It's rare that I find myself agreeing with a column by Eric Zorn. But since I've been saying this for several years, I'd be hard-pressed to change my mind now. :)
I kind of agree that health insurance should be for unpredictable catastrophic things--except that for some people--Shiny, for instance, or Sparkle, the expenses are pretty predictable, but still potentially impossible for a normal family to pay. Unless you're comfortable with these kids going untreated--which I'm not--there has to be some way to pay for them.
But I agree with this piece that we should give serious consideration to single payer. I'm just kind of startled to see you endorse this idea. But cool with it--totally cool with it.
The point of catastrophic insurance is to cover a catastrophe. The thing that everyone needs to understand is that a "catastrophe" can be an ongoing series of medical expenses that continues for a lifetime, not just "I need a kidney transplant".
For example, if you define catastrophic medical expenses as those that consume more than 10% of a family's income in a year, you start getting an entirely different picture of the results. I can't tell you whether Eric Zorn has this in mind, but that's my picture of the situation.
With my leukemia, I get treatments for immune problems on a near-monthly basis, and was in the hospital eight times in the last twelve months. The treatments are around the cost of an IVF, and the hospital stays aren't cheap. (Mostly, I sit around and they pump IV antibiotics in me.)
Is this unforseen? Well, I got this plan in 1983, and yeah, it was unforseen then. Is it catastrophic? Yep.
The individual mandate is a compromise attempt to avoid the obvious solution: Let government — not private companies — provide single-payer, catastrophic health coverage for everyone.
It's not the obvious solution; it's one of several...and the worst one. The best solution is too large for the margin of this book, but:
encourage employers to stop providing medical insurance, and to transfer their current expenditures for that into employees' salaries
adjust the tax code so that expenditures for medical insurance and MSAs are non-taxable, inheritable, and with high-enough limits to absorb the "pay increase"
use the Commerce Clause (appropriately) to enable individuals to purchase such insurance from any provider, in any state
create a Federally-chartered, non-tax-funded, non-profit insurance entity to provide basic medical insurance to anyone who wants to buy it...but at actuarially-sound rates
At the risk of opening a can of worms, I overheard a conversation the morning after the bill was first passed and the subject of he Canadian system came up with the following comment: "They say Canada has really good health care." "Oh, but they really don't!" I won't say there aren't problems with it, but the folks back home wouldn't give up the single payer system for all the tea in China. In fact, if you are ever running for office in Canada so much as hinting at privatizing health care is political suicide. I hear people saying the quality of health care is compromised as a result and that has certainly not been the case in my experience. It may not be the best alternative down here, but I don't believe the health of the nation should be left in the hands of profit-driven insurance companies.
Zorn's starting point, that mandates are a necessary complement to banning the use of pre-existing conditions as a reason for dropping coverage, is correct. Paul Krugman's also written about this. The conclusion, which I've heard many times before, is one about which I hope reasonable people can disagree.
The problems I see with the "insurance for catastrophic coverage only" approach are basically threefold. First, when you're living paycheck to paycheck, and have a job without insurance (or no job), the impact of what Zorn refers to as "predictable events, such as tests, checkups and prescriptions" is huge. This is why there are so many reports of people waiting until things get really bad, then going to the emergency room. As I recall, Bill, in a recent post you mentioned that you take a number of prescriptions that greatly improve your quality of life. How different would your life be if you only had catastrophic coverage, and had to cover the entire cost of those prescriptions yourself? Further, what if you also had a much lower income than you now do?
Second, the analogy with houses and cars is flawed, because houses and cars don't have chronic illnesses or conditions. If the roof is leaking, you pay once to fix the roof. If you develop diabetes, the expense is ongoing for the rest of your life. Perhaps a chronic condition, because of the high lifetime cost, could be classified as "catastrophic". But I'll bet that opens up a whole new can of worms about what does and doesn't qualify.
Third, from a market perspective (yes, the liberal is invoking the market), it's inefficient and not cost effective. When you have a system where people are disincentivized to have checkups, or go to the doctor's office for symptoms that are manageable, you don't catch catastrophic problems before they become catastrophic, and that drives overall spending up, as catastrophic events cost a lot more to deal with. Not to mention the cost in human lives - how many times have you heard/read about the importance of catching cancer or heart disease early?
