100%.

r. Thank You.

Is this your shortest post ever?

I totally agree.

If it didn't already exist would anyone EVER create a system like this?

It became an employee benefit because of the favorable tax treatment of benefits.

At some point we need to focus on doing the right thing, not who pays.

In the end, we collectively spend north of 17% of GNP on it, which is too much for too little.

There are a lot of economists who thought that the tax treatment of health care was an issue as to cost, and for a long time, and that the only reason health care is tied to employment, instead of purchased through say mutual aid societies, or groups, and as individuals, is because of the WWII tie of health insurance to employment due to wage freezes. It would be a major adjustment too, as to timing, but you are certainly correct as to the tie being not logically necessary, if curious to see here.

Wolfman wrote a comment identical to that on my blog at like 1pm. LOL

What we oughta have is universal health coverage for every human being. EVERYONE!

As long as health insurance/health care is provided by for-profit, private entities, we're screwed. Universal health care is the only sane, moral route to go; if our Western, industrialized peer nations can do it, why can't we? Oh, right, we can't go that route 'cause "soshulizm is evil."

One of the biggest mistakes the labor movement ever made was allowing health care to be tied to employment.

Agreed, though. We need national health care coupled with private. Kind of like coach and first class, on airplanes. That said, everybody gets to their desired destination...

Yes, Leepin Larry, it probably is!

The nature of the beast of insurance, though, is that, as long as you're not using it, you're always paying for someone else's health care. But, when you need it and it exceeds the premium, someone else is paying. This is true whether it's tied to employment or not.

I have seen the premiums for my group plan at work go from $5,266 in 1992 to $18,651 last year, with most of that increase taking place in the last 10 years. Bargaining over health insurance has not been pretty. We managed to get a modest decrease recently only by switching to another plan that has more out-of-pocket costs.

That being said, I would love to have health insurance separated from my job and employment status.

Fifteen years ago I went through cancer treatment at a VA hospital in East Orange, New Jersey. I was fairly new to the VA…having come to it mostly because I had no health insurance.

I had many people tell me the VA gave lousy medical service—but for the most part, who really cares how good the service is when you are going for a checkup; to have a troubled ear cleaned; or to investigate some shortness of breath.

Then cancer raised its ugly head. A particularly invasive form of non-Hodgkin;s lymphoma.

Well, I guess if the truth were told, some of the doctors and nurses seemed liked rejects—and many of the staff were less than professional. There was lots of inappropriate chit chat…and more than a fair share of rude responses to questions and requests.

But there were several doctors and nurses who were as good as any I had seen on the “outside”…and the bottom line is that they got the job done. The chemo and radiation worked. As I said, it was 15 years ago and I am still alive.

Some of the other medical treatment was not up to what I thought it should be…but it was adequate. Adequate!

What I am saying here is, socialized medicine (which is what the VA is) may not be five star…but it beats the shit out of not having any treatment from here to Hell and back. Adequate treatment may be second to exceptional treatment…but it is way, way better than no treatment at all.

We NEED a socialized medicine scheme in place in this country…yesterday. It can exist alongside a capitalistic, non-socialized system…and the people who can afford the “better” system can use it. But the ones who need medical attention and cannot afford the “better” system will still get adequate medical care under a socialized program.

Probably the treatment and care will be a lot better than just adequate.

We can train doctors and nurses…give ‘em a free education and have them make their repayment by serving in this socialized system for a set number of years. We can even pay them a very decent salary while they are serving. And at the end of the term, if they choose, they can go onto a private practice…or find positions in the non-socialized systems.

We can build, outfit, and staff medical facilities…for use by the socialized system.

WE CAN DO IT…AND WE GODDAM WELL OUT TO BE DOING IT.

Coming from a country that has had free health care for years my opinion is well known. Get rid of the insurance companies adn join the modern world like Canada, Uk , France etc.
We have had it since 1963 and the country has not fallen apart.
HUGGGGGGGGGGG

I would ask how do we convince the doctors to take the pay cut? Specialists rake in the bucks, so it's not just the insurance companies that ate the bogey men. It's a whole system. And if you give the docs the choice of which system, as Frank suggests, they'd like to work in, then you're going to have medical care segregated by ability to pay. If we socialize everyone will have to be in it together.

Phyllis- doctors have already taken a massive paycut, reimbursement is way down, and the overhead has skyrocketed as we must pay for more and more staff to handle the costs and time of billing and coding, and HIPPA and nice looking buildings and machines that go ping. I don't make a load of money, in part because still only 4 years of practice, cash pay practice and a down economy. I was expecting to make twice this by now, but still far less than most docs who see 40 patients a day. The reduction in burden comes in taking out malpractice insurance (for some it is the dealbreaker, I think an OBGYN costs like 500k a year for malpractice) and paying off med school debts (usually in the area of 250 k). I would love to develop a plan for sustainable healthcare in the country, but politics has a funny way of intervening and deciding what is "affordable" (not what we are doing) and what is "sustainable" (also not what we are doing). Health insurance is not helping most of us, believe it or not. The profits from health insurance companies alone are one of the biggest burdens we pay for in our premiums.

Doctors need to publicize these problems more. The legal community says the rising costs are due to HMOs. Yet, when I worked for an insurance company, they blamed rising costs on doctors charging more for insured patients, and charging a "normal rate" for uninsured patients.

It seems we are stuck in a chicken/egg situation.

Perhaps we need to rip the whole system down, destroy it utterly, and start over again?

I agree, let's separate healthcare from employment. How about universal health care? With secular healthcare, you can opt out of birth control if your religious doctrine demands it.

RW- insurers pay a fixed rate for a billed rate, typically a percentage of global fee. If I bill 250, I won't get it, I will get anywhere from 50 -125 (max) for it, plus all the extra time to comply with codes (designed for billing, doesn't change treatment), paperwork, staff to do the billing, medical software to manage. For the same 50 I get in cash from the patient, I don't wait three weeks to a month for reimbursement. Most doctors give a cash discount to their "global" fee, and medicare pays the lowest fixed rate, which many insurers are now copying. Not worth the time you spend on the patient, so you have to cut the time. Doesn't help the patient. HMOs fix the costs, but patients have to take responsibility for their own health as well. Antibiotics are not a free for all, and infections are one thing. Obesity related care is another, and is causing diabetes, heart disease and cancer. ????

