Minnesota Gov. Tim Pawlenty is very good at playing the sensible conservative. He’s got that aw-shucks, Minnesota nice attitude that makes him sound like the type of conservative who isn’t actually bent on destroying anyone below the upper middle class.
This is what makes him very dangerous.
Because in his heart, Pawlenty is no moderate. He’s a conservative — a radical one — who has never met a tax cut he didn’t like, or a spending cut he wasn’t willing to make, so long as they attach to the right people. (Oh, he was more than happy to cut the renter’s tax rebate program, so people who rent — disproportionately poor people — get less back in taxes. But that’s different. Those people are poor.)
Pawlenty is now running for President, and he is, one assumes, getting ready to move enough rightward to try to make teabaggers into T-Paw baggers. His first step? Kill the poor:
Emergency rooms should be able to turn patients away to cut costs, Minnesota Gov. Tim Pawlenty (R-Minn.) said last night
Appearing on Fox News’s “On the Record with Greta Van Sustren” last night, Pawlenty said the federal law that mandates ER treatment should be repealed.
“Well, for one thing you could do is change the federal law so that not every ER is required to treat everybody who comes in the door, even if they have a minor condition,” Pawlenty said. “They should be — if you have a minor condition, instead of being at the really expensive ER, you should be at the primary care clinic.”
So let’s say a guy with the condition I’m recovering from comes into the ER. He doesn’t have insurance. He’s presenting with some pain and swelling of a sensitive area, but that isn’t necessarily cancer; could be torsion. Could be a hydrocele. Could be all sorts of minor, non-life-threatening conditions. Does he stay, or does he go?
If he stays, he gets the ultrasound that proves it’s cancer, thus starting treatment that saves his life. If he goes, he does so knowing that he can’t afford the doctor. So he lets things get worse. And worse. And worse.
If he goes back — when his guts ache and his brain is foggy — the treatment regimen is now more expensive. And less likely to succeed. A surgery and treatment plan that would have had 99 percent success now gives odds closer to 50/50. If our patient survives, he’ll face crushing medical debt that can only be alleviated via bankruptcy. If he dies, he dies.
This is Tim Pawlenty’s bold medical proposal — let the uninsured suffer, and die, so that ERs don’t have to take in the poor. This is something, incidentally, not even hospitals are clamoring for — they’d just like Pawlenty to sign on to an extension of medical assistance, a bill Pawlenty vetoed because…well, it helps the poor, I guess.
Nobody should risk death because of a lack of health care. The system we have — in which the poor at least can go to an ER to get treated — is absolutely awful. Pawlenty wants to take that last snippet of a safety net, and whisk it away — leaving the uninsured to die in the process. That is not conservative. That is evil.
Actually, I’d sort of agree with Pawlenty in this case. I say “sort of” because as far as I know, unlike ERs, primary care clinics — and urgent care clinics, which is, I suspect, what Pawlenty meant to say — aren’t required to help everyone regardless of ability to pay. (I might be mistaken about that, I haven’t done research.)
It’s certainly true that if we could divert a lot of patients from the ER to urgent care and primary care clinics, everyone — including the diverted patients — would be better off.
But unless we want the situation Jeff describes — people dying for lack of care because they can’t afford care — a situation which is already happening to tens of thousands of Americans a year, but which could be made even worse — then we have to have some sort of mandate for urgent cares to accept all patients, like ERs do.
And the result of that would be that the cost of urgent care would rise substantially. So a lot of the savings Pawlenty is talking about might evaporate. Unless the government steps in to subsidize care, that is — but I bet Pawlenty opposes that (except for people with Medicare).
And I’ll agree with you up to that point — if Pawlenty was proposing comprehensive medical reform, one where all Americans had access to health care, this would be not only unoffensive, but common sense. Of course I should go to a GP or NP first if I have a problem.
But of course, we don’t have that system. And Pawlenty is actively opposed to it. And as long as the ER is the last resort of the poor, pulling it away is consigning people to death.
My impression was that the ER already could turn people away if the condition was not immediately life threatening, that they only have an obligation to treat if you’ll die right then and there without it. I feel like I’ve read real-life stories that go exactly like Jeff’s scenario.
Can anyone with more experience/knowledge speak to this?
All Americans do have access to health care. (Well, maybe some people living out in the Alaskan outback don’t have it, but nobody makes you go live in the outback.) Go to the clinic, wait your turn for an appointment, pay your bill: bang, access to health care.
Not all Americans have access to health insurance. The two are not identical.
Pawlenty’s suggestion is one piece of a conservative approach to health care that would work. End state and federal mandates that require every insurance program to cover every condition, so that people can actually buy the coverage they need instead of the coverage that the late Sen. Kennedy thought they should have. End tax breaks that make employer-provided care so much more economically attractive (while making little sense in an ever-more mobile and uncertain working world), and even the playing field so that people’s insurance costs what it costs, rather than what it costs after going through ten distortion fields of government regulation. Empower companies to sell insurance across state lines so that there is price competition on a national level. Etc., etc.
End state and federal mandates that require every insurance program to cover every condition, so that people can actually buy the coverage they need
I can’t possibly understand what you mean by this. How is a person supposed to know what disease or condition they are going to get in advance? Ok, you can make some educated guesses-a 70 year old with high blood pressure and high cholesterol is at higher risk for heart disease than acute HIV-and can rule out a few things a priori-Robert’s at no risk of cervical cancer-but buying insurance that only covers some conditions strikes me as impractical.
Dianne – typical mandates are not things where you would need to predict the future. Check out http://www.ncpa.org/pub/ba237 for some of the most common mandates (which all told can boost insurance premiums by 30% or more):
Minimum stay maternity
Speech therapy
Drug abuse treatment
Mammography
Well Child Care
Podiatry
Pap Smears
Vision
Chiropractic
Alcoholism Treatment
Fertility Treatment
Mental Health Care
All of these are things that a rational person can look at and decide whether they wish to insure themselves. I don’t need to predict the future to know I’m not going to a chiropractor, to know I’m not going to seek fertility treatment, to know I’m going to buy my own glasses.
Mandates are just incremental socialism. Some people want this, so let’s make everyone pay for it so that it’s cheaper for the people who want it.
Amp / Jeff / Mandolin / other mod – I mistakenly used the word for a certain economic system in my response to Dianne. Your spam filter has it now. Please to rescue.
[Done. But try to hawk your black-market cialis pills on “Alas” again and you’ll be banned! Banned! Damned spammer. –Amp]
Terribly curious as to what economic system puts a post in moderation…V!agraism?
So-CIALIS-ism
The concept of enabling emergency rooms to defer from treating conditions that are not actually emergencies makes sense to me. The details – which from Pawlenty’s viewpoint is most certainly NOT “let the poor suffer and die” – can be worked out. It would save a lot of money without particularly affecting the actual quality of care people get. I’d say yours was the extremist viewpoint, Jeff, not Pawlenty’s.
I do agree that the guy turned away from the ER with pre-creeping-awfulitis is a problem for the system. The solution is ensuring that he can actually go to the walk-in clinic the next day and pay for care. If he isn’t on Medicaid, then the government ought to serve as a lender of last resort to loan him the $150 for the checkup.
So you’re saying that if elected state governments choose to mandate insurance coverage for people going blind, the Federal government should step in and overrule them? How is this different from “we believe in state rights, except when the states democratically elected legislatures pass a law insurance companies don’t like?”
Regarding “30% or more,” actually the study you cite used 30% as the upper limit; their exact words were “up to 15% – 30%.”
It’s also notable that the first ten items on your list are cheap — it’s really two expensive items (fertility and mental health care), plus a bunch of other stuff thrown in as filler. According to the analysis you linked to (which I have doubts about, but let that pass for now), insuring the first ten items combined costs less than the final two items do.
Okay, so let’s take mental health, which is far more expensive than everything else you list. What do you think should happen to people who have a dire need for mental health treatment — whose untreated conditions will impair their ability to work or even endanger their lives — if they can’t afford treatment and just took the insurance package their small business employer offered them? Which is better for the economy, do you think; them being treated, or untreated?
* * *
Just to ground the discussion of mandated insurance coverage a little, let’s talk about the Senate plan (afaik the House plan is similar in this regard). According to this plan, in order to be part of the federal health exchanges, the plans have to cover:
So that’s what we’re talking about.