I'm still a single-payer supporter, and am currently encouraging friends to support Alan Grayson's "Medicare for all" bill, which will provide a strong public option at cost. But I will say that this bill, however flawed, is better that what we've had up to now.
(For whatever it's worth, I'd be happy to characterize the mandate as a tax. I see it as an acceptable tax.)
The first thing you need to understand about my position on issues is that they don't necessarily revolve around what's best for me. (Sometimes, yes. But not always. :) )
I believe that a first cut reasonable definition of catastrophic coverage is a stop loss that kicks in when you've spent more than 10% of your income on medical care in a year. That means that someone making less money would have less out-of-pocket expense before the plan kicked in than someone making more money.
So, yes, this plan would probably cost me money, because I'd end up paying for my own prescriptions. On the other hand, that would have to be offset against what my employer and I pay currently for health insurance and netted against what the government would end up collecting to fund catastrophic insurance. But just because I might not be as well off under this plan, doesn't necessarily mean that it's a bad idea.
The problem with single-payer is that there is no longer a market. There's an edict that determines what the government is willing to pay for a service and what services the government is willing to pay for. This tends to reduce the supply of doctors and to reduce the ability of a patient to see a doctor on a timely basis for an acute condition. So the trade off for the check ups is that you may not be able to get timely treatment for a non-emergency but nasty condition. (My recent dental problems come to mind immediately.)
I'm not convinced that's a trade off that I want to make.
Further, single payer is a great system until the government decides not to treat your life-threatening condition. I read recently of a Canadian gentlemen with a brain tumor. They took several weeks to decide that they weren't going to operate. After that, he went to the Mayo Clinic. They managed to remove most, but not all, of the tumor. Then they prescribed Avastin as follow up chemotherapy.
It turns out his Canadian healthcare would cover Avastin for some cancers, but not for the one that he has. So now he has to pay for the surgery and the prescription.
Needless to say, he's absolutely thrilled.
You're welcome to say that this is an edge case. But people use edge cases all the time to criticize our healthcare system, so I consider it fair game.
My brother told me this same story more than a year ago. It might be propaganda. I'd be interested to know where you heard it.
I would be fine paying for my own insurance as long as the monthly payments were low. I also want dental and vision.
I went to my doctor last year and he wanted me to have some tests done. I told him I didn't have insurance, and he said he didn't care about that, that it was my problem, and the tests were important. He sent me to the gyno to have tests done there. And he told me I needed some minor surgery, which I have not yet had.
All of this cost me over two thousand dollars, which I'm still paying off, and which bills have been sent to collection agencies, making my credit scores go down. I've been trying to pay them, but it's not fast enough for the hospital. Things come up, you know? Car repairs, dental care -- I had to get some work done, another couple thousand bucks, and I'm not done yet.
And, to add insult to injury, no one ever called me to tell me the results of any of those tests.
I like the idea of them lowering the age for Medicare.
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But I agree with this piece that we should give serious consideration to single payer. I'm just kind of startled to see you endorse this idea. But cool with it--totally cool with it.
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For example, if you define catastrophic medical expenses as those that consume more than 10% of a family's income in a year, you start getting an entirely different picture of the results. I can't tell you whether Eric Zorn has this in mind, but that's my picture of the situation.
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Is this unforseen? Well, I got this plan in 1983, and yeah, it was unforseen then. Is it catastrophic? Yep.
Simple, obvious...and wrong.
It's not the obvious solution; it's one of several...and the worst one. The best solution is too large for the margin of this book, but:
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"They say Canada has really good health care."
"Oh, but they really don't!"
I won't say there aren't problems with it, but the folks back home wouldn't give up the single payer system for all the tea in China. In fact, if you are ever running for office in Canada so much as hinting at privatizing health care is political suicide. I hear people saying the quality of health care is compromised as a result and that has certainly not been the case in my experience. It may not be the best alternative down here, but I don't believe the health of the nation should be left in the hands of profit-driven insurance companies.