" I am for freedom of conscience, in both directions. "

me two.

I want the same health care that Dick Cheney gets.

BRAVO!! Thanks for voicing what I have been saying to my family and friends for some time. Gosh, it is so good to know I am not alone in this. Can you run for political office or maybe we could make you Supreme Ruler for a Day so you can change this for the betterment of all in this country?

Frank is right. Universal health coverage for everyone is the only possible solution that would really work.

I'm not familiar with how healthcare works in America, but whe I read your pieces I know I'm often reading the voice of reason, O.
R♥

Amen!

Odette- universal health care is a philosophical ideal, but realistically can't exist. What defines health care? when is it appropriate to stop medicating people? What part of the responsibility to pay and comply with self care does the patient have? If your insurance premium (for universal health care, you still have to pay in to get it back out) reflected how well you take care of yourself, people would be motivated to be more responsible. My experience shows me that when you pay out of pocket, you are more inclined to take responsibility. Not all diseases can be modified that much, but most of what's costs a lot is stupid accidents (self inflicted) from alcohol, drug use, thrill seeking, eating crazy amounts of food, eating bad food, not exercising, over exercising to the point of repeated injury, working insane hours that result in anxiety and insomnia and depression, wearing bad shoes (low back pain, sprained ankles), drinking beverages that cause headaches and mood imbalances. I don't see how universal health care can absorb the cost of self inflicted damage. So, the parameters of socialized medicine will be decided by "death panels" and their ilk. In socialized countries, you don't get all the meds you want for cheap, only the meds that they deem necessary. It's not like people are getting free boob jobs either, but that is still medicine. Most medication is not life saving, just symptom mitigating, and big pharma isn't going to let socialized medicine decide how much Ambien you need.

So, would it work better if there were an alternative to insurance? They charge huge premiums and try to cut payments to the doctors. As a middle man, they seem to have a serious conflict of interest in that they want profits more than they want to help people. There would be some bumps in sorting things out, but this system has issues.

Excellent post!!
rated with love

I'm for Universal Health Care. I believe that all the "self-inflicted" damage Oryoki Bowl lists are, in fact, quite treatable within the system as it stands.

Here's why I think this:
Health Care must include Health Education, which, if we're going to be talking Universal Health Care, that Health Education should be a conjoined effort within our Public School System. As we're talking about food habits, our Public School system, which includes cafeteria services, require some care and concern as well.

We need to stop serving crap for lunch. We need to focus on balanced and nutritious, low carb, mid protein meals that are not full of corn based sugars and starches.

As with our current insurance bloat, which includes the enormous fees insurance companies collect for malpractice premiums, we have this same sort of regurgitated try to save a penny at the cost of a pound in our Public Education.

Health Care has to provide for the whole body. This includes how we train our population about diet and nutrition -- and that includes enforcing social responsibility on the food producers in our world to act responsibly. We cannot continue to blame people for poor dietary habits when they are financially poor and have little choice other than to buy highly pre-processed foods to heat in the microwave after coming home from a hard day of stressful work where the employee is basically told, "Shut up, don't complain, do your job and just be glad you have one." And what to do about their kids, when both parents (when the jobs are available) have to work to be able to keep up with their necessary bill payments?

It's a twisted, convoluted, interconnected series of issues that synergize, and not in a good way, with each other to make it hard to change the system for the better. So the most obvious choice from which to begin would be Universal Health Care. It's the low hanging fruit in the equation.

Once done, we then start to take copious notes and start analyzing where we need to make changes, invest more time and attention, and how to go about doing so.

It starts, though, with separating health care from employment. The only feasable way to do this is to provide a sort of Minimum Acceptable Standard that everyone gets, period. I don't care if you're a poor underserved citizen, a middle class blue collar worker, an upper crust white collar businessman, the President, a foreign student, a work visa immigrant or a visiting tourist. If you want better and can afford it, then you pay for a better room, a private room, personal nursing, etc. If you think you might be in the hospital for whatever reason and the idea of Universal Coverage isn't good enough for you, then you buy Additional Coverage and pay into it.

As soon as we can manage that, then we can start using our Public Health Education to actually start changing the country's piss poor dietary knowledge. Along with that, we have to change at least the offering of foods in our schools.

Notice that I never mention the word Free here. Universal Health Care, like Public Education, comes from the tax revenues government (in whatever form) brings in to provide for all these sorts of Public Weal Programs.

The problem is complex, but we can tackle individual aspects of it, one leg at a time, as long as we pick the most sensible course to get started and then stick with it. I believe it starts with providing Universal Health Care first. We can work our way out from there.

--r--

Dunnite Owl-I totally agree. Still, people like to have their freedom to live their lives as they want, eat what they want, smoke what they want, etc. I think there is a balance there, but first there must be conscientiousness- which does begin in school, at the supermarket, and in the nursing homes. If you go into a Walgreen's, take note of all the things they make a load of money from - candy, soda, alcohol, cigarettes, snuff, beef jerky, pringles, etc. How is that a pharmacy?

There are a number of countries that link health care with your employer - including countries with universal healthcare like France and Germany. The difference is that they are tightly regulated and they have coverage for people who aren't working. The link with employers is mostly for convenience and organization, as far as I can tell. But here in the U.S. we seem to be allergic to regulations that might make this type of system work for everyone.

Oryoki, "individual health care freedom" leads to discrimination against pre-existing conditions and the gradual weeding out of those most in need. Why not a publicly funded single payer system, versions of which most other rich countries already have with cheaper overall costs and better results?

You go, girl!

A very important reason to get rid of the tax advantage to employer health insurance is the market distortions. Republicans are always talking about letting the market work, but in health care, for the vast majority of Americans, the insurance company pays the bills and their employer chooses the insurance company --- leaving the patient quite removed from the bills.

I'm not a fan of high deductible plans, because the only tinker at the margins. If your deductible is $5,000, do you care if your cancer treatment cost $10K or 50K, when you're dealing with the devastating discovery that you have cancer?

There's an interesting article http://www.princeton.edu/~reinhard/pdfs/MAYNARD_PAPER_25TH_JAN_2012.pdf

Which states that all health care systems have two goals: providing care for patients and providing income for providers. It's taboo to talk about the second goal, so we don't. But the paper argues that the income side is much more powerful than it should be.