As I understand it — and I’m not 100% sure about this and don’t have time to research it, sorry — insurance companies are still free to offer plans that don’t meet those standards. However, those plans will not be eligible to be part of the Federal exchange.
Different kind of mandate, Amp.
What do you think should happen to people who have a dire need for mental health treatment — whose untreated conditions will impair their ability to work or even endanger their lives — if they can’t afford treatment and just took the insurance package their small business employer offered them?
Someone should pay for their care. Could be charity, could be family, could be the state. I used to work for a psychologist who did a lot of work out at the state mental hospital, paid for by the taxpayer. Not ideal – better for private organizations to do it – but OK as a payer of last resort.
Which is better for the economy, do you think; them being treated, or untreated?
Insured, not treated. We’re talking about how to finance health care, not its provision.
As an atomic transaction, where only their costs count? Them being insured. As part of a series of transactions where 300 million people must buy insurance for something they (likely) won’t need, them not being insured, most likely.
It’s cheaper to have 50 state mental hospitals for the indigent than it is to require 300 million people to buy mental health insurance. A lot cheaper, I’d wager.
And yes, insurance companies would be free to offer care that doesn’t reach those levels, Amp – except in the many, many states who have barred such policies by law. If we’re leaving health care alone on a national level, those states can do what they like; if we’re kicking over the system and building a new one from Washington because of OMG THE SUFFERING, then let’s realistically acknowledge that there are uninsured people out there who are uninsured because the mandates are the cost delta that puts insurance out of their reach.
May I completely ignore ethical issues for a moment and talk straight economy? OK, then:
Which is better for the economy, do you think; them being treated, or untreated?
Depends on what they do. From an economic perspective, a minimum wage day laborer is not a great loss while a potential neurosurgeon is a significant loss.
Of course, from an economic perspective,the goals of economy match reality. The neurosurgeon (rich!) is likely to buy mental health care irrespective of cost, while the poor person is not.
So the economically-valuable people tend to self-select for either treatment or insurance, I’d say.
Just as a reminder that i’m not talking ethics here…
This question is in the “what does providing health care mean, anyway?” If it means “keep people from dying in pain” then mental health is sort of oof the charts. If it means “focus on economic solutions to health problems” then mental health is sort of on/off the charts depending on income.
Since we’re talking only economy, perhaps you’ll engage in a little thought experiment with me: Can you identify categories of care (however you define it) and/or categories of people, which you believe SHOULD NOT have a right to services?
I’ll try to have something substantial to say later on, but for now I’m just going to say that if I ever invent an erectile dysfunction drug it’ll be called PITAL (as in ca-PITAL-ism). Just for the equal opportunity spam filtering.
Dianne, I just swiped that and tweeted it. :-)
Robert – I’m taking exception with your comment that all Americans have access to health care : “Go to the clinic, wait your turn for an appointment, pay your bill: bang, access to health care.” That’s fine if you can afford to do that, but I know people who are working, make too much money to be eligible for Medicaid, don’t have insurance through work, and live paycheck to paycheck just putting a roof over their heads and food on the table (and they aren’t living extravagant lives, they’ve cut out every extra they can think of, just in order to pay utility bills and have gas money to get back and forth to work). After all the bills are taken care of, there is NOTHING left over to pay Urgent Care or a doctor’s office, not even for routine care, let alone an emergency.
So if you don’t have the money, and don’t qualify for state assistance, you don’t have access to health care unless you can go to an emergency room (and then you still have bill collectors and collection agencies calling you for years afterward trying to collect money you don’t have now and didn’t have then to pay for health care you needed and couldn’t afford).
Been there done that, and it sucks big time.
An appointment at urgent care costs $114. (Local cost, pretty typical; YMMV)
There are people for whom that is a major cost; my sympathies to those people, esp. as I have been among them in my life, and even today there are days when an unexpected $114 expense would be significant. However, major is not insurmountable.
There are people for whom $114 is an insurmountable cost. Those people are indigent, and if they aren’t on Medicaid, they should be. People not taking advantage of a program is not evidence that the system is broken; some people are too proud to ask for help. We have a fairly decent system for indigent care in this country. Note that basically none of the provisions in the current health care bill have anything to do with the truly indigent. The financing of their care is not at issue, other than in the rhetoric of the left-leaning. What is at issue is the financing of the care of the working poor and above.
There are, broadly, no Americans without access to health care. (As noted, as of the status quo ante, you can always show up at the ER.) There are many Americans without access to health care financing.
I decline to conflate the two. Bill collectors hounding you for payment of ER care received is not an anecdote about you not getting care, it is an anecdote about you getting care and not being able to pay for it after the fact. Sympathy-inducing, yes; something we should do something about, yes; you not getting health care, no.
Those people are indigent, and if they aren’t on Medicaid, they should be.
Some of them make too much money to qualify for Medicaid. Others aren’t citizens and so don’t qualify. Others are too depressed, overwhelmed, or just lacking in the education needed to negotiate the system and obtain Medicaid.
ETA: To give an example, in New York, a single person must make less than $9000/year to qualify for medicaid. I would suggest that $114 per visit is a lot of money for a person making $10,000 a year.
Far be it for me to encroach on US territory, but something is wrong with this picture.
What strikes is the abject dependence of the public on the current model of health and it’s professionals.
It is this structure that for me is and always has been, untenable. Everyone knows it, that’s why we’ve all embraced preventative medicine so enthusiastically, only to be disappointed by the fact that it follows the same untenable model it is supposed to to relieving/saving.
Ths system is designed so that when we have a health crisis, imbalance or whatever, we rent out temporary wellness from the healthcare professionals in pill form. Until serendipity, spontaneous remission, or something else like we just get used to the crisis and learn to respond to it in a way we can live with and so forth comes into play.
It’s like the saying- “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime. ”
Being given a fish for your hunger is like being given a pill for your health problem. Being able to fish would be like resolving the underlying cause of the health crisis before it has to get to the professionals.
Everything is designed around the principle of fish receiving-which we of course pay for- we are held to ransom in this system by the drug companies. Only regulation can spare us in that situation. But what’s the point in regulating dysfunction as opposed to better design?
In the end, I don’t give a damn whether there are nice caring health professionals who wish to do charity work or whatever, I’m not a proud person, but I’ve absolutely no desire to cue for pity when I know full well that I’m there because of the system that favours those dispensing ‘charity’.
I want sceintific research to shift towards helping us to deal with as many human imbalances as we can, ourselves, so that we only have to use professionals for the rest.
Research ought to reflect our needs, no ideology is not going to solve this whilst the cruel absurdity of the system remains intact.
There can be a lot of hidden costs in treating people in the ER, many of them related to insurance – no, not health insurance. Medical Malpractice Insurance. A couple of bloggers I follow who are doctors in the ER. I respect their opinions because they work there, doing what it is that we want doctors to do – treat people in the ER. I don’t always agree with them, but we all seem to agree the current system is untenable.
ER Stories
WhiteCoat’s Call Room
At the same time, and I’ve said it here before – some people cannot afford to waltz into a clinic and just pay out of pocket. If you can afford that, then you have a privilege. Conservatives seem to have hard time checking that privilege and frankly, it’s pretty fucking offensive. I’ve belabored this point on other threads, so I’m not getting into it again. Besides, it really gets me heated and considering the likelihood of anyone changing their minds, its mostly not worth it.
As to Robert’s point about the neurosurgeons, not all of them come from privileged backgrounds. It would be a shame to lose one who just didn’t happen to have health insurance due to sepsis or something else treatable by $3 worth of medication.
A great many conservatives have a hard time envisioning their ability to pay for something they want or need – an ability that they have earned through their labor – as a “privilege”. Or, if they do see it as such, they see it as one that they have justly earned and should not feel guilty about exercising.
The concept often put forward here is that their ability to do so is based upon the oppression of others. Understand that this is a case that has not been widely made and is not something that you should expect most people to even understand, never mind accept.
RonF wrote:
Well and good, but there is a hidden assumption there. People with money often argue that they earned it, and therefore deserve the benefits more than another person who hasn’t earned as much, but that argument rests upon the implicit assumption of a level playing field and an even starting line, where everyone has a roughly even chance to succeed.
The field is not level, and nowhere is it more dramatically slanted than in personal health. Only a small amount of our personal health is within an individual’s control. For instance, I can do everything right and still come down with cancer, like Jeff. I can do everything right and still be in a head-on at 40 mph + 40 mph, like a local man I know who lost six months of his life and had to have his knees and pelvis reconstructed after another driver fell asleep behind the wheel and crossed over.
