 1 in 7, but it’s interesting that you mention a ‘clawing up’ scenario like this. In my original post I almost included a quote by Eugene Debs, but I thought I was getting too wordy & preachy:
If you go to the city of Washington, and you examine the pages of the Congressional Directory, you will find that almost all of those corporation lawyers and cowardly politicians, members of Congress, and mis-representatives of the masses — you will find that almost all of them claim, in glowing terms, that they have risen from the ranks to places of eminence and distinction. I am very glad I cannot make that claim for myself. I would be ashamed to admit that I had risen from the ranks. When I rise it will be with the ranks, and not from the ranks.
I’m certainly not in the top 2% but I’m sure that if I ever am it’s because the top 2% will have expanded to represent a whole lot of people. I don’t know if that’s right, but some of the counterarguments boggle my mind. I can’t accept that it’s okay to have starving, suffering people in the world, let alone in the US and in my city and I can’t accept that health care for everyone is a logical extension of inalienable rights in today’s world.
*eyeroll* As someone who paid ~$80 for two tickets to watch Professor Hawking speak many years ago in an auditorium with 5000+ people I’m pretty sure he could come up with money to take care of himself. I get your point, but hate the example.
My grandmother, by comparison, invented Pepsi and spent the majority of her adult life as a ward of the state of Wisconsin. It’s a shame that she didn’t have money to get herself better care, but of course her Pepsi claims wouldn’t have held up well in court since she was schitzophrenic and didn’t actually invent Pepsi, just liked it a lot.
I love Professor Hawking’s work and have read half a dozen books by him, but I think my grandmother would be a better example for your ‘what if’. She deserved better care than the decades of overmedication she received even if she didn’t imagine black holes and baby universes. If people don’t care about her, they likely won’t care about Professor Hawking either.
Yeah, somehow the conservative outcome makes it in a parent’s rational self-interest to stay unemployed and on Medicaid/ CHIP, if the alternative is employment without health benefits and any of her kids have a medical condition requiring steady care. We can’t have universal coverage, because then people might actually be able to maximize their potential instead of having the question “Will I still have coverage?” shadow every decision.
Very much this. I’m starting to look for jobs now, and in addition to the practical limitations that I have — is this job in a city near a doctor who can treat me? Is the university and surrounding area reasonably accessible? and so on — I’ve also got to look into whether taking that job would cut me off from insurance entirely.
Robert:
Do you have a source for this? I’m an American living in Britain, and anecdotally I haven’t seen any of my older friends/relatives being denied healthcare. The only treatment I know of that is denied to older people is IVF. All prescriptions are free to people over the age of 65.
I don’t have time for a full search on the subject, but a quick search turned up the following from the Telegraph (a right-wing paper) Don’t treat the old and unhealthy, say doctors. Complains that doctors are planning to deny treatment to the elderly, which suggests that it is not currently the standard practice.
As someone who paid ~$80 for two tickets to watch Professor Hawking speak many years ago in an auditorium with 5000+ people I’m pretty sure he could come up with money to take care of himself. I get your point, but hate the example.
Stephen Hawking the famous professor, yes. Stephen Hawking the graduate student (or was he a post-doc at the time?) developing ALS (or whatever he has: it’s rare for a patient with ALS to live as long as he has, no matter how good their care), no. I used Prof Hawking as an example because of the infamous right wing scare comment about how if he’d been born in Britain Hawking would have been left to die. He wasn’t, obviously. But he probably would have been in the US, unless his illness developed after he was already famous.
Jon,
I don’t make that assumption at all, though frankly funding health care largely through inheritance and excessive capital gains sounds like a great start to me.
Define “excessive capital gains.” Also, the federal estate tax raised only $22.5 billion in revenue in 2007. That’s not enough to cover health care, and of course that money already is being used for other things.
The assertion you made to which my comment @49 responded was “The top 2% has a lot to learn from the bottom 98%.” If you concede that the 2% of top income households are not made up wholly of people born in the top 2%, what is it that you think the top 2% has to learn from the other 98%?
One of my managers at a company where I used to work was the VP of Marketing and a black woman, and the company itself was founded by a black man. Both came from working class families; both leveraged their academic achievement into business success. Barack and Michelle Obama both came from middle class families. They’re all certainly in the top 2%. What is it that you think they can learn from you, simply by virtue of your not currently being in the top 2%? They know what it’s like not to have lots of disposable income; they grew up that way. They also know what it’s like to be able to exploit their genetic gift of intelligence through hard work and some lucky breaks to be able to make a lot more money. What do you have to teach them, exactly?