In fact, as I understand it, Medicare is explicitly forbidden to consider cost in deciding whether to cover a treatment and there is little research or standards on cost effectiveness. The result is that patients aren't given the the lowest cost treatment first. For example, daily aspirin works well for many (but not all) heart patients. It should be tried before angioplasty, but there isn't any protocol saying so.

hmmmm.... interesting views. Necessary and sobering.

I was with you until the last paragraph. Of course it's stupid to have healthcare tied to a job. However, freedom on conscience has no place in the financing of healthcare, whether through insurance or socialized medicine. The point of insurance is to pool risk. It doesn't work when insurers or customers get to cherry pick what is or isn't appropriate health care based on their personal prejudices. Taken to its logical conclusion, that means Catholics can opt out of paying for anyone to receive contraception, and you get to opt out of paying for people with high cholesterol (the implication being they brought it on themselves through their diet), and I get to opt out of paying for people to have kids (because we're over-populated already). This is in keeping with our toxic individualism, but is a piss poor way to spread the cost. Instead, we should recognize that we are responsible for each other. Spreading the cost is what it's about. Personal preferences, prejudices, arrogance should not enter into the equation. (I'm young and slim! Why should I pay for fat people's heart attacks? I don't smoke! Tough shit on your emphysema. I disapprove of your loose lifestyle and don't want to pay for your STD tests!) For any health care system to be financially feasible, we must all share the risk that any one of us might need a doctor. Social policy can be fought out in some other arena.

Right on! Thank you

First step, allow companies to purchase Medicare at cost.

Sirenita- I get your point about pooled risk- that is what insurance is about, and in some ways, so is socialized medicine. However, I don't really believe that "conscience" is the basis of discontent with this system. There are pros and cons to private vs public health insurance. The very wealthy aren't going to notice a much of a difference, and they tend to get considerably better healthcare- and also spend a lot more out of pocket to get it. Socialized medicine provides equal opportunity- and there is also much earlier education about personal risk and responsibility. It doesn't mean people get all the meds they want- acetominophen is only available behind the counter, or ibuprophen. Countries with socialized medicine also have socialized education, public transportation, commonwealth and unemployment/disability. There is an attitude of responsibility for each other that does not exist in America- and can't be legislated. Sadly, many of them are also seeing their systems go bankrupt and turn towards privatization. The likely answer lies between a certain level of socialized care and a certain level of individual responsibility.

Of course it's possible. Plenty of countries are doing it quite successfully. It isn't some crazy, unprovable theory. I'm not sure why you're trying to pass that off as a good argument, but it's not.

As for 'being responsible,' no, I don't agree at all. Here's the thing: In all of our lifetimes, for one reason or another, some because we weren't responsible, some because we had genetics that worked against us, some because we had bad luck, but ALL because we are human beings with fallible bodies that get sick and die, we will get sick. We will get sick. All of us. There is no "being responsible and not get sick" truism. You can live with great health and gusto and still die of something or get sick from something and so on. You can be a child and get sick. You can be an older person and get sick. You can get cancer in your early 20s and die. You can get cancer from smoking or from doing nothing wrong at all.

Getting sick is something we all do. Period. So, it seems to me that we should follow the rest of the civilized world and recognize that. I don't approve of making sickness some sort of personal commentary on the way that you live your life. Good people who treat their bodies well do get sick. But, even if you mistreat your body and get ill, that does not mean you deserve to die alone and untreated in your house or have to pay enormous insurance payments that don't cover your illness.

No. Being ill is part of life. It is not something to be measured to force the idea of "the Elect." I do not want to live in a Puritan society. I do not believe God chooses Elect individuals to be wealthy and healthy. I do not believe that wealth means you've worked hard to earn it either. It can mean that, but it can also mean your capitol gains are working for you. So, I really truly want to blast away the idea that being sick is your own damned fault and too bad for you. That is an evil and extraordinarily stupid stance, made while overlooking the uninsured child with cancer. It's very, very wrong. I won't ask you to reconsider this stance. It is my experience that this idea of the Elect and Good Healthy Wealthy myth is unbreakable by those that believe it. They want to believe it because they are afraid. Afraid that sickness can happen to anyone. Instead, they concentrate on the virtue of money. Money. Why it will cost me some money if we have universal health care! I can't be helping those evil, fat individuals out there smoking!

This stance is complete nonsense, of course. If you run the numbers, universal health care is cheaper and better. If you look at the examples, universal health care is better and cheaper. If you look at the ethics, universal health care is better and cheaper for the soul, too. If you look at your community, universal health care is better and cheaper. If you look only to yourself, since one day you will be sick and the insurance company might drop you and you might suffer and die or might lose your house to medical payments, then universal health care is better and cheaper.

But, these are just facts. They won't make a dent in the belief system of 'every person for him or herself' and 'money matters most.' That much is true.

Sad. When did 'being responsible' stop extending to the community? Because that's the most irresponsible stance of all.

PS--I pay individual coverage. It's ENORMOUSLY more expensive and covers far less than coverage that is work-related. It would be an insurance company's dream if we all had to be covered individually. Think of it. Millions who have to have health insurance because we all get sick. The point is that they can charge enormous fees because, otherwise, we're up a creek. :/

Odette- that is not my stance at all. Personally, I believe in health care for everyone, and all children, but there is no such thing as universal health care for all forms of "illness" as we treat people medically today in the US. Much of what we call "disease" is a condition which results from our actions combined with our genetic propensity. Giving people anti-osteoporosis drugs but not telling them to stop drinking soda, eating sugar, and to start doing weight bearing exercise is not healthcare- it is medication against lifestyle. Get off your high horse, if you read any of my other posts, you would know that your argument against me is not even founded. As to universal healthcare, I have a mother and whole side of a family who lives in a society with socialized medicine, and I have lived there myself. Is it successful? Well, right now, they are cutting back a lot of benefits that were considered rights. The line of "universal" will keep moving. If you consider chiropractic care medical care, which it is in this country, you won't necessarily get that somewhere else.
China has "universal" medical care too, and I think they do a piss poor job of taking care of their citizens.

I've said this for years. I hate the health insurance coverage is at the whim of the employer. I'm a freelancer and for 14+ years, was on my husband's health insurance...until he got let go. and then we laughingly went through COBRA and crappy, expensive private insurance with two major surgeries and a toddler with a serious medical condition that required weekly blood draws and 4 hospital stays (and we were lucky). Now we are thousands in debt, while still paying thousands in medical coverage.