I can do everything right and still come down with Gaucher’s Disease, like a friend of mine. Treatment costs $550,000 annually and must be continued for life, and until recently simply did not exist. She is otherwise reasonably healthy, and there is no doubt that the treatment is effective. (Cases like hers cast arguments over rationing into stark relief: she could live for fifty more years, but unquestionably her treatment would drive costs up for everyone, especially in a small insurance pool.)
To my friend, to the local man, it’s abundantly clear that their monetary success no longer has anything to do with how hard they work. (I won’t presume to speak for Jeff.) And anyone who suggests that they don’t have enough money to cover their children’s medical costs because they didn’t work hard enough? Well, that person is a word I can’t use in polite company.
So, yes. Your comparative physical health, my comparative physical health, ANYONE’S comparative physical health, is a privilege. We can avoid certain risk factors, but after that health is fundamentally unearned, AND UN-EARNABLE (as many sages have observed through the ages).
Furthermore, your access to healthcare is an accident of circumstance: if you lived in many other nations, you would have no such access, either because it simply doesn’t exist, as in many “third world” countries, or because you lived before it was invented, or what-have-you. You didn’t earn the fact that you’re American and born in the Twentieth Century, and neither did I. This is true of all such people, liberal or conservative or otherwise.
Considered in this light, a “conservative” is someone who has fallen accidentally onto a pile of money and now lays claim to it, and a “liberal” is someone who thinks such people should share the wealth.
Before anyone brands me as a communist, I’m in favor of private ownership, reward for hard work and personal initiative, and so on. And I’m aware that the line between what we can and can’t control, and take credit for, is a broad, fuzzy one, subject to reasonable debate. But I’m also conscious that the field I’m playing on is tilted, that health care is one of the areas where it is MOST tilted, and I don’t try to ignore those facts when I’m called upon to make policy decisions, or to vote.
And I say all of this as someone who is doing well in the current system: I’m healthy (as far as I know) and make a decent living in the wealthiest large society in human history. (Wealthiest economically, that is; by other measures, probably not so much.)
Grace
Your viewpoint has much to commend it, Grace, and it’s a powerful argument that the fortunate should help support the unfortunate. My faith makes the same argument. But it’s not so powerful an argument that the government should have the right to compel them to do so by force, and decide how much you must give.
Let me add to what Grace has said. I believe in the accumulation of wealth, either be accident of birth or hard work. I believe in the advantages and privileges and rights it brings with it. You can own vacation homes in the south or ski chalets in the north and you earned them. But wealth does not bestow a second vote, nor should it. There are some things that cannot be reserved for the wealthy. Good, prompt healthcare is one. Enjoy your personel pleasures, you’ve earned them, or someone earned them for you, they’re yours, and rightly so, but you have not earned better protection by the police, even though you pay more taxes. If you want more protection you can hire a bodyguard, but you still have to pay for equal police protection and healthcare needs to be considered in the same way. If you want better protection, you can buy a better policy, but you should still help pay for everyone to recieve good healthcare. So Ron F, yes, the government should tell you to pay your share. There’s good reason for paying for police protection and so to for healthcare.
Ed C.
I’ll ask again, because it got lost in the shuffle:
Can anyone who believes society has a moral obligation to provide health care, stand up and identify a type or category of health care which they think should NOT be provided by society? And/or, a category of people who should not be eligible to receive it?
I see a lot of talk about how we should provide health care. And I admit that it’s easy to duck the question about where the cutoff(s) should be, when there are so many people lacking minimal health care. Who cares about cutoffs when we’re not even vaccinating, right?
I care. And a lot of other people do, too.
And I think a lot of “health care for all!” people are ducking, rather than answering, the question: When you say “health care for all,” what do you mean by “health care” and “all?”
Well, the the most obvious is cosmetic surgery for the purposes of beautification rather than correction. I would also be comfortable with not covering keeping patients in a vegetative state on life support indefinitely. Finally, and I think that this is where the vast majority of cost is, I think it makes more sense to cover basic health necessities (like vaccination) for the very young than to cover extremely expensive life-extension for the very old.
For me, it’s a question of cost vs. return. If we’re weighing $10,000 for an extra 10 years for 100 people versus $1,000,000 for an extra 6 months for one person … well, the choice, to me, is obvious.
When you ask this, though, you should realize that under the current proposal, your question makes no sense, since insurance companies will continue to make the primary decisions about what’s covered and what’s not.
—Myca
Finally, and I think that this is where the vast majority of cost is, I think it makes more sense to cover basic health necessities (like vaccination) for the very young than to cover extremely expensive life-extension for the very old.
Yes – I think it’s borderline criminal that the government paid 100% of the cost for my 90+-year-old great aunt to have a shunt installed in her heart, but 0% of the cost for my 32-year-old sister to have an experimental treatment for the crippling back pain she’s suffered ever since she was hit by an uninsured motorist two years ago. I love my great aunt but she has had a long and full life. My sister teaches kids to read, and will do so for a long time if the back pain doesn’t make her permanently disabled.
If you want more protection you can hire a bodyguard, but you still have to pay for equal police protection and healthcare needs to be considered in the same way.
The police have the authority to protect you but not the responsibility; that remains yours. “Police protection” is a function that the police CAN perform but are not REQUIRED to perform. And a bodyguard is not enforcing the law, they are helping you exercise your right to self-protection. That doesn’t make them “private cops” – e.g., they cannot start handing out speeding tickets in front of your house.
The police’s job is enforcing the law. Your statement equates exercising the police power – which is a legitimate function of the State – with health care. They are in fact not equivalent. The State is the only legitimate source of laws; the whole concept of the foundation of our country is that only the governed, and not an individual or oligarchy, has the right to create the laws. The State in it’s role as the agent of the governed thus is the only legitimate party to enforce them. You yourself cannot enforce the law except under very limited exceptions and then only until the cops show up.
But the State does not create health care. It is not it’s ultimate source. Health care is a private good, not a public one. The State only regulates it in the interests of public safety, much as it regulates other things it neither creates nor supplies. But that does not create the obligation or the necessity on the State’s part to provide it to people by forcibly depriving other people of their property. The fact that you have more money than someone else absolutely gives you the right to buy and have more of it than someone else, just as you have right to buy more of other life necessities such as houses or food or clothing or water.
Make the argument that it is in the public interest that the State should by such means provide at least minimal health care to indigent individuals and I’ll listen. I’m sure that we can find common ground, actually. But health care is not a right, and it’s not equivalent to the police function.
Which is why I’m willing to accept changes in insurance regulation that makes competition among insurance companies greater, especially by making it easier for people to change from one to another.
Elective abortion. Anyone.
But then, by my lights elective abortion is not health care, any more than elective cosmetic surgery is (e.g., breast augmentation for appearance’s sake only).
If the health care debate carried no issues of morality–both openly and through implication–then I’d agree with you. But it does, even when we’re talking about health insurance.
Oh, sure, and I’m perfectly happy talking about what I’d like to be covered, just so long as it’s recognized that there’s no relation between my preferred option and the option on the table.
—Myca
Consider it recognized ;)
The Republicans (newguy, wossname) have been saying that they think health care can be saved by “eliminating waste and fraud.” (Doesn’t much help the person who can’t get any to start with, but OK.)
As both a consumer of health care (I had four doctor’s appointments last week) and a provider (I used to bill several different insurance companies for my services, let me assure you that a major source of “waste” in the US health care system is competition among insurance companies.
Maybe what we need is to get rid of HMO/PPOs and go back to health insurance that paid whatever doctor/hospital you saw, with no restrictions. Maybe it’s not that the insurance companies need to compete with each other, but that they need to quit placing so many restrictions on doctors and patients (I remember when I was a sophomore in high school and broke my ankle getting out of our car, our car insurance paid my medical bill and they didn’t place any restrictions on which GP my parents took me to, nor did they did care which orthopedic surgeon they took me to when it looked like I might need pins in my ankle). My parents’ insurance through work was the same way when I broke my ankle when I was in the 8th grade (yeah, that was back in the 60s, before health insurance got to be all about profits for shareholders and denying as many treatments as possible to patients in order to maximize those profits).