Finally, plenty of the people who have made their way up in this country are immigrants, often non-white ones (my dad, whom I talked about in another thread, is one of these). Their fortune in being able to succeed in a capitalist system causes many to believe that such a system is a good one, and that others who don’t succeed in it simply lack various virtues (responsibility with money, ability to delay gratification, hard work, persistence, etc.). That’s the American Dream they pursued. Why is their American Dream less valid than yours?
Ruchama,
I’ve also got to look into whether taking that job would cut me off from insurance entirely.
Yep, I have a friend who cannot leave Massachusetts for school or work anywhere else, because in Mass. she has coverage, whereas elsewhere she may not. I am very thankful that Mass. is universalizing coverage; I just wish the rest of the country would as well so there could be greater freedom of movement.
To be in the “top 2%” (I assume we mean “of people living in the USA”), requires exploitation of plenty people unable or unwilling to commit the level of exploitation you did to get there.
Wealth disparities that great are never 100% creations of ethical behavior.
Read here to learn about the extreme levels of income inequality in America.
This level of income inequality is unjust, and anyone who participates in and benefits from this inequality is perpetuating oppression. A system that allows a tiny fraction of a nation to siphon off the majority of a country’s wealth is a system to be restructured.
In the meantime, applying taxes to ill-gotten gains to help relieve the misery of the bottom majority is absolutely necessary.
To be in the “top 2%” (I assume we mean “of people living in the USA”), requires exploitation of plenty people unable or unwilling to commit the level of exploitation you did to get there.
Wealth disparities that great are never 100% creations of ethical behavior.
Really? Whom did my dad exploit in order to become a successful physician? Did he exploit the U.S. government or its citizenry by immigrating on the basis of the U.S. having a shortage of doctors in the 1970s? Did he exploit by working in an inner-city hospital and then a rural community? Did he exploit his patients by being willing to work 7 days a week and be on call at all hours of the night? Did he exploit the community in which he settled by being willing to risk the little money he had by investing in higher- tech facilities than most of the physicians who’d been practicing there before him, thus attracting patients who otherwise were suspicious of a foreign doctor?
Honestly, looking over my dad’s life, the only people I can see who have gotten any negative from his career are his own family members. He left his parents and siblings in order to go to school and then to the U.S., and his siblings had to pick up the slack on the family farm when he was doing schoolwork and then going away for school. His wife functioned as a single parent (except financially) and his children saw very little of him for most of their childhoods. But of course these are the people who benefited first from his wealth; he supports both his family back home and in the U.S. He’s also been part of a group that built a teaching hospital and medical school in the town near his birthplace, providing the students with education opportunity and the town with a hospital, something it previously lacked. Both of my siblings also work in health care, one of them in an academic/ research center and the other in public health. I’m probably the most evil of my father’s spawn, being a lawyer.
There are problems with wealth disparities in the U.S., and I would say our system as a whole involves exploitation. The fact that my dad can buy tomatoes cheaply is due to the exploitation of workers; if they were paid better, theoretically his tomatoes would be more expensive and he’d have less accumulated wealth. He’s buying the only tomatoes that are available, because it’s not like Super Wal-Mart offers Whole Foods type options.
But demonizing all wealthy people as evil exploiters of less-wealthy-therefore-more-virtuous people doesn’t really further debate on what the policy response to wealth disparity should be. Do you not know anyone whose household has $250k a year in income? If you do know such people, do you really feel confident that they’ve all been exploiting people in order to make that money? None of them could have made that money by providing good and useful services to others?
I gave up at this comment:
Or do you seriously expect the top 2% of the population to carry the medical expenses for 100% of the population?
That’s exactly what I expect. Further, if the top 2% doesn’t, I expect them to be ostracized, boycotted, or in the case of governmental and other elected posts, voted out.
Let’s play some games with math, shall we?
They don’t actually break out the top 2% of income figures, but they get close. The US Census Bureau says that the top 1.5% of US households have a household income of $250,000 or more. Another 1.17% have income between $200K and $250K.
Let’s stretch a point and use those two categories – that gives us 2.67% of the households, which (rich households being smaller) probably comes in around 2% of the population, overall – 6 million people or so. How much money do they make?