I finally gave up, stopped freelancing, and took a corporate job with health insurance. It certainly isn't great, but it's better than what we had.

I strongly believe that the employment landscape would be much different if health insurance was easily accessible and affordable to individuals outside of an employment situation. I know many people who would quit instantly (or would have before the economy tanked) or switched to part time, if they didn't need to cover insurance. We would have been fine on my freelance salary if it wasn't for the medical bills. The fact that the religious right is bringing this to the forefront may actually be a positive. As more people argue that employers shouldn't have to pay/cover/support this or that drug or procedure, the public option will start looking like the way to go...and then I can return to freelancing.

Good psoat as tour healthcare policy posts always are.

Your insistance in responses that every facet of helath care needs reform, except physicians like yourself, does not add to credibility.

RE: "If you don't want to pay for my contraception, then don't. I don't want to pay for your cholesterol medication."

It seems to me that being in a risk pool with individual subscribers will mean doing exactly what you refer to here. But that's okay if those who don't want to play, and pay, go find themselves a risk pool that suits a religious ideology. It means they can't force their ideas on the rest of the participants.

As to a separation of employment and insurance, I very much doubt it will happen in this decade, if ever. The first premise of the so-called ObamaCare premise, based, as it was, on RomneyCare, was, if people are already covered by their employers let's leave well enough alone. That's pretty much the way it went. Not that I agree with it, but that's what happened and we're stuck with it.

Oryoki:
What is "socialized education?" Maybe public schools? The Republicans are trying to use "socialism" as a boogeyman, but the real difference between European "socialism" is that their taxes are higher and cover health care. If you add the costs of American health care to the tax rate, you get similar rates.

Maybe in the land of the free, you currently don't have to buy health insurance, but all that means is that the cost of your care is socialized when you land in the emergency room.

Much agreed. Wonderful that you got an EP.

Steve- I don't think how things done don't need reform, including education and triage. Most patients don't need to see a physician for a lot of the things they get regular care for. As for me, I am not in the insurance system, and not part of medicare or medicaid. I already charge a lot less. The system as a whole needs reform- that includes cost and burden of education and operating expenses- which includes education, insurance, time, liability, overhead, etc- for all practitioners- not just physicians. And pharmaceuticals. And suppliers. And hospitals. And medical imaging. And durable equipment. Demanding physicians take a pay cut is just insulting, it assumes they are the reason why it's so expensive. Or that they haven't earned their salary.

Malusinka- socialized education is universal public schools that are differently structured than the American model. For one, more standardized curriculum, so that your child doesn't go down in education by moving to another school district. Higher standards for achievement, which means that students are actually taught instead of just tested. Vocational education if you aren't going to go to college. And then your education paid for by society as you go through life. Socialized medicine is only one component of society- it is part of the larger fabric of communal care that goes from birth to death, and all citizens are enfranchized. Specifically to education, that means comprehensive sex education from an early age, access when you need contraception, and strong education about nutrition and exercise. Based on science.

Most hospitals and physicians end up writing off between 25 and 50% of their "billed" expenses as bad debt- this goes uncollected. You many not sue a medicare, medicaid, disabled, or uninsured patient for unpaid bills. Of what is left, 50% typically goes to overhead. If you are getting primarily reimbursed by those parties, your collection of fee is typically 25% of your billed fee, maybe less, because they set a fixed reimbursement rate. Until the cost of life doesn't increase, and people don't want raises anymore, and don't think the staff should be getting up to date education and new equipment or a building that doesn't fall apart, and an office staff that can do more than just the bare minimum, we will need people to be able to get paid for their work.

The vast majority of people who get regular health care don't pay for the cost of their care, even with insurance. The folks who pay and don't use it are paying for the difference. The risk pool is covered not just by the group you are in, but your own status. Regular health care is not insurable, because you know the patient will need to use it, so instead it just increases the risk. The idea that someone is paying for your specific medication is academic. You are paying the insurer to be part of a risk pool, and from the funds they get, they pay for certain medications and procedures. All insurers negotiate cost with suppliers- practitioners, hospitals, pharmaceuticals, etc. Many people will find that outside of big expenses (like hospitalization for surgery, etc), paying for insurance is more expensive than paying the cash price for the same - just need to go to a different location. If you bill insurance, and it is denied, you will be charged the full insurance billing price, not what the insurance company would have paid, and not what you would have paid if you prepaid with cash. This doesn't get reformed by practitioners- who must do the same work- it is resolved in congress and in private industry, who are making tremendous profit and blaming cost on the patients.
There is a major shortage of doctors taking new medicare and medicaid patients because they can't afford to stay in business. Most doctors do some kind of pro-bono care, but if it isn't voluntary, it is neither fair nor free. And, realistically, there aren't that many people who can do medical care as a career, and we have weeded out a lot of them just for bad pay, long hours, and little appreciation. Socialized doctors have their education paid for, they work limited hours, have the same social benefits of others, and no individual liability. Still, when given the chance, many of them move to the United States where they can make a lot more money to do the same job.

@ Oryoki Bowl
As I read your essays here, while I agree with much of what you say, either universal health care or an insurance based system health system does provide at least some sort of checks on how money is spent for care.

All of our systems are based on the Western model of evidence-based medicine.

If as you propose, 'People should get the money instead, in the form of better actual wages, and keep track of their own health plan.' then there will be this huge flood of money given to individuals who rarely have the ability or the opportunity to judge whether a specific care or treatment is efficacious or just hand-waving.

The government and society has some responsibility towards keeping healthcare standards; just dropping money on people might be a great boon to the currently unlicensed therapies but I don't share your belief that it will raise the average standard of health.

Traveler- I think that people should have the freedom to choose the kind of health care they want, and manage their own insurance. If someone wants to use chiropractic and acupuncture, they should be able to get plans that help pay for that or reimburse them for it. That isn't hand waving, it is a fair amount of patient's taking their health into their own hands. That "flood" of money is money they have earned, that is spent on their behalf, often for insurance that doesn't benefit them. Even if you buy as an individual, you are still part of a group. That is the nature of the insurance business, which is not the same as socialized medicine.