That still wouldn’t solve the incredibly wasteful need for an army of “billing specialists” on both ends of the phone, in every doctor’s office and every group practice and every insurance company, to hash out paperwork and assign and track payments and match patients with group numbers and check benefits and bounce back anything that isn’t a “clean claim” and point out that someone entered the service code wrong when they typed the claim into the computer so it really was “clean” when you sent it and make phone calls to ask where the money is and take the “where’s my money?” phone calls and swear that the check went out and argue that the check was $250 short and enforce the 12-visit maximum and argue for a parity diagnosis and insist that really, the provider did sign a new contract and provide an updated copy of their license and insurance information this year and maintain the Warehouse 13-like reams of paper on both ends of the equation according to HIPPA laws.
Or for small private practitioners to do their end of all that nonsense themselves, when they could be providing services to clients, which rams up what they have to charge clients for actual visits and services because you just know that if you see 15 insurance clients there’s going to be 5 hours of paperwork and phone calls involved and that’s in a good week.
Can anyone who believes society has a moral obligation to provide health care, stand up and identify a type or category of health care which they think should NOT be provided by society?
No. This may be self-serving in multiple ways, but I think that society is best off simply covering all health care. The basic argument is this: deciding which treatments are necessary and which people are “worthy” of care wastes time and money that would be better spent simply providing the care and not worrying so much about it. To give an example, how much has been wasted in terms of time, money, and even lives (RIP Dr. Tiller) on the abortion debate? Do we really want to have our congresspeople spending their energy and our money deciding whether to include this one procedure? Frankly, I suspect that if we simply ignored the issue we could save enough money to provide birth control for every fertile woman in the country in perpetuity, reforest half of Brazil with the trees not made into white papers on the issue, and use the mental energy freed up to save the economy. Much as, I’ll admit, I love debating embryology and ethics, doing so is not a good use of our lawmakers’ time to endlessly write laws to include or exclude treatment of accidental pregnancy into insurance laws.
Likewise, say you exclude plastic surgery that is strictly for cosmetic reasons. You’re still going to allow reconstructive surgery, right? And surgery for birth defects, etc? But then someone has to examine each case of reconstructive surgery to make sure that it really is being done for non-vanity reasons. And what to do about the marginal cases? Would repair of a facial scar that someone acquired after an assault be allowed? Repair of an umbilical hernia? Breast reconstruction after mastectomy? By the time you consider all the time and money that would be wasted on reviewing the cases, filing appeals, fighting with the patient and/or doctor, it’d really be cheaper to just pay for the occasional nose job and forget about it.
Additionally, it can be hard to tell what long term benefit a particular treatment will bring or whether it is really causing the system to lose money or not. The first use of rituximab in lymphoma was highly disappointing: less than a 30% response rate. We learned better ways to use it and now people with many types of non-Hodgkin’s lymphoma have a better than 50/50 chance of cure. If one looked at rituximab from the “do we fund treatments that only give a 6 month survival improvement” 20 years ago, one would have to say no, forget it. And many people now living after curative treatment for lymphoma would now be dead. Likewise, unless one is willing to let people die in pain and distress, comfort care is not free. One study from Canada in the late 1980s or early 1990s showed that treating people with incurable stage IV cancers with chemotherapy not only extended their lives by modest amounts, it improved quality of life and lowered costs-supportive care isn’t free. So refusing to give palliative chemotherapy for cost reasons is a money losing proposition.
So, again, my philosophy is do it right the first time, treat everything according to the best medical knowledge available and work out the social consequences from there.
And/or, a category of people who should not be eligible to receive it?
That’s easy. People who won’t benefit from the proposed intervention. But that is best determined on a case by case basis where the lack of benefit is agreed on by the individual and the treating physician, with input from relatives, consultants, etc. Not by insurance companies, governments, or unrelated bloggers.
Interesting.
It sounds like you’re making an assumption that your plan will be equivalently-priced or even cheaper than putting some limits or boundaries around the provision of health care. This assumption seems to hold even though you don’t make any exception for (for example) end-of-life care, or unusually expensive procedures, or anything else. Where are you getting the basis for that assumption? I don’t think anyone else is doing it; what leads you to believe that an “open menu for all” health care policy wouldn’t functionally bankrupt us?
Dianne, I’ve got about $100,000 in optional care on the back burner. Let me know when your water-can-so-flow-uphill plan gets implemented; I want to beat the rush, before the government goes bankrupt and stops payment on the checks.
In order for an insurance-providing entity to remain solvent – not even profitable, just solvent – they have to be able to determine what they will and will not cover. Now, this should be something negotiated up front and the terms should be as clear as possible so that both parties to the agreement understand what’s covered and what isn’t. But if control over what’s covered and what isn’t is turned over to third parties, the entity providing the coverage will not be able to determine what their expenses will be, what kinds of revenues they need and what kinds of reserves they need. It becomes impossible for the insurance provider to stay in business; again, even on a not-for-profit basis, even if nobody at the insurance company gets paid more than $100,000 a year.
Making the Federal government the insurance provider instead of private parties will not change that one bit. All it will do is make you and me and other taxpayers the source of the reserves, and will make predictions of what future tax revenues will be needed to cover expenses incalculable . The result will be that they will inevitably expand beyond any current calculations or predictions because the people who determine what will be paid out will not be the people responsible for paying it. It’s always easy to give away money if it’s not yours; any politician knows that.
This assumption seems to hold even though you don’t make any exception for (for example) end-of-life care, or unusually expensive procedures, or anything else.
How do you make an exception for end of life care? Dump people who are dying out on the sidewalk? Futile care should be stopped because it is futile, whether it is expensive or not.
And as for the infamous “keeping someone alive for 3 months at great expense” category, I contend that the right treatment is no more likely to be expensive than a lesser treatment, as in the study of chemotherapy versus supportive care above. I suppose we could start denying narcotics to people dying of cancer, but do you really want to live in a society that does that?
Similarly with expensive treatments. Take, for example, bone marrow transplant. A not-entirely-hypothetical example: A young man who was visiting the US (planned length of stay=about one month) started feeling tired. Then he started getting fevers. Then he started bleeding uncontrollably, which is what brought him to the emergency room where he was found to have severe aplastic anemia. Putting him on a plane back to his home country was out: he didn’t have the physical reserves to make it. The standard of care would be a bone marrow transplant. Unfortunately for him, bone marrow transplants are considered “non-emergency” procedures and so aren’t covered for non-US citizens. So the options were letting him die and second line immunosuppressive therapy. The latter was tried, resulting in a massive reaction and death after 2 months in the ICU. All at higher expense than the transplant, which probably would have resulted in him living another 60 years, would have been. More expense, worse outcome.
At heart, it’s always easier to say we’ll never let people die for lack of care, ever.
Practically, I don’t think we can avoid it. Unless you want to go all True Scotsman on me, then your idea of “futile” care is going to be someone else’s idea of “necessary” care. And if the meme is “never deny health care” then we will end up giving that, and even more, because nobody wants to say no.
Which is, frankly, up in cuckoo land as far as I can see. Perhaps you’re an exception, but most people I know don’t really think we can (or should) provide all health care to all people who want it, all the time.
See, when I see people complaining about how X person can’t get health care, it frustrates me when they use rhetoric of “there should be no limits.” Bullshit. There will ALWAYS be limits in a system even vaguely like ours (or any other existing system in any other country); they will just be different limits. Or if there aren’t, we’re talking about a major sea change in everything.
And that’s not the conversation that “more health care!” people like to have, because they probably know (correctly) that they risk pissing off someone on their side who thinks THEIR limits are too low, etc.
Sailorman, your insulting guesses at Dianne’s motivations for claiming to believe in unlimited care are exactly that: insulting guesses. Given that contempt for your fellow participants is something you have been often warned on, maybe you should back off a little on the contempt and the insulting insinuations.
In any case, we currently allow most people who are dying who need futile expensive care to get as much of it as they and their doctors want for them to have. If you are on medicare or medicaide, you can run up unlimited emergency care bills. Allowing the smaller number of people who are blocked access to such care because of their age and lack of insurance to have access to that care would not radically change the cost of health care in this country (particularly since it is easier to get futile emergency care than it is to get non-futile non-emergency care that would keep you out of futile emergency care). Personally, I think that decreasing the amount of futile care is an important goal, but that education is a better way to cut back on futile care than enforcement of arbitrary restrictions on who gets futile care, or hard rules on what constitutes futile care. Well informed doctors and patients will decide best what care is futile and what care is necessary. This is what is currently done. Imposing hard rules is what would actually be a giant sea-change.