Income figures are a little tetchier, but we can get an idea. The top 1%, according to Czech’s helpful link, pull in 12.8% of income, while the next 19% get another 39.1%. Just to make the math easier, let’s figure that the 2nd 2% are getting 7.2% – a figure that I’m sure is high.
Total US income is very roughly $8 trillion. (That’s money to people, wages, salaries, stock returns, etc.) 20% of that is $1.6 trillion. That seems low. Let’s again be conservative and skoosh it up a notch. Call it $2 trillion total.
Our 6 million household members in the top 2% bring in an average of $333,333 apiece! Wow! That’s a pretty good wage. Those people are living well. Surely, they can indeed afford to pay for the healthcare of other people besides themselves.
Except…there are only 6 million of these people. The next percentage points make far less money; I’m not even going to figure them up.
Let’s assume we can tax 80% of the richest’s income. We can’t – we don’t take half that amount for most of these folks – but let’s say 80%. That means we can get about $267,000 from them each year. But wait – we already tax these folks and use their money to pay for much of the expense of government. We can’t get another 80% out of them – we’re already taking about 40%. We can get another 40% out of them, though. So $133,500 per capita donated to the health care fund – let’s round it up, again, and call it $150,000.
There are 300 million people in this country. Only 6 million of them are in the top 2%. That means each of those 6 million must pay for the health care of 49 people, in addition to their own.
$150,000 divided by 50 is $3000.
So, let’s recap.
We’re going to take the richest people in America – nobody richer – and essentially take another half of their income away from them to pay for health care. We will totally shatter the tax expectations of our middle and upper classes, and set off a class war.
And the total we collect is going to be about one month’s wage for the US median worker, per capita.
And I’m sure that jacking the tax rate on the richest 2% to 80% will have no negative effects whatsoever. It won’t cause people to move to Canada, or shelter their income, or work less to drop out of the 80% bracket. It’ll be GROOVY.
And now you know why I dismiss the idea. The math doesn’t work. There’s not enough money for the rich people to pay for everything.
We have to pay for our own health care. We can collectivize that to whatever degree we wish, but the idea that there are some magical rich people who will wave their wands and give full coverage to all is a fantasy. If you aren’t in the bottom third or so of the income distribution, there is no subsidy available for your healthcare and there never can be. You can pool your risk, you can hedge against disaster – but the job-holding, reasonably successful citizens of the richest country on earth are not going to find a group of richer people they can bilk for their doctor bills.
Someone asked for a source for the idea that the British don’t treat their elderly patients all that well. Here you go.
Now, it’s not quite a list of “ways we’re going to kill the old people”. But you wouldn’t expect that. Rather, there’s a culture and an expectation that past a certain age, certain kinds of care don’t happen. They don’t say “you cannot have a new kidney”. They say “you wouldn’t be a good candidate for a transplant”. It’s not written down; it’s the judgment of the practitioners involved.
They might even be right, it should be said, but the decision isn’t really in the patients’ hands. Or so has been my impression gathered from talking with Britons and reading their experiences.
Except that article had nothing to do with cost-savings. It was about an approach whose intent was to improve palliative care but perhaps has become too rote.
And people in the U.S. get told every day that they might not be good candidates for transplant. If your doctors say you’re not a good candidate, your chances of getting a kidney from a transplant list are pretty slim. In fact, people who don’t have insurance are considered bad candidates for transplant because they have no way to pay for the necessary drugs or get the necessary follow-up care.
Hey, they’re saying that to my fiancee’s father right now, here in the United States.
The decision isn’t in his hands. That’s the way it works here.
—Myca
Robert @62:
Thanks very much for the link. That’s a very recent article, and it will be interesting to read how the NHS and/or left-wing papers respond to it.
I was curious to see how life expectancy varied by country for the elderly. I found this data: Life Expectancy by Age, Sex, Country and Year
2005 is the most recent year for which both the UK and the US have data. Life expectancy at age 65 is 20 years for US women and 17.2 years for US men, while the UK is a hair behind at 19.8 and 17.1 years, respectively. This suggests to me that, on average, UK care for the elderly is about the same as in the US. Interestingly Canada beats them both, with 21.1 and 17.9 years.
UK life expectancy goes up for 2006 to 20.2 and 17.5, but I don’t know if the US had a similar improvement.