Oryoki
I think you're making a mistake when you assume that centralized education means higher quality. England has a national curriculum and a national Office of Standards in Education. But their public schools aren't much better than American schools. Oxford and Cambridge say that kids who went to private schools tend to be two years ahead of public school students. UK public schools are mostly paid for by local taxes, like in the US. So, I find it hard to see how their education might be socialized and ours not.

I guess I'm objecting to the way 'socialism' gets abused. It's first cousin to Stalinism on the right, but you seemed to be using it as a synonym for quality. Neither is helping us decide how to deal with complex questions, like how to structure health care.

I'm all for a national curriculum, but, frankly, I think that we'd be more likely to get Mississippi's than Massachusetts's. Because adopting Massachusetts's standards means saying that almost all of Mississippi's students are well below grade level.

Malusinka: but don't Japan, South Korea and Taiwan also have national education?

From what I understand, "public" education in Britain is reserved for the elite, and "private" education is reserved for everybody else, right?

Malusinka- actually, I was using the scandinavian model as an ideal. As I lived there, and have family there, I am a bit qualified to comment on it. From what I can tell, their kids are much better educated by 14 than most of ours are by 18. Including being fluently bilingual, and having a better understanding of what government, liberty and social democracy means. England still has a far more entrenched class system. And they are also dismantling parts of the NHS. But they, like other countries, have extensive testing that is more rigorous than ours, and kids who aren't good at school get vocational training. Adults get education if they are not in a good job situation. This is not like No Child Left Behind or AIMS, they have much higher standards than we do.

Judging by the side tracks taken and the assumptions being made and arguments being presented, all I can really say is that I was right when I said:

"It's a twisted, convoluted, interconnected series of issues that synergize, and not in a good way, with each other to make it hard to change the system for the better."

Public Eduction in the US is socialized education. Period. The difference between socialized systems here and in the EU is not as much a matter of quality, but application. Private schools, no matter which country you live in, tend to be pushing their students' academic potentials higher than socialized education.

Is this wrong to do? I say it's not. What is wrong, however, is to, as Malusinka put it, call socialized systems, be they health coverage or educational programs, the Bad Idea or Bugaboo that the far right seems to be screaming -- all the while doing their level best to dismantle both aspects: Education and Health Care.

Countries in the EU are having trouble with making payments into their systems. This is not because the systems are bad ideas or that socialization of such things don't work -- the real reason is that the World Economy runs pretty much the same there as it does here: with an elite few who wield considerable and disproportionate power and control based on aggregated and concentrated wealth compared to the many who would stand to benefit if these systems of wealth generation were as socialized (ie: regulated and policed from malefactors, cheaters and frauds) as our public education and public health care systems were in either the EU or the US (and other locations around the world.)

What it boils down to is the ability of a few very powerful people being able to wield considerably disproportionate control and influence over systems which they are above in terms of need and financial affluence. The question then becomes, how do we treat a nation based on the desires of a few over the needs of the many?

The answer is: Look around you right now and see how the systems designed to provide for an entire society are being dismantled and corrupted by the desires of those few. You want it to continue like that, then let's all just do nothing and keep arguing over the minor details.

In the meantime, some other facts should come as a surprise to many:
While tax rates in the EU are noteably higher than the average up front out of paycheck rates than the US, they have health care for all, unemployment for all, education for all and while it might not be as high quality as privatized sectors, the average middle class EU citizen has more time off and more financial wherewithal to travel than the average US citizen does. They are also, on the whole, better educated, better informed politically and socially and, in general, have better overall healthcare without being robbed into the poorhouse to deal with it.

You may not like those facts, but you do a little looking and research and you'll find I'm not talking out my ass. Universal Health coverage should come out of our paychecks or pockets in the form of a tax. Not tied to my employer's desire to cut costs by getting the cheapest provider it can, or by making me pay more out of my pocket for one plan than another that doesn't increase my overall quality of life care.

Socialism is part and parcel of living in a society. Regardless of your politics, religion, status or education, social systems require socialized answers. You can't even have capitalism in a world without a society. Societies require a certain level of socialism, simply because that's what societies require.

Thanks Owl- I just wrote a post addressing my experience of exactly those things when living abroad. Amazingly, I learned more about the real definitions of many of our terms while in language school, and more about human rights there than I ever did here. !

I like this idea, though the health care system in France works well enough for me, too: you get basic universal coverage that is taken out of your income tax, and then, your company could offer a separate insurance policy that would allow you to save even more money - or you could purchase a policy as you choose. But whatever the case, you are covered (even if you don't work, you will have access to inexpensive healthcare here - for example, a visit to the g.p. is only 20 euros, even for foreigners who aren't in the system. I like that feeling of safety. But your idea works very well, especially in places where, as you point out, healthcare is otherwise provided by companies who can make choices for you.

I couldn't possibly agree more with this. I agree with this so fully it is makes me want to dance and sing.

Whenever I hear someone level the criticism that the ACA might cause some employers to drop health coverage I think yes, wouldn't that be nice because it will hasten the day when we can go to a single payer plan. We are foolish to fragment the risk pool on the boundaries between private concerns. And a single payer would have the clout to negotiate lower drug prices.

And wouldn't it be nice if the government could subsidize medical laboratories doing medical research in partnership with medical schools and other academic pools of scientific expertise? Such an institution could do the research done by private firms who need to recover the investment costs using patent protection to protect their monopoly pricing? Government funded medical research would not be done for profit; it would be for humane reasons of healing and done in the pursuit of knowledge by scientists rewarded with salaries to do the fascinating work they love. Instead skimming from the flow of cash paid to relieve suffering and misery, all for the sake of subsidizing rich profits and IPOs and fat bank accounts and corporate jets, government funded research could discover medicines free of patent protection, and the cost savings on drug prices would be the long-term dividends funding the research efforts.

I for one will never shed a tear over the absolute demise of private health insurance companies or private pharmaceutical research. They've enjoyed a great party while it lasted, but every party comes to an end.

There are some very good points here. I think the race is on now for employers moving away from providing any kind of healthcare for their employees or making it so costly workers will decline participation. My fear would be that they would still pay only the minimal salary they could negotiate. People trying to purchase health insurance on their own still find it unaffordable. At present , Cobra would cost my wife and I over $1200 per month. That's more than the highest mortgage we ever paid for a new home. In this economy I just do not see people making the kind of salaries that they could devote that kind of money to health insurance with all the other expenses to live. I do not see any quick and easy answers.