I agree with Myca that elective plastic surgery shouldn’t be covered by the single payer system I’d like to have, so there are now at least two people on this thread demonstrating (contrary to your insulting claim) that “more care coverage is better” folks are willing to risk the wrath of our cohort by specifying what care is too much. I also think that there are plenty of non-treatments that shouldn’t be covered, although I feel largely unqualified to determine what treatments are non-treatments, and certainly don’t trust insurance companies to decide what treatments are non-treatments or are too experimental.
I don’t know what Robert’s $100,000 in backlogged medical care consists of, so I can’t say what portion of it I think the single payer should cover. Probably most of it, unless it is a bunch of cosmetic surgery.
I think orthodonture is the area where I would have the hardest time drawing the line. There is some orthodontal work that is pretty clearly medically necessary, and some orthodonture that is pretty clearly purely cosmetic, but it seems like there is a large middle ground of orthodonture that is probably somewhat medically valuable, but probably mostly done for cosmetic reasons. I think medically necessary orthodonture should be covered, and some level of medically valuable orthodonture probably shouldn’t be covered. I’m not sure who should get to set the line though, or how you would draw a clear bright line.
FWIW, I didn’t find sailorman particularly insulting. I do, however, think he’s wrong on this issue. Or, maybe, looking at it the wrong way. One problem with the law is that it’s awkward and slow. Medicine is an area of rapid change and laws restricting care in one way or another are likely to be lapped by technology very rapidly. For example, I’ve been told (sorry, haven’t verified) that the British national health care system doesn’t cover more than 2 rounds of chemotherapy. That used to be reasonable and rational, at least in the majority of cancers: the cancer drugs were similar enough that if the cancer was resistent to 2 it was probably resistent to all and further chemo was pretty futile. But now we’re got all sorts of new classes (angiogenesis inhibitors, antibodies, TKIs, classic chemo, hormonal therapy) many of which are non-cross reactive and third line chemo is starting to look reasonable. But how long will it take the system to notice this and change?
I don’t know what Robert’s $100,000 in backlogged medical care consists of, so I can’t say what portion of it I think the single payer should cover.
From hints Robert has dropped in the past, I strongly suspect that the answer is all or almost all of it. And that he maybe should apply for public assistance if his insurance isn’t doing it, before the $100K becomes $1 million.
None of the things on my list are things that most people would consider trivial or cosmetic.
I am in the upper percentiles of wealth and income; varies by year, but we usually do OK.
There are medical expenses that I would incur, if I had infinite wealth or if I could con some other sucker into paying my bill, but that I can’t afford on my own. I have to budget them, and pay for what I can pay for, as I can pay for it.
Not everyone in the USA has the same level of health needs as I might, but a lot of people do. There is FAR more demand for health care than there is money to pay for it, or capacity.
That is the empirical rock upon which all “we can pay for everything” ships must smash.
Robert, the specifics of your medical needs are none of my business and I’m not asking, but if you’re sitting on a health time bomb, I would urge you to go get the pr0blems taken care of and just work something out with the hospital and/or doctor’s office. They’ll usually deal with a payment plan if needed.
As far as the cost to society goes, what about the cost of the productivity lost to health problems? You’re already ridiculously productive with problems, but think how much more you could do if you were healthy. And multiply that by all the chronically ill people in the country. Not treating treatable illness is a waste of talent and potential.
It might be a waste, Dianne; as Sailorman pointed out, it depends on the person. It makes fiscal sense to spend $100,000 to cure the cancer of a 30-year old neurosurgeon, who will then go on to pay $10,000,000 in net taxes over the course of their career. It makes no fiscal sense to spend $100,000 to cure the cancer of a 60-year old busboy, who will go on to cost the taxpayers another $500,000 in social welfare benefits before finally dying.
Horrible? Surely. But once you start talking government funding, you have to make those calculations. The reason to cure the busboy’s cancer is humanitarian and basic decency, not because you expect it to be a paying proposition.
For paying propositions, we don’t need the government. People will do paying propositions all on their own.
On the other hand, the cancer might cause the busboy to say, “Whoa, I’m wasting my life being a slacker”, get serious about life, start a company and end up paying $10 million a year in taxes. And the neurosurgeon might say, “I almost died without fulfilling my dream of becoming a novelist”, give up neurosurgery, and spend the rest of her life as a starving artist. People are a gamble and always will be…which I suppose means that I agree with your basic point that the argument from humanitarian grounds is a better one, but I’m always a little afraid to make it because I can’t hear the counter-argument without fearing for humanity.
Quote one of those guesses, please. You actually should quote two, since you’re using the plural, but I’ll settle for one.
I don’t have contempt for Diane personally. I do think that her position is utterly implausible, to the degree that it is worthy of ridicule and contempt. NO system approaches the “unlimited care for all” model. No system even comes close. It’s not a discussion which is even on the table, anywhere, as far as I can tell. Which probably makes some sense, assuming that the role of government and society is to provide something other than health care, every now and then.
Suggesting that it would be nice if everyone could get all the health care they ever wanted? Sure, I’m in. Advancing the proposal that it would pay for itself, or be possible to achieve, in something like the world we’re in right now? I don’t think that’s an argument grounded in reality.
Unless you want to have an imaginary land full of unlimited resources, where you never have to make hard decisions–shades of John Lennon here–you will, eventually, have needs that exceed your resources. Why should that imaginary land be respected in a discussion?
You might get around calling things limits by offering unlimited care, unless it was futile care, or elective care. But that’s just putting limits on it, and using “futile” or “elective” to define those limits.
Look, the real question is whether society owes a limited or unlimited obligation to each and every citizen. Because there’s no particular logic in suggesting that it’s OK to spend unlimited amounts on health care for someone, while accepting that we can limit the amount we spend to educate/raise/care for/train/etc that same person.
There’s nothing extra-special about health care. The degree to which someone’s life is helped or fucked up by something isn’t all about your health by any means. There’s this conception that the Body Issues Trump Everything, which doesn’t seem to match reality very well. Yeah, it sucks to have my knees hurt all the time. But it would suck more to lose my house or my job, and/or custody of my kids.
So what, I get money for one (unlimited, if I need it!) and not the other? Or perhaps I live in a utopian society in which I can have both, as much as I want, and so can everyone else?
Even at the Star Trek level of resource management, there are limits. Not everybody gets to have a starship – though at that level of wealth, effectively unlimited healthcare seems to be the norm.
Sadly, we’re a lot poorer than Star Trek.
1 quote, 2 guesses:
You are guessing that Dianne doesn’t like to have this conversation and that the reason that she doesn’t like to have it is because she is afraid that if she states limits to “more health care for all”, that she will offend her even more extreme allies. You are making the same guess about Myca and me.
Not important, but annoying.
At this point, I’d be happy with the passage of practically any health insurance bill, regardless of its restrictions. Anything is more than nothing.
Aren’t covered by whom?
He was an alien in the U.S. on some kind of temporary visitor’s visa. I presume, then, that he didn’t have health insurance with an American health insurer. Why didn’t his health insurance from his home country cover this? Given how much we hear about how the U.S. health care system is so much worse than just about everywhere else, I presume he had some kind of coverage from his home country. Who was it that refused to cover this?
Sailorman, will you acknowledge that we currently have basically no restrictions on spending on futile end of life care for most people in this country who get end of life care?
You are arguing with ghosts.
Who is trying to get around calling anything limits? I would limit coverage by not covering elective care. I would not limit treatment by not covering futile care, although I would try to limit futile care by soft means. I would limit coverage by not covering all orthodonture, although I’m not sure where I’d draw the line. Myca would also limit coverage by not covering elective care.
What I want is to have care provided to anyone who needs it, to the extent reasonable or possible, rather than providing all possible care to some people, no care to other people, and nonsensical care to other people.
I recognize that some form of limitation may be necessary to prevent people from coming to the country specifically to get free care, although I don’t think that requires not providing any care to any non-resident aliens. I’m open to ideas on how to limit care in that direction to prevent a free rider problem, although I’d have to see how large of a free rider problem it would actually be. I’d pay 1-2% extra to cover free riders in order to cover everyone who is in the country for reasons other than being a free rider. I’d be more in favor of limits on who gets coverage if the free rider problem was going to be 5% extra, and I’d definitely favor restrictions once we got to 20% extra.