I don’t like the way the conversation has turned; no one (and I don’t think even Jon) is seriously arguing that “the top 2% pay for the healthcare plan that covers the bottom 98%”. Let’s get real. Well-to-do people have options the rest of us don’t when it comes to insurance or healthcare; they can formulate whatever plan they feel they need, and have access to the cash to put it into place.
What we need is a “Medicare for all”, that gives a public option to the people who are falling through the cracks. Who are those people? People who are under 65, and have too low an income to buy their own insurance, but too “high” an income to qualify for Medicaid (earn $400 a week? You’re already too wealthy for Medicaid). People whose employers don’t offer healthcare (or don’t offer it at a rate affordable on one’s wage), who not only can’t afford the high price of private insurance, but maybe can’t even get it because of their medical history or pre-existing medical conditions. People who did buy private insurance, but can’t get their pre-existing conditions taken care of, and can’t afford medical care for those pre-existing conditions and the just-in-case insurance and basic living expenses. People who lost their jobs that did provide insurance, but can’t make the COBRA payments on unemployment. People who lost their jobs because of their medical condition. People who lost their jobs because they were considered a health insurance liability by their employer.
I’m really irritated that this is framed on the right (hello, Robert!) as people asking for “a mansion” or “a beautiful car”. This is people asking to get on the damn bus. I’m resentful that people without insurance are being framed on the right (hello, Ron F., on the other thread!) as “non-productive” (yeah, I caught that “why should productive people…..” Nice to see that a working person’s entire history of productivity can be erased the moment that pink slip comes. Nice to know our status moves immediately to “deadbeat” once the economy takes a dive. Even nicer to see that people working the low-wage, no benefit, long hour jobs (or two) are “non-productive”.).
Medicare. For all. A public option for those who choose it, who can get on that bus when they need to, or (for those who have the desire and resources) can keep that as a reserve option as they maintain their current situation.
So, as we move into Labor Day weekend, anyone want to explain to me why this is a bad idea? As opposed to the huge percentage of bankruptcies due to medical bills? As opposed to people remaining out of work in order to keep Medicaid? As opposed to medical professionals having to hire extra personnel to fight the insurance companies, as their bean counters practice medicine and/or refuse to pay claims? As opposed to poor public health statistics (such as low birthweight or infant mortality) because people can’t afford to seek medical help when they need it?
I don’t really think it is.
There are many, many, people in this country who believe that people generally have no particular right to a lot of medical care. That doesn’t mean they wouldn’t want those people to have care, if it were magically available. It simply means that they don’t think they are especially obliged to provide care on their own dime.
As the level of care moves away from “emergency” to “preventative” to “maintenance” and so on, the number of people who consider that “not a right” gets higher and higher. And as the patient in question moves away from categories like “disabled veteran” or “young child,” towards “theoretically productive adult,” the number of people who don’t want to provide care also grows.
You may personally feel that providing universal care, including emergent, preventative, maintenance, prescription, and psychiatric services, is more “city bus service” than “Mercedes.” But you would have to ignore the fact that this involves an enormous sea change in the level of care.
They might even be right, it should be said, but the decision isn’t really in the patients’ hands.
It never is, entirely, anywhere. You can’t simply walk into the hospital and order a new kidney. Not even if you have renal failure. In general, in the US, a person with renal failure will be evalutated for transplant in terms of their suitability medically and socially. Of course, the patient’s preferences are part of the eval (if s/he doesn’t want a kidney they don’t get one, even if it is the medically better option, obviously) but they aren’t the end all be all of the situation. A person who wants a new kidney because they’re tired of the renal diet won’t get one if their renal function doesn’t qualify. A person who is likely to die of, say, metastatic cancer, in the next 3 months won’t get one.
And, unfortunately, quite a few people are disqualified because they don’t have the means to pay for anti-rejection drugs. This is necessary: a person with a kidney transplant who does not take ant-rejection drugs is going to die. But it’s crappy nonetheless. But having access to the drugs is not enough: some patients are disqualified because they don’t have a permanent place to live, a phone to contact the hospital in case of emergency, or money to pay for transportation to and from the clinic for checkups. Yeah, I know that sucks too but I don’t see what to do about it on the individual level: putting a new kidney in someone and then leaving them to die because they had no way to contact the hospital when they have a fever (which might be either infection or rejection) isn’t doing them any favors.
You may personally feel that providing universal care, including emergent, preventative, maintenance, prescription, and psychiatric services, is more “city bus service” than “Mercedes.” But you would have to ignore the fact that this involves an enormous sea change in the level of care.
