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Physicians for a National Health Program

by crowsfoot / October 30, 2004 6:45 PM PDT
Single-Payer FAQ
Currently, about 64% of our health care system is financed by public money: federal and state taxes, property taxes and tax subsidies. These funds pay for Medicare, Medicaid, the VA, coverage for public employees (including teachers), elected officials, military personnel, etc. There are also hefty tax subsidies to employers to help pay for their employees? health insurance. About 17% of heath care is financed by all of us individually through out-of-pocket payments, such as co-pays, deductibles, the uninsured paying directly for care, people paying privately for premiums, etc. Private employers only pay 19% of health care costs. In all, it is a very ?regressive? way to finance health care,

A universal public system would be financed this way: The public financing already funneled to Medicare and Medicaid would be retained. The difference, or the gap between current public funding and what we would need for a universal health care system, would be financed by a payroll tax on employers (about 7%) and an income tax on individuals (about 2%). The payroll tax would replace all other employer expenses for employees? health care. The income tax would take the place of all current insurance premiums, co-pays, deductibles, and any and all other out of pocket payments. For the vast majority of people a 2% income tax is less than what they now pay for insurance premiums and in out-of-pocket payments such as co-pays and deductibles, particularly for anyone who has had a serious illness or has a family member with a serious illness.

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This presents an interesting question, but ...
by Bill Osler / October 30, 2004 9:00 PM PDT

I have real ambivalence about a single payer system. I do think we need universal health insurance if it is achievable in a sane fashion, but a single payer system will create its own problems. Although the Clinton plan was reviled at the time, I still think he and Hillary had some good ideas. IIRC some of those ideas have actually re-surfaced in the GWB plan. I've listed some major issues regarding a single payer plan. Note that I won't argue about "rationing". We already have rationing. The argument, then, is whose care is actually being rationed. You don't want to open that can of worms.

First of all you need to realize that when all the shouting is done that "payroll tax" the proposal talks about will come out of the employee's pocket. IOW, the actual tax will be something like 9% of income for employees and somewhat less for people who have a lot of untaxed income. For MOST people that is a whole lot more than the co-pays and deductibles they are paying now.

Secondly, the article implies that their system will abolish cash co-pays when it talks about the income tax replaces the co-payments currently made. That is incredibly naive. There is good evidence that health services utilization increases when co-pays disappear, and it is human nature to devalue things we do not have to work for or pay for. I cannot imagine a workable system that does not include some cash payment for services. OTOH, if they do not intend to abolish co-pays or deductibles, then they are being less than honest in their presentation.

Thirdly, they claim that the government will not interfere in the physician-patient relationship. These folks must think we were all born yesterday. Managed care companies already interfere in the doctor-patient relationship in more ways than I can list here. I have to select medications based on my patient's insurance company's approved list, use the radiologists or hospitals that the insurance approves of, select treatments based on whether the patient's insurance covers them, ... and that is for private insurance. Medicaid is even more intrusive in certain aspects of child care. Medicare has some of the most Byzantine coverage rules you could imagine. Even the Medicare "help desks" frequently can't figure out the rules.

Fourthly, there is no way that the government is going to pay for the care. Current Medicare funding is insufficient. We (and most medical offices) believe we lose money when we accept the Medicare fee schedule. We are quite confident we lose money when we see Medicaid patients. The VA system is chronically underfunded. You don't want to get me started about the quality of care issues that used to come up when I was in training at a VA hospital. I cannot comment much on the other large US government health system (the military system), at least not from personal experience, but my impression is that its performance is spotty. All of the government systems have inadequate funding. How is that going to improve if the government becomes the only payer? The reality is that if the government controls insurance, then the reimbursement rates will become political footballs. Resources will become more scarce, and access to services will be increasingly limited. This is one of the biggest problems with a single payer model.

There was a time when I would have enthusiastically endorsed a single payer national health insurance plan. Over the years, as I've learned more about the realities of the federal plans we already have, I'm a lot less enthusiastic about the prospect. There are some real problems in all of the single payer systems I've read about. Maybe the problems can be fixed, maybe not.

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Re: This presents an interesting question, but ...
by crowsfoot / October 31, 2004 12:25 PM PST
Note that I won't argue about "rationing". We already have rationing. The argument, then, is whose care is actually being rationed. You don't want to open that can of worms.

Hummm... Okay then. I know y'all do the best you can, or most of you do. My dad certainly did more than his share. The current rationing hits the guys I work with, and their families, very very hard. (single-employee contractors) And insurance is way more expensive for us than almost anybody else. Choices are a bad thing for us. "Choices" are a smoke screen for hiding inadequate, over-priced plans. I was interested to hear Bush mention collective bargaining, but knowing him it'll be more of what's now available.

So anyway, I'm just asking how this stacks up compaired to the mess we've got now, cost wise. There would be savings and there'd be expenses. I'd think billing would be less work for you? The cost of a whole branch of the insurance industry would be gone from the health care total.

You've obviously put more thought into this than I, and hearing what you had to say is the main reason I posted this.