I don’t think you can properly consider that question unless you couple it with the reverse; what obligation does every citizen owe society?
Sometimes I think that President Kennedy would be a Republican these days. Remember – I remember hearing it live – “Ask not what your country can do for you; ask what you can do for your country!” I can’t imagine a Democratic politician saying that now. They’d be pilloried for being insensitive to the needs of black/poor/LGBT/illegal aliens/[insert_victim_group_here]. It sounds more like something you’d hear at a Tea Party movement rally.
That is simply ridiculous Ron.
Anyway, the Tea Party version is “Ask not what your country can do for you, ask how you can secede from your country.”
Let me get this straight: In a thread where I specifically refer to a variety of positions, you’re claiming I insulted Dianne because I made a “probably” allegation about an ill-defined group to which she purportedly belongs?
Er…I am actually sorry in this case, because I’m usually very good about putting in the appropriate qualifiers. I would ordinarily have included “most” here as well, together with “probably,” but I forgot. But I’m surprised you’re taking it so seriously, or that you’re so annoyed that you threaten a banning repeat. It’s almost a–what’s the phrase again–“Tone Argument.”
Or maybe not. Consistency is important, and I try to achieve it. Given your stance here, can I count on your opposition to general statements, no matter who is making them? You aren’t the type to raise the issue only for those you disagree with, I hope.
No, I’m arguing with Dianne. Who, as far as I can tell, believes that we shouldn’t have restrictions, or that they should be so minimal as to make almost everything covered. i haven’t finished the discussion with her yet.
No.
We will keep people alive to some degree, even when they are largely brain dead. but we will not perform certain procedures on everyone. Not everyone who wants all levels of care gets it.
Some of those limits have other names. We may call it “medical necessity,” or “practicality.” But those things are part of the limiting system. If a 95 year old wants a $150,000 bypass surgery and he’s willing to accept the risk, but his doctor refuses because it’s not “medically recommended,” or because the patient doesn’t meet the “other qualifiers for surgery,” then that’s an excellent example.
I believe that you’re simply changing language rather than effect. If you cover “non elective care only,” then the fight simply becomes about whether something should be classified as elective or non-elective. So instead of having the question “should we cover therapy?” we have the question “is therapy elective care?” I sort of consider these the same thing at heart.
Then you and I are on the same page, at least goals-wise.
Where I suspect we differ is in our predictions regarding what is reasonable or possible.
Me too. Though I don’t know what that is. One would think we could set up some sort of ‘exchange’ program to reflect the fact that many of us get care in other countries.
That’s really a “do you think illegal immigration should go up” question: if we provide free citizen-level health care to everyone then it will vastly increase the incentives to immigrate here by any means necessary. But that’s another discussion.
Sure, ths’d be reasonable, so long as it didn’t incentivize the problem to go up.
[shrug] Then trade. Republicans and a lot of moderates don’t like the idea of paying for care for non-citizens, especially non-citizen illegal immigrants and especially non-citizen illegal immigrants who aren’t in the country yet but who might be drawn by health care. If you want to get support for a broad system which isn’t focused on excluding free riders, you need to make immigration/enforcement proposals which will cover the free rider problem.
And I’d start with a cutoff closer to 1% than 20%. Hell, even Massachusetts just stopped its health care plan, so that it would exclude LEGAL immigrants. That money-saving move may be held unconstitutional, but it’s certainly an indicator of the dislike of non-citizen support.
Sheesh.
That’s not even as accurate as claiming that all Republican presidents prior to Reagan would be Democrats these days. And that claim is hardly unassailable.
If a 95 year old wants a $150,000 bypass surgery and he’s willing to accept the risk, but his doctor refuses because it’s not “medically recommended,” or because the patient doesn’t meet the “other qualifiers for surgery,” then that’s an excellent example.
In this situation, the 95 year old wouldn’t get the surgery even if he had cash because the surgery isn’t going to help him. He’ll have a better chance of seeing 96 with medication and/or angioplasty than with a bypass.
But there’s a difference between a doctor evaluating a 95 year old and determining that the patient is not going to benefit from surgery and a law saying that surgery will not be covered for 95 year olds no matter what. In some circumstances, a 95 year old might be a very good candidate for bypass surgery. Should we refuse to treat them simply because the majority won’t be?
Where I suspect we differ is in our predictions regarding what is reasonable or possible.
So, then what’s your proposal of what should or should not be covered by public health insurance? I think that your question about what is elective care is a reasonable one as well. When does a procedure become “elective”? Is breast reconstruction after mastectomy a non-covered elective procedure? Is revision of a keloid scar? Is prescription of birth control pills to relieve menstral pain? Then there’s the whole v!agra and abortion question…In short, once you start drawing lines you have to make detailed analyses of where those lines are. The simpler the better, IMHO.
I recognize that some form of limitation may be necessary to prevent people from coming to the country specifically to get free care,
IIRC, Canada doesn’t have any such restrictions: if you’re in Canada you’re covered by the Canadian national health insurance system. Maybe the rumors of 6 month wait lists for appendectomies are put about by Canadian immigration to discourage health care tourism.
I’d certainly support starting with no restriction and a clear rule on what level of free rider problem would be acceptable before some restriction would be imposed. The MA tactic of kicking of legal aliens is just cost cutting by excluding people who can’t vote (for one thing, MA obviously is going to have way more problems with citizens moving in from other states than they will with non-citizens of any stripe), which seems politically efficient but obviously immoral.
I got free healthcare in the UK when I visited there for two weeks and wound up needing to visit the emergency room. The only thing that cost me was the prescription… and that cost less than half of the fare for a cab to and from my hotel. And the scrip cost about 20% of what a nearly-identical prescription from my US doctor cost me just two weeks prior (similar antibiotic for separate conditions), because I happened to be uninsured at the time (meaning, once I paid the cost of the office visit plus the prescription, my UK medical care cost less than 5% of my US medical care).
Sailorman:
Hell, even Massachusetts just stopped its health care plan, so that it would exclude LEGAL immigrants. That money-saving move may be held unconstitutional, but it’s certainly an indicator of the dislike of non-citizen support.
On what basis would such a thing be held unconstitutional? And whose – the State or Federal constitution? It seems to me that the State is entirely free to discriminate on the basis of citizenship when providing services. Are there court decisions that would contradict that?
BTW, you are using an imprecise term that is confusing. I presume that when you say “legal immigrants” you actually mean “resident aliens”. I doubt that Massachusetts is discriminating against immigrant citizens – people who have immigrated into the US and then gained their citizenship. Those people are also properly described as “legal immigrants” but as U.S. citizens I rather doubt that Massachusetts is refusing to provide them the same benefits as native-born citizens.
Charles S.
(for one thing, MA obviously is going to have way more problems with citizens moving in from other states than they will with non-citizens of any stripe),
You’re right, but perhaps not by as much as you might think. MIT, Harvard, BU, BC, Tufts, etc. attract a whole lot of aliens on student and faculty visas, and a lot of the tech companies around there have resident aliens on H2B visas working for them. You’d be surprised how many resident aliens – nevermind illegal aliens – there are in the Boston area.
Elusis:
Free to you, maybe, but not free. Thank the U.K. taxpayers. You owe them a debt. Do you intend to repay it? Or do you disagree that you have any moral obligation to them?
A friend of mine was in Germany when a friend of his basically had to have his finger sewn back on. He said “Here in America that would have cost $26,000, but there it was free!” I told him “It cost $26,000 over there too – he just freeloaded off of the system while the taxpayers there paid for him.” Yeah, O.K., the cost could have been different, I have no idea what the actual cost was. But the principle holds.
Dianne:
Or maybe it’s just that moving to Canada is less desirable to U.S. (the only country bordering it) citizens. I’m minded of the unofficial North Dakota state motto: “40 below keeps out the riff-raff”.
Canada’s main worry about health care tourists are U.S. citizens. U.S. would have to worry about Mexico as well. The standard of living differential between Canada and the U.S. is a hell of a lot less than the standard of living differential between the U.S. and Mexico. I suspect that you could say the same about the standard of health care as well.