I've been saying that other people shouldn't have to pay for my "this or that" or I have to pay for your "this or that" for years. However, if GOVERNMENT is funding my this or that or your etc., other people ARE paying.

If you want freedom of conscience AND just plain ole freedom, you have to get government out of medical insurance as well. Let people pay for themselves (turn to charitable institutions when they can't) and stop thinking of medical care as a free ride and you'll bring down prices (I'd suspect) and save me and you from having to pay for other people's care via force. (I may well want to volunteer.)

We definitely need to separate health care from employment but I don't think it's realistic to have individuals each cherry-pick details of coverage from for-profit insurance companies. Their dominance is the heart of the problem. Once agan, we're hearing that America can't possibly accomplish what a couple dozen other countries have successfully done. Corporate dominance of America is the only reason for that. That's the elephant in the room that must be confronted and challenged if we are to have real reform.

@Rw:
I was using "public" in the American sense. Private education is also called "Public" in England, because when the first schools were established, private education was a tutor in your castle and a school with many other students was "public". I should have used the English term, State Schools.

Oryoki:
The British government is busy dumbing down the tests, so getting the top grade on the A-levels no longer guarantees that Oxbridge will take you. It's news to me that the mediocre students get vocational training in the UK. What I heard about constantly when I lived there, was the low standards of the 'bog standard' comprehensive, which was the typical high school. I noted that errors of spelling, grammar and punctuation were very common on signs.

The NHS had some really stupid practices and I thought some small injection of market forces (like a co-pay) would help them a lot. But, for all its problems, the NHS was much better than what we have in the US. And universal health care isn't expensive. The difference is that the Europeans tend to pay for health care in their taxes and our health care costs aren't part of our tax rate.

I don't think Sweden is a good comparison to the US. It is the size of California with a quarter of California's population and it lacks the diversity of the US. If, for example, you took Connecticut and Massachusetts, which have a combined population similar to Sweden's, you'd get much better schools, higher standards, more college grads, higher income and much higher health insurance coverage, than you do looking at the US as a whole. So, does Massachusetts have "socialized" education and, say, Mississippi not?

Regardless of how you structure it, people have to pay for health care. It all comes down to which system of structuring payments and organizing care providers is the most effective and humane.

The question then is not "how do we avoid having people pay for health insurance?" The questions are:

1) What is the most effective way to manage people's health care payments so that we can meet some baseline standards for delivering care?

2) How do we organize and manage the delivery of care so that it meets baseline standards of quality care, and so that it is cost effective, i.e. we try to maximize some metrics on the amount of care delivered per dollar spent, and minimize the rate at which these costs increase over time.

The solutions range from everyone out for themselves and a totally free market, to some form of single payer insurance and government managed care delivery.

In the case of a totally free market, there are problems. I'll just summarize the theoretical benefits (I think everyone basically knows what those are): competition between businesses and bargaining between individuals and providers lead businesses to charge the optimal price and consumers to pay the optimal price, i.e. in both cases what is in their best interest. For businesses (insurers and care providers) this means charge prices that are low enough to attract customers and high enough to ensure a profit. For individuals this means don't pay for care that provides low value of care per dollar; pay only for the care you need, and pay the most efficient from among the providers.

The big problems with this market ideal when it comes specifically to health care are that the ability of people to know what they are paying for is limited and widely variable because of the complexity of health care, and the need for care varies widely from person to person. Also in the insurance arena it fragments the risk pool, which leads to numerous inefficiencies and limitations. And as we have seen with recent problems on Wall Street, businesses have ways of trying to increase their rewards beyond what the efficient market hypothesis should predict. An unregulated market will result in volatility and bubbles and disastrous consequences for consumers who do not meet a business' criteria for economic feasibility, namely if they are really sick and don't have lots of money, which is exactly the case a caring and humane society would want to address, and which could happen to anyone at any time.

The need for care is not just a voluntary option for the consumer, like "shall I buy a TV or not buy a TV". When cancer comes or a heart attack occurs, you don't want it and you don't plan it. These are reasons why I see using the free market approach as immoral because it is cruelly unfair: it might produce the best average results (but it might not), but too many consumers will come up short based on their inadequate knowledge of the complexities of care, or based on their inability to pay. And coming up short on health care is not the same has having no TV or a smaller dimension screen; it's more like coming up short when trying to jump over a ravine: you plunge to your death.

In my view the health of the nation is as vital a national interest as the security of the nation, and the devastation of poor health is just a slow motion version of the kind of devastation that a violent foreign invasion can cause to life, limb, and wealth of individuals. In other words, it's worth addressing with at least the same vigor and blood and treasure we are willing to put on the line for national security.

I think that it comes down to a question of how do we balance the value of blood against the value of treasure. Right now it seems we value treasure much more than blood when it comes to health care. I think we need to value blood more, and we really should muster our national will to see how far can we kick private for profit businesses the hell out of health care.

We could for example work with what we already have started: expand Medicare to everyone, and expand the VA system to everyone, and shift all the money that goes into the private health care industry today into paying for those. We could also have a partnership between government and academic researchers to develop pharmaceuticals without patent protection, but developed rather with the public interest at heart. Naturally this would have to be a gradual long term project. This would give businesses time to redirect their resources on other markets, and give government time to develop the needed infrastructure.

Why can't providing good health be more like a patriotic duty, a humane service, and a fascinating scientific pursuit, and less like a pathway to a richly rewarded career, or a life of luxury, or even a life of obscene opulence as in the case of the executives?

you may now join the throngs of idealists who also believe that holding a job should bear no relation to food, clothing, shelter, cable tv, cell phones (the government spends $1.6 billion on free cellphones for the poor annually), automobiles, college, etc.

if everything is free - why would anyone bother to get a job?

and then who would pay taxes so the rest could relax with all that free stuff?