The reason it’s not a Mercedes is not because it’s not a change but because it’s people’s lives were talking about, not some luxury we can do without. Having only emergency care available means people die who would not otherwise die. That’s why it’s a city bus. It’s the bare minimum necessary to live. Even if it is a sea change.
I also not sure that’s the principal objection to health care reform. Certainly some people are philosophically opposed to creating insurance policies that people could afford if they don’t work in a profession where employer-provided care is the norm. But the main concerns I’ve seen in polling is that expanding access will negatively effect the insurance people have now (for example, cause employers to stop providing coverage).
The hurdle I continue coming up against is that creating a large-scale public insurance option basically is the same thing those of us who have employer-provided insurance have now, except larger. As a young healthy person whose only burden on my insurance companies was the birth of my son four years ago, I have paid way, way more over the years than I have ever taken out of the system. A co-worker who needs chemotherapy already is getting care on my dime. I continue to fail to see any difference between that and someone who is not my co-worker, who works at a job that doesn’t provide insurance, getting care on my dime. And someday, it may be me getting expensive care, subsidized by some healthier person. But that’s true even on my employer-provided group plan.
Okay, so as everyone has made clear in regards to kidney transplants, Robert doesn’t know what the hell he’s talking about. Granted.
I think the larger issue it points to, though, is that resources are limited. We only have so many kidneys to go around, and there are more people who need kidneys than there are kidneys to give. Period. Reread that sentence. That’s the issue.
We only have so many kidneys to go around, and there are more people who need kidneys than there are kidneys to give.
When conservatives start freaking out about rationing, and about how under universal health care, all of a sudden, we’ll have some official panel deciding whether or not we’re eligible for certain procedures, it’s worth asking which part of that equation they think is goign to be different under UHC.
Will there be fewer kidneys to go around? Unlikely … it doesn’t seem outlandish to posit situations in which there would be more transplants available, but at the very least, there isn’t a plausible scenario in which there would be fewer.
Will there be more people needing kidney transplants? Also unlikely … in fact, if UHC seems to go the way everyone has been talking about, with a focus on preventative health care, regular check-ups, and the like, it seems extremely likely that there will be fewer transplants needed.
Those are the only two conditions here. Number of kidneys versus number of people needing them. That’s it.
Right now, the kidneys are distributed based on overall health, likely lifespan, how likely a patient is to take care of the new kidney, insurance, and personal wealth.
Under UHC, the ‘insurance, and personal wealth,’ categories stop being as important.
That’s it.
If someone tries to scare you with stories of rationing and is unable to explain how UHC either reduces the supply of health care or increases the need for health care, they’re lying to you.
—Myca
I’d also like to add that if the private insurance industry was going to come up with a magical method to make this untrue and to provide a kidney to absolutely everyone who needs one, they would have done it already.
—Myca
Myca,
Thanks for pointing out that kidneys (and other human organs) are radically scarce resources. That they will be rationed, even under RonF’s definition of “rationing,” is unquestionable; the only question is what method we should use. Is the UNOS method we have in this country, in which wealthy people who can afford to maintain multiple addresses can fly around the country and sign up on multiple states’ waiting lists, really the most just way to do this? Any method of rationing inherently leaves some people without something those people want.
Actually, over ten years, the total cost of repealing the estate tax would be a little over a trillion dollars — enough to pay for even the more generous health care proposals in congress. (Note that the costs of repeal go beyond just direct lost revenue — there’s also indirect lost revenue, due to deficit financing and lower gift taxes paid).
For me, the takeaway point isn’t that the estate tax is how we should pay for health care. It’s that the same people who say that a trillion dollars is far too much to spend on health care reform, will have absolutely no hesitation about spending the exact same amount of money on a tax cut which favors the ultra-rich.
Geez, Robert. All that government health-care in Australia must have bankrupted us by now. Funny how we manage to keep affording it and still also manage to be coming out of the recession ahead of the US of A. If my choice is between not seeing a doctor of my choice (which I can still pay for, if I choose to do so and can afford it) or dying, I’m taking (and have taken) the doctor. I’ve suffered some life-threatening illnesses in my time which have made it impossible for me to afford private health insurance, and it is because of the public health system that I am still working and contributing money as a tax-payer. I read a lot of US blogs and I’m constantly amazed by the brazen lies of the shills for the insurance industry.