As I understand it, if as a non-citizen you’re in Canada long-term (work visa, permanent resident) you’re generally covered by the government system, at least after the first 3 months. If you’re there as a tourist you aren’t. For students it varies between provinces, although if not covered by the province you’re required to get roughly equivalent private insurance which exists for that purpose (e.g. UHIP in Ontario).
Update: The 3 month waiting period is an interesting one in this context, since the people most affected by it (i.e. having to buy private insurance) are Canadians moving back to Canada from abroad (foreigners on a work visa generally get coverage immediately, Canadians moving between provinces are generally covered by their previous province for the first 3 months). I suspect it does exist as a deterrent to a particular kind of “health tourism” – if you’re a Canadian living abroad and hence not paying Canadian taxes, you can’t take a quick trip “home” for free medical care.
It’s virtually certain that it cost a lot less in Germany. At every level, the US costs more.
Of course.
But IIRC, Amp has asked that nobody use the term “illegal aliens.” In an effort to enhance clarity, I chose the comparison between “illegal immigrants” and “legal immigrants” over the comparison between “illegal immigrants” and “resident aliens.”
I suppose you could debate whether that is more or less clear than comparing “illegal immigrants” and “legal/resident aliens,” but that’s why I used the phrase.
Canada’s main worry about health care tourists are U.S. citizens. U.S. would have to worry about Mexico as well.
A lot of Americans travel to Mexico for medical care now. There is a small amount of health tourism now from Mexico, but it’s these weird little health/spa/shopping trips marketed to very wealthy Mexicans who are paying full fare for everything, and I don’t think that’s what we’re talking about. Given the type of system we’re looking at, where people would still have to buy insurance, it wouldn’t make much sense for Mexicans to come to the U.S. just to get medical care.
American insurance companies are evil. I’m currently trying to get a clearly necessary test approved. So far they’ve refused and have frankly made it difficult to even find the right person to get a no from. Don’t ever deal with Americhoice or Medsolutions if you can help it.
I told him “It cost $26,000 over there too – he just freeloaded off of the system while the taxpayers there paid for him.”
Freeloaded my posterior. He (may have) paid taxes and paid into the health insurance system. Your health care is supposed to be covered when you do that. And I’d rather have people spending my tax money getting their fingers sewed back on than going to random countries to blow other people’s fingers off. Taxes are higher in Germany but you get something for your money: health care, bike lanes, responsive local government…the occasional foreign war but generally only following allies into it these days.
It’s cheaper. Rules are different (malpractice, etc.) and obviously there’s a currency and general financial difference. Same thing in certain parts of Asia. It’s especially popular for plastic surgery. If you want to get a facelift and tummy tuck, and spend three weeks recuperating in an oceanside resort being waited on hand and foot, you’ll pay a lot less outside the US.
You’re right. As far as I understand it, the usual reason that people travel to the U.S. for medical care is that the care is either because certain things are available here but not elsewhere; or because the specialists/facilities are better. There’s no point in comig here for a standard operation, usually.
We know that getting a “better life” is a big motivator for both illegal and legal immigration. We also know that health care (for you or our loved ones) is very important to a lot of people. It would seem pretty obvious that a significant difference in available health care would serve as an incentive for legal and illegal immigration, just as would a significant difference in potential income.
I believe Mexico’s health care is actually fairly good overall. I don’t know how good a job they do providing for the lower-earning portions of their population.
It would seem pretty obvious that a significant difference in available health care would serve as an incentive for legal and illegal immigration, just as would a significant difference in potential income.
I guess my point, which might not have been entirely clear, is that there wouldn’t be a significant difference in available health care because without an insurance policy, all you’d be able to access is emergency care, which isn’t enough on its own to serve as an incentive. There’s a pretty good system of low-cost clinics throughout most of Mexico. If you’re poor and you need a highly specialized type of treatment or operation, I think you’ll have a problem, but most people can get basic care.
Freeloaded my posterior. He (may have) paid taxes and paid into the health insurance system.
Actually, he didn’t. He was a visitor. So you don’t know what you’re talking about.
But IIRC, Amp has asked that nobody use the term “illegal aliens.” In an effort to enhance clarity, I chose the comparison between “illegal immigrants” and “legal immigrants” over the comparison between “illegal immigrants” and “resident aliens.”
True, he has. But by not using the term you miscommunicate. Your comment is wrong. Massachusetts is not cutting off taxpayer-provided health insurance for legal immigrants. They are cutting it off for that subset of legal immigrants who are also not citizens of this country (for which the term “alien” has exclusively been used in English and American law for hundreds of years and appears some 1100+ times in the U.S. Code). I’m guessing that they had already excluded people illegally in this country whether they were immigrants or transients.
So what’s more important; being PC or communicating accurate information? The only way to phrase this accurately while not using the term “alien” is to say that Massachusetts cut off taxpayer-provided health care insurance for non-citizen immigrants and transients after having already cut it off for illegal immigrants and illegal transients. Seems convoluted. Especially when “resident alien” and “illegal alien” is not only much shorter but reference the actual terms that would have been used in the law itself.
I was there as a tourist, spending money every single day that went into their economy for goods, services, and tax. If I’d had to fly home early to be treated by a US doctor, that’s a week worth of my money that the UK wouldn’t have.
And more to the point, clearly the UK has decided that this “debt” you say I owe them is one they can manage just fine. The catastrophic “OMG what about foreigners” rhetoric that comes up as yet another health care reform red herring is disproven by the fact that at least two countries have been named in this thread so far that manage the “foreigner problem” just fine.
Nor do I see any acknowledgment of the point that two nearly identical drugs cost such vastly different sums of money. Of course, my point elsewhere about the costs of dealing with multiple insurers has been roundly ignored in this conversation as well, so I don’t honestly know why I try to contribute anything to this discussion.
Though this wasn’t directed at me, of course, I intend to repay it. I intend to repay it by agitating for America to adopt a system of health care that covers foreign visitors … I figure if they take care of us when we’re there, we can take care of them when we’re here.
That’s what civilized people do.
Since the alternative is weirdly inefficient (and inhumane) stinginess, I think this is a pretty good answer.
—Myca
There are other alternatives, Myca.
There are two fundamental problems with American health care.
1. Insurance is a fundamentally stupid way to pay for anything other than severely catastrophic events in medical care.
2. Nearly everyone using the healthcare system has a grossly distorted view of price, because nearly everyone using the health care system has a third party paying the actual costs of care.
So any health care reform predicated on “fixing” the insurance system is akin to health care reform predicated on raising the IQs of everyone in the country by 100 points. A, we don’t know how to do it, and B, it wouldn’t solve the problem.
Care providers are in a position where it is very difficult to compete on price within a discipline. It doesn’t matter that you’ve reworked your lab and office staff procedures to provide the same level of care at 90% of the cost; nobody making the decision of which doctor to use cares about that. So nobody is even trying. What cost-based reform exists, is top-down, pushed by insurers trying to boost their profit margins – but those margins can be much more efficiently boosted by fucking over the customers, so there’s little interest in actual efficiency gains. The energy is better spent cutting people’s benefits.
To “fix” healthcare – that is, to increase access, reduce cost, and preserve quality – we need to get the insurers out of the picture as primary conduits for non-catastrophic care, we need to reassociate the actual cost of care with the actual patient experience, so that patients will ration for themselves on the basis of cost, and we need to create or enable funding mechanisms that permit people to budget for their care needs and reach reasonable optima on the cost-benefit tradeoff curve.
Super-truncated version of how to do that: end the tax credits for healthcare insurance, provide subsidies for catastrophic care policies for the working poor, provide generous tax credits and matching funds (for the working poor) for medical savings accounts, and create a government-backed lender of last resort for medical expenses not payable through a patient’s MSA or catastrophic coverage.
The real money-losing part would be the government-backed lender. That would cost us some tax money. It would cost a lot less than what we’re doing now. We could recover a lot of those expenses by making it work like back taxes work now – if you get a refund or windfall from the state while you’re in arrears, it simply goes against your debt. Debts die with patients – another source for the taxpayer to suck it up, but again, cheaper than what we do now.
Everyone could get care – by paying for it. If the care is more than you can afford but isn’t a catastrophic event, you can take out a no- or low-interest loan to cover it. We could get rid of both Medicaid and Medicare; to buffer transition costs, people enrolled in either program could get a nominal (but large) deposit into their individual MSA from the state. Sorry, grandma, no more free coverage – but there’s $100k in your MSA and you can use that as you need. Make MSAs heritable and you build in an automatic disincentive for elders to spend millions on futile last-month-of-life care; “no, don’t give me the transplant, don’t be stupid, I’m 93 and it would empty my MSA…just let me go and my granddaughter can use that money for the new eye she needs.”