Thank you, Bill.
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Are you at all familiar with the Canadian system?
by Ziks511 / October 31, 2004 1:13 PM PST

It covers everyone for significantly less than 9% of earned income though it is assisted by other tax dollars. Over all, as I understand it, it costs about 9% to 9.5% of GDP as compared with the US system which is currently running around 11% of GDP and doesn't cover everybody. We choose our own doctors and get referrals on non critical matters in 4 to 6 weeks, if your problem is deemed critical you jump the queue. All physician and hospital services are covered though in Ontario chiropractic services are being de-listed i.e. they will no longer be paid for, as are physio-therapy outside the hospital setting (A big mistake IMO) and eye exams unless you suffer from a listed problem like glaucoma or, my personal favorite since I was diagnosed last week, cataracts. You can never be cut off and never see a bill. Private insurance is a top-up coverage system, so unlisted services and drug benefits fall into that realm. Most people have a drug plan, people who work for the City of Toronto get the most extraordinary benefits like massage therapy, orthotics, frankly the list amazes me.

We moved here, as mentioned before, so that my wife, a physician, could do a Fellowship in Endoscopy loved the place and ended up staying. Should the US adopt a Canada-style system I think you would all be pleasantly surprised, except for the insurance companies.

Having worked for the National Health Service in England as well, the Canadian system pales somewhat by comparison but costs are higher and there are restrictions that I think Americans wouldn't stand for, particularly in the area of Dialysis treatments which until recently were not plentiful.

Both my wife and I think there is a lot to be learned from Canada, as well as European government provided systems. Germany started its health service in 1870 and I understand has the most cost efficient system providing a vast array of services including medical holidays at recognized specialist centers. Its running cost if my memory can be trusted is about 8% of GDP but that was before reunification which may have spiked costs considerably because of the high rate of environmental pollution and work-related health problems.

Hope you get a good system soon.

Oh, and my wife says there's a lot less paperwork.

Rob Boyter

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I'm only slightly familiar with Canadian system ...
by Bill Osler / November 1, 2004 9:27 AM PST

Since the Canadian system uses rationing that is a bit more explicit than our system the rationing is more obvious to the majority of citizens. Canadians have apparently accepted that rationing. It is fairly clear that many Americans are not willing to do so.

Actually, there are a fair number of Canadians who effectively opt out of the Canadian system for elective procedures that have long waiting lists in Canada. They come to the US instead of receiving their care in Canada. I presume that they do so at their own expense, although I do not know that for a fact.

The Canadian system appeals to me from an efficiency perspective and from an epidemiological perspective. I have to admit, though, that the little bit I know about it would make me reluctant to participate in it as a patient or as a physician.

Realistically, though, you don't really want the US to change to a Canadian style system. If the US were to regulate drug prices as tightly as most Western governments do, the drug companies would lose their most lucrative market. They could no longer assume that the US market would absorb most of the R&D costs for a lot of their drugs, and they could no longer assume that we would generate such large profits for most of their drugs. Drug innovation would decrease, and any new drugs that did reach market would be comparatively more expensive for non-US markets. The US would derive a short term benefit from drug price controls, but the entire world would suffer in the long run.

I wish that people were motivated by the common good and that the drug companies would continue their large scale research if the profits were substantially lower. It would be nice, but it is incredibly naive to think that drug companies would act that way. Marx was completely wrong regarding "from each according to his ability, to each according to his need". Economic incentives are the only reason the majority of people do useful work.

Capitalism, like democracy, is the worst possible system except for the alternatives. (apologies to Sir Winston Churchill)

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Re: This presents an interesting question, but ...
by Dave Konkel [Moderator] / November 1, 2004 12:24 PM PST

Hi, Dr. Bill.

>>There is good evidence that health services utilization increases when co-pays disappear, and it is human nature to devalue things we do not have to work for or pay for.<<
There's equally good evidence to say that more frequent access to health care early in the course of a disease or condition is much more cost-effective than waiting until later -- and the co-pays etc. give people an incentive to do just that.

-- Dave K, Speakeasy Moderator
click here to email semods4@yahoo.com

The opinions expressed above are my own,
and do not necessarily reflect those of CNET!

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Some results depend on the disease ...
by Bill Osler / November 1, 2004 9:00 PM PST
There's equally good evidence to say that more frequent access to health care early in the course of a disease or condition is much more cost-effective than waiting until later

That depends a lot on the disease in question. Unfortunately, figuring out how to help people get timely care for conditions that matter without encouraging them to waste resources requires the wisdom of Solomon.

Perhaps I'm not up to date on this, but I'm not aware of any outcome data showing that reducing/eliminating co-pays actually does improve outcomes for chronic disease. I have seen some economic research that suggests it might improve outcomes, but that is hardly the same thing.
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Anecdotally ...
by Evie / November 1, 2004 9:25 PM PST

I would not discount that for SOME people the security of only being leveled a co-pay might result in their seeing a doctor earlier on. But I don't think that's the reason the majority of folks don't go to the doctor more regularly or early on when they feel something is not right. Or even for regular screening. They put it off all the same for other reasons -- don't like doctors, fear of finding something serious (ignorance is bliss in a way), busy schedule (I've been bugging the hubby for 6 months to go for a stinkin' routine dental cleaning and he has had to cancel no fewer than four appointments because schedule changed), etc. I also think that those who are likely not to see the doctor for the cost of a doctor's visit (vs. copay) are likely to not want to pay the premiums for a low copay insurance plan to begin with.