Malusinka- to be clear, this post is about separating your health insurance from your employer and your employment status. I wrote a follow up blog, since so many people here want to talk about national health care. I lived in Denmark, which is like Norway and Sweden and Iceland. You are right, you can't compare. However, most people equate national health care with universal health care with free health care. They are all different things. England has a different history, and btw, their NHS is getting cut back all the time. Even if we gave Medicare to everyone, they are reducing services and payments from there on an ongoing basis-which is why fewer and fewer doctors are willing to contract with them as private physicians. Now, if you want to make the whole country a top down, socialized medicine only model, you will need to figure out how to also educate the entire staff, and provide all the materials and equipment and medicine, on those same taxpayer for medicine dollars. People who paid into medicare didn't pay for their medicine, they bought into a pool. People on medicaid typically haven't paid that many taxes at all- children, mentally ill, disabled, unemployed. Americans like the idea of equality, but we don't actually believe in it. It would require many of us to give up more than we get back to make sure our neighbor gets the same, regardless of effort. This post isn't about that, though. It is about freedom of health care. Anyone can buy health insurance on their own, and it is not always more expensive. Small group insurance is typically more expensive (through a company) for the premium, and COBRA is definitely more expensive.
Whether we go to single payer, or stay with for profit, insurance payer, will not be decided in the years our economy is floundering. But that may be the cause the pushes so many people to change their mind and consider the value of socialized healthcare. That would also mean seeing the value in your neighbor's life, health, education and safety net as important as your own. We could do this on a state by state level, but local taxes would have to change, since some states have a higher concentration and distribution of wealth than others. Just like with school districts having a lot or a little money depending on the property taxes of the area, money would have to be redistributed to even things out. Americans consistently vote against that. Those with the money put laws in place to make that illegal.

Jeff- I think we can say we value a lot of things, and yet still not put money into it. I defy anyone to define what is the standard meaning of family values, equality, liberty. I do think that the first step towards better health care freedom is getting your wages in actual money, instead of inflated benefits. Individual coverage from health care still puts you in a risk group, based on what your demographic is. I can tell you, though, that insurers are rejecting covering certain kinds of conditions, like obesity, more and more, because they are seen as lifestyle choices rather than health conditions. How we believe medicine should be practiced (pro active, preventative vs palliative, reactive) will determine the allowances and costs. Medicare, medicaid only covers the prevention that is required by law - which now includes a mammogram and a pap smear, it hasn't always. It comes down to cost effective. More and more companies are providing health screening services at the place of work (blood pressure, blood sugar, cholesterol and obesity) because people aren't going to the doctor for those things until after they already have them. Most doctors are paid to medicate them, not offer lifestyle changes that can effectively change those things for the healthier. But, cognitive behavioral changes must take place for many things so that patients can reduce the burden on themselves, and stop causing the health problem to escalate. If you think people with health insurance, full benefits, paid for by work, take better care of their health, that would be a mistaken belief. Most of them don't even go to the doctor once a year for a checkup, and doctors don't run screening/prevention during their 8 minute visit about erectile dysfunction, migraine and insomnia. That's how medicine is practiced in the real world, with or without private insurance. Patients who pay the extra money, or make the extra wellness visit, often out of their own pocket, or god forbid, their own deductible (which no one wants to pay for) tend to be more proactive about prevention. I think the system has to change, but universal and passive health care isn't going to make people healthier. It will just mostly slow down the rate of disease progression for some. As so many people like to use the idea of antibiotics, I agree, infectious disease should be stopped asap. Most infectious disease isn't diagnosed until after it has been around for a while, and most of it is palliative care after that, with the exception of bacterial (and some fungal, which is very difficult to treat). Whether or not you personally believe in vaccine isn't the issue, vaccine doesn't apply to most infectious disease. If you are sick and contagious, you should be allowed to miss work or school without repercussion, and stay home. Most schools and many offices require doctors notes, which are a time and money burden, and so people only miss when they have to, which spreads disease.
That is not an insurance issue, that is a societal issue, and an employment issue. Not everyone who works full time gets health care from someone else, and not everyone who has a job is protected from being fired if they call in sick. Many people do not collect wages if they don't clock in.

Dr. Bowl on the cover!
It's a greed nation. When I get sick, I will die. I'm used to the idea now. Will not buy for profit insurance, mandate or no.
So there ya go. Noble thoughts here tho

Tr ig- good to see you. One thing many people don't realize, is that you can get an HSA- health savings account- from some banks, like an IRA. If you can save money in their towards health related services, you can get a tax deduction and use that money to pay for it, up to 5k a year. That means anything a doctor can see you for, write a script for, or a licensed practitioner (there is a long list from the IRA as to what counts) in your state. I realize savings are hard on us all these days, but every little bit of untaxed revenue helps. Until we can buy into national health care, we have to break free from the stronghold insurers have over our belief system on medicine. Meanwhile, stay healthy friend.

I am in total agreement about employers not paying because it is a burden on business, and it is fundamentally unjust. The people with the higher paying jobs, for whom healthcare is more easily affordable within the parameters of their budget and discretionary income, are the ones most likely to receive it from their employers.

I think that tying what a person must pay to their lifestyle choices makes sense, but we don't need a private system to factor such incentives in. They can be handled with co-payments or deductibles in either a private or public scenario.

It also makes sense to me that how much people can pay should in some way connect to what they can afford. It just is absolutely morally repulsive to me that a person who can't afford the cost of care should be refused essential care, when it is available to another person because they are more economically successful. This kind of affordability calculus makes sense to me when considering vacations, and quality of clothing, size and location of housing, style of automobile, ability to purchase conveniences and luxuries, but when it comes to health care I feel that we as a society should endeavor, in fact ought to feel obliged to endeavor to ensure that a fairly high level of essential baseline health services are affordable to everyone (and free to nobody). Even the most indigent homeless should be able to kick in a few bucks; the scale should depend on ability to pay. It shouldn't be cheap to anyone; it should be affordable to everyone.

Here is my most strenuous objection to privatization: it's like having the mob provide law enforcement. They might be very effective, but they are out for their own interests only. Typical soldiers and peace officers on the other hand have motivations, in varying degrees, that are informed by a sense of duty and obligation to public service.

Again, I find it morally repulsive that people would endeavor to make a profit from the misery and suffering of others. I don't trust private business in this domain, and the recent fiasco of the housing bubble and Wall Street irresponsible risk taking only underscores the moral hazards created by unregulated markets.

What do you think of ACOs? I think there is something very promising in the concept because it eliminates or reduces the perversity of incentives that a purely free market FFS system entails. The perversity I mean is the incentive to encourage unnecessary treatment or tests. I was once a member of Kaiser-Permanente, which is, as I understand it, effectively a type of ACO. I liked it. Payment is in terms of a fixed annual premium and a system of light co-payments. The organization has a commitment to maximizing the total health of a population and thus minimizing their costs in order to be efficient. Kaiser is non-profit, which I like. The incentive to maximize profits in health-care is a poisonous infiltration of self-interest into a field that should be about health and healing and service.