Sure, if you assume that the population is, in general, comprised of rational economic actors. What data I’ve seen indicates that this is not not the case.
Alternatively, we could go to a system proven to be less expensive, more efficient and that has a much higher customer satisfaction level. Kind of like the rest of the industrialized world.
It seems to me that the real money-losing part would continue to be the cost of care for preventable conditions as people continue to put off seeking medical help early on or getting regular checkups because they don’t think they have enough money to do so. Whether that is done through a government backed “lender” or continues to be done the way that we do it now.
To be fair, there are countries with very good health care systems which do put part of the actual cost of care on the patients (with greater subsidies for very poor patients and very expensive treatments), and it’s not always a bad idea. France and some Scandinavian countries operate this way, for instance (iirc). So in that way I have to agree with Robert; some degree of cost-sharing from patients can be part of a good system.
However, where I think you’re mistaken, Robert, is in thinking that insurance can’t be part of any good system. Insurance — and not just catastrophic care insurance — is part of every health care system in the wealthy world that isn’t a pure single-payer system, and in countries outside the US it seems to work pretty well.[*] In fact, I can’t imagine how you’d prevent non-catastrophic health insurance from being an important part of any health care system (other than single-payer) in a country with a free market, unless you’re suggesting that we outlaw non-catastrophic health insurance outright.
[*] Note that I said “pretty well,” not “perfectly.” No health care system works perfectly, but some work much better than others.
Anyone who wants to make a bad bet should feel free to do so. (They might even be right that it’s a good bet for them.)
I don’t think Las Vegas should be shut down. I just don’t think it’s the model we should base our healthcare on.
In countries where insurance is an important part of the financing scheme for health care, it isn’t as much insurance as it’s a heavily regulated tax-and-redistribute system under another name. We could do that here, too, if people really wanted to. But there’s no economic reason to do it that way.
@Jake – I know of no better way to incentivize people into behaving as economically rational actors, than to assume that they are such and make the rewards and consequences of the system flow that way. People used to say that blacks weren’t responsible enough to vote. The answer is to let them vote anyway and let the consequences fall where they may; the people will soon enough bring themselves up to the level the system expects of them.
Like Barry, I am a supporter of what is called the mixed economy. This is an economy run on basically capitalistic lines, but with considerable state intervention into certain vital humanitarian sectors.
Some of the interventions that our state performs in the health care sector are benign. Medicaid, for example, has flaws but aside from the inevitable fraud, waste, and abuse I would be skeptical of claims it has a net negative effect.
Others have benign intent, but have produced perverse results. One such is the preferential tax treatment given to employer-funded health care plans. It’s not that employer-funded plans are bad per se; if the employer can gain a utility difference by giving benefits instead of pay and the employees like the trade, then God bless them all.
But the preferential treatment penalizes people who play ball a different, equally productive way. Some would argue that the fix is to extend the preferential tax treatment to everyone, but that would be quite expensive. It would be a relatively huge cut in revenues.
Normally I’m all for huge cuts in revenues to the state, but at the moment we’re pretty broke. Sorry, Dad can’t quit that part-time job quite yet.
I would argue to end the preferential treatment. (Some would lose employer coverage; most, I suspect, would not. Employer-provided coverage has a certain morale and productivity benefit that intelligent employers see the value of.) A lot of working people’s taxes would go up, somewhat. That does suck.
Amp, I suspect, will agree with me about the desirability of fair tax treatment for everyone, but always says that this argument is naively utopian because it can never happen.
I don’t think it can never happen. I don’t think it can happen without first reforming our political system so that elected politicians have different incentives than they do now.
Eliminating the tax break for employer-sponsored tax plans is a good idea, and I suspect that most Senators — of either party — would, if speaking off the record and outside the partisan fray — agree that it should be eliminated. But it’s unimaginable that a reform that big could happen without bipartisan support, and the incentives of our system now lean strongly against bipartisanship. Why would either party want to give cover to the other party, and thus give up a potential election issue?
(The current HCR does set a system in place that will gradually reduce the tax break for employer-sponsored tax plans; but it doesn’t go far enough.)
Ooh, check it out. Canada does have to deal with obnoxious health care tourists. Sarah Palin/a> for example.
It’s interesting to watch the lefties swarm over this one, more proof of Palin Obsession than anything else.
Canadian health care, at the time she was using it, was not socialized – it was on the free market. They were crossing the border to the nearest town with decent medical care – which happened, in the Alaskan wild, to be a Canadian town rather than an American town. And then they were paying their free-market bill with free-market cash.
From Wikipedia:
Palin was born in 1964. So if her brother’s broken leg required a hospital visit, then the Palin family did indeed use socialized medicine.
But who cares? Palin was at most five years old at the time. She wasn’t a decision-maker. I don’t see any hypocrisy here, nor is it something that should be a story.
They were crossing the border to the nearest town with decent medical care – which happened, in the Alaskan wild, to be a Canadian town rather than an American town.
If the link can be trusted (and I’ll admit I haven’t verified the information), the family was 1 hour from Anchorage, 11 hours from the nearest Canadian city. So whatever the motivation, it was not likely simple convenience.
Amp, I see your point about her not being the decision maker, but she’s now busy telling people about it in a positive way and that is her decision.
ETA: Updated source states that they were equally far from the nearest Canadian and US cities. So they had a more or less equal choice in terms of convenience and chose Canada. Again, not Palin’s decision, but it is her decision to bring it up.
Yes, she brings it up and points out that it’s ironic. I don’t see anything to disagree with, or criticize, in that.
I can think of many sensible, reasonable reasons that even someone opposed to Canadian-style health care in principle would still, in a particular situation, choose the Canadian system. Just because Juneau was equally distant doesn’t mean that it was equally convenient; maybe the train line to Juneau ran more frequently. Or maybe they just happened to like the doctor in Whitehorse better than the doctor in Juneau.
Or maybe Palin’s father was a big hypocrite. I still don’t see any reason to criticize Palin herself for that.
And I’m not crying crocodile tears for Palin, a liar who deserves no sympathy. (How much needless suffering will her attack on reasonable end-of-life care as “death panels” cause?) I just think that making a bad attack argument, like “Palin used a Canadian doctor when she was five!,” is probably not good for the cause of health care reform.
I just think that making a bad attack argument
What! How could you criticize a fellow liberal? I’m going to have to report you to the hive mind for this one. Our evil Communist overlords will not be pleased.
Don’t worry Dianne. As long as the seams on his aluminum foil hat are at least triple-folded he should be fine.
It seems to me that the real money-losing part would continue to be the cost of care for preventable conditions as people continue to put off seeking medical help early on or getting regular checkups because they don’t think they have enough money to do so.
I saw a report of a study – and I confess that I don’t have the link handy – that claimed that annual colonoscopies as preventative care are in fact a money loser. The assertion was that the amount spent on the colonoscopies is more than it would cost to treat the cancers that would otherwise occur. It was in a column that claimed that similar situations for many kinds of preventative care exist. Not all, mind you, we’re not talking about vaccines here. Of course, that’s a straight up cost of prevention vs. cost of treatment equation; I don’t know if they took into account lost productivity of the affected individuals, and quantification of the emotional loss, etc., would be quite difficult. But then those costs don’t affect insurers.
Believe me, I don’t lobby to strike preventative care. I fairly regularly have a date with 6 feet or so of fiber optic cable myself. And I’m damn glad that the $2000 is picked up by my insurer (I paid $15.25 out of pocket for the last one). In fact, at my last one a few months ago I was firmly convinced that the doctors WOULD find something, but they didn’t! I was in quite the emotional state for about a month. But the math of “preventative care would save insurers money” is apparently not as uncontroversial as you might think.
I’d like to see a comprehensive study of how the general application of preventative care affects health care costs. There might be some surprises. Again, I don’t ask for this to move towards eliminating the money losers. But if you want to talk about making changes to the health care system then estimates of the cost changes should be based on real data as much as possible.
Not sure if it’s related to my link, but this blog was mentioned in WhiteCoat’s post here.
Also, HuffPo has an article claiming the same thing I have been on here – that patients cannot just walk in and see a doctor. Here