Evie Happy

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Re: Physicians for a National Health Program
by Evie / October 30, 2004 9:41 PM PDT
Currently, about 64% of our health care system is financed by public money: federal and state taxes, property taxes and tax subsidies.

And THIS is why healthcare costs are rising faster than the regular market driven rate of inflation. The solution is LESS government subsidizing of healthcare and MORE free market.

Evie Happy
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So where are you Reps? CUT SOMETHING! ANYTHING!
by crowsfoot / October 31, 2004 11:51 AM PST

We're going down!


Or raise taxes to the point where we don't sink the boat. Is it that y'all KNOW the people will rise up against you? Better to point fingers and starve the beast, huh? Like Reagan supposedly did to the USSR? Maybe just a little water slopping over the gunwales to keep 'em honest!

Gated-communities FOREVER!

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Facts are a stubborn thing ...
by Evie / October 31, 2004 2:33 PM PST

... but they are still the facts. Lower tax rates have INCREASED tax revenues Bob. I hope the Republicans gut all government spending not called for in our Constitution. Unfortunately, with half of Americans paying next to nothing in income taxes, and expecting all the "Bread and Circuses", it doesn't seem likely to happen.

Evie Happy

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Re: Facts are a stubborn thing ...
by crowsfoot / October 31, 2004 4:02 PM PST
Lower tax rates have INCREASED tax revenues Bob.

I just don't believe that.

I hope the Republicans gut all government spending not called for in our Constitution. .

That, I believe! But that's not what they're doing. They ain't cutting NO spending to speak of. Instead, they're increasing that gigantic heat-sink of a place for wealth to go, The National Debt, at a rate undreamed of by the composers of your precious Primeval Constitution.

Unfortunately, with half of Americans paying next to nothing in income taxes, and expecting all the "Bread and Circuses", it doesn't seem likely to happen.

Is there much poverty in your neck of the woods? I know it's pretty uncouth to whine and demand something without exerting any effort, living in a country filled with opportunity (plunder, one might even call it) as we do, but ya' know what? Isn't wealth derived income pretty much a thing without effort too? And hasn't wealth been very sufficiently swaddled of late, thank you very much? And are we not running the highest debt and deficit of any group of creatures in the known universe since the very beginning of time itself? And why, I'm asking you, is THAT? To drive the next generation into abject, sing-for-your-supper serfdom is my guess.


"Mankind has become so much one family that we cannot ensure our own prosperity except by ensuring that of everyone else." - Bertrand Russel
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Re: Facts are a stubborn thing ...
by Evie / October 31, 2004 4:07 PM PST
I just don't believe that.

That doesn't change the FACT Bob. And it happened under Reagan as well.

Evie Happy
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Re: Physicians for a National Health Program
by Mac McMullen / October 31, 2004 1:34 AM PDT

Every proposed health program has had some good
points. A sole-source, particularly when government,
is the worst of all possible scenarios.

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Re: Physicians for a National Health Program
by crowsfoot / October 31, 2004 11:58 AM PST
A sole-source, particularly when government,
is the worst of all possible scenarios.


Maybe so, Mac. I used to think we were great and could do great things if we pulled together. When the majority party is against all things government, is it any wonder we can't?
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I have experience of two government health schemes
by Ziks511 / October 31, 2004 2:21 PM PST

in Canada, and in England and from the inside as both my wife and I work in health care. Both experiences have been very good. Canada's scheme is cheaper than the current total cost of healthcare in the US as a percentage of GDP and covers everybody. Give it a try

Rob Boyter

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Love it !
by Chorus-Line A1-QMS / October 31, 2004 2:31 PM PST

Supplemental insurance is also available.

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But the question is...
by dirtyrich / November 1, 2004 9:59 PM PST

How would such a health care system affect the US economy as a whole. Everyone says wonderful things about socialized health care overseas (except for those waiting 6 months to a year for a simple procedure because the waiting list is too long), but these nations do not have the same economic circumstances as we do. Europe, in particular, is economically stagnant in general, and what part does socialized health care and its economic burden play in that result?
Also you have to consider population size, medical infrastructure and distribution, and even the population's attitude torwards medicine as a whole. US culture generally demands a higher quality of life, placing a much higher demand/strain on the medical community. Our population is significantly larger, and distributed across a significantly larger area than most of these nations. With Canada, though, how accessible is health care to remote communities... how effective is the system in that case?
Plus, medical and drug researchers have turned to the US economy to support research and development because other nations, through price fixing, refuse to foot the necessary bill. Socialized health care would necessarily establish price fixing in the US also, slowing progress in medicine.
All these are potential issues and problems that could result from socialized health care. There might be solutions or workarounds to them, but I have yet to see any significant and convincing effort by socialized health care proponents to address them, so any talk to jumping into such a system anytime soon seems rash and impulsive.

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