Jeff- I have heard about the Kaiser system, and I agree with what you say on many levels. I will have to get in touch when I end up doing my PhD in sustainable healthcare, one of my personal visions for changing the conversation in this country is defining what that means. I understand, in the Kaiser system, doctors are employees, not contractors, and their liability is managed by Kaiser as a group instead of individual. This reduces cost tremendously because of the time and money that must otherwise be spent to pay for individual administration. It allows the doctors to focus on their job as physician, instead of as private business person, entrepreneur. I don't know where they fall in the realm of student loan reimbursement, which will vary from person to person. I have long thought we should be able to start a non-profit health org, now called ACO, in Arizona. My friends and acquaintances who have been in health care a long time- either physicians working on their own, for the VA, for the state hospital, or people in administration of private hospitals- all want to see better, more affordable healthcare for more people. It is the top offices in the state and the top brass in the executive boards of insurance and industry- equipment, pharmacy, and billable services- who prevent this, legally and in practice, from happening. In reality, most doctors are private contractors, or part salary, and must bill to make up the difference- since about 30-50% of what they bill is written off as uncollectable, and what is left is typically 50% overhead and advertising and insurance. You still can make more as a private contractor, but the hours tend to be much longer and the job of running the for profit, cash side needs a business manager and staff you can trust to not embezzle from you. Not as easy as it looks. I still don't think your health insurance should be tied to your employer or your employment status. Whether fully private, partially private, or fully public, insurance is not about the future. It covers only the term you are in, and ends when you are stopped. National health care doesn't stop when you stop paying into it.
Personally, I think all children up to age 19 should have 100% public coverage regardless of what their parents make. Why 19? Gives a gap between graduating and a chance to get a job or go to school where you can buy student insurance. I think all prenatal and post natal care should be covered. That's my personal preference and belief, and it doesn't end there.

When I recently found myself in the emergency room, the first thing the doctor asked was whether I have insurance. Later, in the ICU, the nurse told me that it's a good thing I have insurance because I would get better care. Something's wrong somewhere.

Sarah- that's pretty amazing, it's totally inappropriate for them to ask you about it much, other than what kind, in case they need to send out billing to a different lab. The ER is supposed to be a neutral zone. You aren't supposed to get better care with or without insurance, particularly if it is an emergency. I know private hospitals have their own "rules" but the only time I see the reason to ask is due to which labs/imaging centers to refer to (since they are all contracted differently with each insurer, like providers are). Yikes!

Speaking of insurance as not being about the future, I think this is mainly a consequence of private insurance, and it's one of the things I meant in an earlier post when I mentioned fragmentation of the risk pool. The fragmentation occurs over time, and over space or population.

Here is what bugs me: suppose I have been insured for 30 years in perfect health, and then for whatever reason I need to change insurers (because I change my job for example). Then within a year I'm diagnosed with cancer. What has happened is the insurer for 30 years has effectively pocketed my premiums, and the new insurer regards me as a burden on their profitability. It's even worse if, as happened to my neighbor, your business gets hit by the recession 2 years before medicare eligibility. He couldn't afford to continue his insurance, and hoped he'd make it until 65. As luck would have it he got hit with an expensive operation for an embolism that nearly wiped out all of his home equity. The decades of payments he had made didn't help him one bit. This seems terribly unfair, and it is a regular occurrence in a fragmented private insurance system but not in a national single payer system.

It could be that this effect averages out for large insurers, but it seems to me that it means that many medium sized pools need to charge more per person than one large pool based on actuarial calculations, because regional differences and shifts in demographics could combine to really hurt a particular insurer while benefiting another. So while the insurer is calculating things based on a term, as you say, why shouldn't it be true that a person who has paid premiums for decades of health has some kind of health spending credit?

Likewise, if I self insure, say with a health savings account and accumulate a large savings over a healthy lifetime, I may never need major hospitalization. The person next door may do the same and end up really needing it. If we pool our money together in theory we could each spend less and cover the odds of one of us needing a very expensive surgery or major hospitalization. The odds improve if more people are added to this pool. It seems to me that the larger the pool the more efficient it will be both in terms of what share of society's medical risk each person needs to pay for, and in terms of administrative efficiency. So a single payer insurance that everyone must pay into is about the future and about spreading risk across the largest possible group in the present.

Since you do have a professional interest in health care, if you don't already you might want to keep an eye on the blog "The Incidental Economist". Also the Henry J. Kaiser Foundation has lots of reports and data. (Separate from Kaiser-Permanente). www.kff.org.

I totally agree. Also, it should be beneficial to an employer not to have to be involved in employee's health care. Imagine the cost savings by eliminating a whole department of HR. It might provide additional funds for companies to expand, hire additional people, pay better wages, etc. Consider the innovative people who would like to start their own business, but can't risk losing health coverage for themselves and family.
During 40 years on the job, I encountered co-workers who had a self-employed spouse. While the spouse made an excellent income, my co-worker provided the health care insurance. Often this resulted in a colleague who had little interest in doing their best work. There are really plenty of reasons to separate health insurance from employers. It is such a dead idea.

Oryoki:
I admit that I've come to the conclusion that insurance is a poor way to pay for health care, which leads to single-payer system.

But a separate issue is that the current American system is not paying any attention to costs. It's easy to find people who claim it is immoral to use cost as a metric. We spend 17% of our GDP on health care, and most European countries spend 12%, tops. The UK spends 8.3%

So, if the UK has to spend more than they've been spending to get good health care, that fact has little to do with whether the US can implement an NHS type system that provides great care and costs less than the mess we have now.

But, anyway, until we can get a single payer system, I definitely support getting rid of the employer exemption for health insurance.

I couldn't agree more with the basic premise. And if nothing is wrong with you - no big problems - individuals coverage and paying cash for service can be cheaper than a traditional health plan. The problem with that, which would have to be addressed in some way if group coverage was not part of the picture, is that large medical bills under an individual plan are often barely covered at all. I am a universal health care proponent myself - that would be truly portable, never mind where you work or live.

Agree, agreed all over the place! As a self employed person, I have to buy my own insurance, so I know what I've got. Rated RRR