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The problems I see with the "insurance for catastrophic coverage only" approach are basically threefold. First, when you're living paycheck to paycheck, and have a job without insurance (or no job), the impact of what Zorn refers to as "predictable events, such as tests, checkups and prescriptions" is huge. This is why there are so many reports of people waiting until things get really bad, then going to the emergency room. As I recall, Bill, in a recent post you mentioned that you take a number of prescriptions that greatly improve your quality of life. How different would your life be if you only had catastrophic coverage, and had to cover the entire cost of those prescriptions yourself? Further, what if you also had a much lower income than you now do?
Second, the analogy with houses and cars is flawed, because houses and cars don't have chronic illnesses or conditions. If the roof is leaking, you pay once to fix the roof. If you develop diabetes, the expense is ongoing for the rest of your life. Perhaps a chronic condition, because of the high lifetime cost, could be classified as "catastrophic". But I'll bet that opens up a whole new can of worms about what does and doesn't qualify.
Third, from a market perspective (yes, the liberal is invoking the market), it's inefficient and not cost effective. When you have a system where people are disincentivized to have checkups, or go to the doctor's office for symptoms that are manageable, you don't catch catastrophic problems before they become catastrophic, and that drives overall spending up, as catastrophic events cost a lot more to deal with. Not to mention the cost in human lives - how many times have you heard/read about the importance of catching cancer or heart disease early?
I'm still a single-payer supporter, and am currently encouraging friends to support Alan Grayson's "Medicare for all" bill, which will provide a strong public option at cost. But I will say that this bill, however flawed, is better that what we've had up to now.
(For whatever it's worth, I'd be happy to characterize the mandate as a tax. I see it as an acceptable tax.)
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I believe that a first cut reasonable definition of catastrophic coverage is a stop loss that kicks in when you've spent more than 10% of your income on medical care in a year. That means that someone making less money would have less out-of-pocket expense before the plan kicked in than someone making more money.
So, yes, this plan would probably cost me money, because I'd end up paying for my own prescriptions. On the other hand, that would have to be offset against what my employer and I pay currently for health insurance and netted against what the government would end up collecting to fund catastrophic insurance. But just because I might not be as well off under this plan, doesn't necessarily mean that it's a bad idea.
The problem with single-payer is that there is no longer a market. There's an edict that determines what the government is willing to pay for a service and what services the government is willing to pay for. This tends to reduce the supply of doctors and to reduce the ability of a patient to see a doctor on a timely basis for an acute condition. So the trade off for the check ups is that you may not be able to get timely treatment for a non-emergency but nasty condition. (My recent dental problems come to mind immediately.)
I'm not convinced that's a trade off that I want to make.
Further, single payer is a great system until the government decides not to treat your life-threatening condition. I read recently of a Canadian gentlemen with a brain tumor. They took several weeks to decide that they weren't going to operate. After that, he went to the Mayo Clinic. They managed to remove most, but not all, of the tumor. Then they prescribed Avastin as follow up chemotherapy.
It turns out his Canadian healthcare would cover Avastin for some cancers, but not for the one that he has. So now he has to pay for the surgery and the prescription.
Needless to say, he's absolutely thrilled.
You're welcome to say that this is an edge case. But people use edge cases all the time to criticize our healthcare system, so I consider it fair game.
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I would be fine paying for my own insurance as long as the monthly payments were low. I also want dental and vision.
I went to my doctor last year and he wanted me to have some tests done. I told him I didn't have insurance, and he said he didn't care about that, that it was my problem, and the tests were important. He sent me to the gyno to have tests done there. And he told me I needed some minor surgery, which I have not yet had.
All of this cost me over two thousand dollars, which I'm still paying off, and which bills have been sent to collection agencies, making my credit scores go down. I've been trying to pay them, but it's not fast enough for the hospital. Things come up, you know? Car repairs, dental care -- I had to get some work done, another couple thousand bucks, and I'm not done yet.
And, to add insult to injury, no one ever called me to tell me the results of any of those tests.
I like the idea of them lowering the age for Medicare.
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