I honestly hopes this works out for America. I was very happy for them to see it passed, but like so many people say it's a different country with different people and a much bigger population, so differnt strokes. However, you can't argue that giving millions of people health care that could not afford it in the past is a great thing. As a Canadian, I couldn't be happier with what we have up. My daughter was born 3 months premature, so I defend to the death that paying more in taxes pays off in the end. It works out for people that way more often than not in my personal experience.
I like the idea of reform but have two problems with this bill, both of which I consider more commonsensical than political. 1. Pre-existing conditions are excluded for a reason--to prevent adverse selection. If you were already buying insurance and switch, the new company shouldn't be able to discriminate against pre-existing conditions (because that's not adverse selection). People occasionally have to do that if they switch employers or make some other kind of necessary change in their lives. But if people can just opt out of the system, then suddenly buy in the minute they get sick, the price of insurance will shoot upwards for everyone. People who never pitch in will be able to reap the benefits, and the people who actually play by the rules end up being forced to pay for them. EDIT: I'm not sure what the fee is to not get health insurance since it's now (if passed fully) required, but I believe it's still far less than the cost of opting in. If I'm wrong here, disregard. 2. Taxing based on market share. First of all, I have no idea what the logic is behind this other than "we're the government, we want more money and people hate corporations right now, they're easy targets." Beyond that, though, the health insurance companies will just pass that cost on to consumers in the form of higher premiums. It'll end up being one more hidden tax on us.
Significantly. I don't have exact statistics, but the majority of breakthrough medical technology comes from the U.S. This is both a good and bad thing, though it might seem purely bad at first. Because drug/tech companies know they can get the most money from the U.S., they typically introduce new technologies here first. They then slowly roll them out to other countries with pure single-buyer (monopsony) countries getting them last. However, because they have single-buyer systems, they can use their monopsony power to negotiate much lower prices. If you have insurance (arguably good insurance, but if you just mean "insurance" that's all but 6% of the U.S. population), you can get the best healthcare in the world in the U.S. because we have the cutting-edge technology. One of the areas where this is extremely significant is pharmaceuticals. A lot of politicians (McCain was one) have suggested a repurchasing plan where we basically let the Canadians buy drugs at lower prices then buy back from them. The problem with this is the drug companies aren't idiots. They do very advanced financial analysis when they sell their drugs. As soon as they catch the scent of their drugs ending up back in the U.S., they'll just kick up the prices to the Canadians initially.
Like I posted in the other thread, the two biggest drivers of cost in our system are Tort costs, and Falsely driven insurance cost inflation. In my opinion, that is. The tort reform would be to drive down the Malpractice Insurance that the doctors have to cover. The other problem is that people having insurance never shop around for costs for the actual services rendered. And given the lack of competition, prices go up and up not based off of supply and demand, but off of a whim of what they can charge. This may seem extreme, but I think it would be best for us to completely do away with Health Insurance for a while, say 20 years. This would bring down the costs to actual reasonable levels commensurate with what people could actually afford. Take away the doctor's ability to ask for a blank check, and suddenly it'll only cost a couple hundred bucks at worst for something minor like a broken arm. But I realize that will not happen. For 60 years now Americans have been trained day in and day out that they absolutely need Health Insurance to function as a Human Being. So instead, we've given a difficult industry to an extremely inefficient entity, and expect rainbows and sunshine. No government in the history of all the world and all of the times has been efficient at accomplishing anything, yet this time it'll be different.
Canada doesn't get cheap drugs because big pharma is nice to us. The patented medicines price review board examines prices and dictates that they can't be higher than the mean and median prices of that drug in other developed countries. They even levy fines against companies for drug prices that are too high. Don't ask me why it works because it's not legally enforceable, but it does. As for the idea of the U.S. subsidizing medical development because of high drug costs, well, I really don't think that holds a lot of water. The US is obviously a large, rich country and as you'd expect from a large rich country, produces a lot of great medical advancements, but I think the insinuation is that other countries somehow piggy-back on the States or that the States punches far above its proportional weight in making medical advancements. The US is not the only profitable market for pharmaceutical companies. Considering that pharmaceuticals spend ~20 billion per year advertising and marketing in the U.S., there's plenty of space in the budget to cut into if money starts drying up on research. Well, that, and just because Pfizer makes a killing on Viagra doesn't mean that money is going to experimental brain surgery, or new imaging technology, and so forth. Now, if Pfizer comes out with an amazing blockbuster drug in the next 5-10 years because of their revenue from Viagra (specifically, their American revenue from Viagra) and not from buying a smaller biotech start up with a promising experimental molecule, I might concede the point. It must also be said that other countries produce a lot of medical advancements, too. The PET scanner was invented in Hamilton (perhaps ironically OHIP has not started paying for it yet - but the cost is so prohibitive that it's not common in practice yet anyways). The first partial and full lung transplants were performed at Toronto General Hospital, which remains one of the top transplant centres in the world. The University of Toronto is the birthplace of stem cell research, and where the gene that codes for cystic fibrosis was discovered (along with the Hospital for Sick Children, one of the best pediatric hospitals in the world). The United Kingdom Prospective Diabetes Study is the study by which type II diabetes treatment is gauged. All in the context of a single payer government run health care system. Good research and good clinicians don't flee just because there might be more money to be made if they upend their lives, take a new battery of licensing exams, and start working in a foreign country. Interesting factoid - the nexus of Canada's current health care system, Saskatchewan, underwent quite an upheaval during the campaign to have the government turn into a single-payer provider for all primary care physicians visits (the government previously paid for all hospital costs). The American Medical Association was involved in the campaign against it. The province's doctors threatened to go on strike if the bill passed. Well, the doctors actually did end up going on strike, and they had to bring in doctors from across the country to fill in the gaps until shit got back to normal. Can you even fucking imagine that happening today? Crazy, but true.
I wasn't saying you get them more cheaply because they're "nice." You get them more cheaply because your government has this: http://en.wikipedia.org/wiki/Monopsony. Ours doesn't. I'm also not singling out Canada. I'm no specialist on your system or anything, I just know that you're an example of a system that has more monopsony power than we do (and I assume McCain chose Canada because the shipping costs are significantly less than any other country we might use). You also completely misinterpreted my argument (which is only an argument insofar as it summarizes what basically every health economist has said). I'm not saying the U.S. subsidizes medical technology because of drugs, I said drugs are an example of where that happens. We pay WAY more than any other country for new drugs (please please take a look at the comparative difference between even the most basic drugs), but we also get them earlier. U.S. hospitals and other health care providers pay more for the newest technology as soon as they can get it. As a result, we end up getting more stuff than we need usually (e.g. CAT scan machines) but we also have the highest capacity in the world. The net result of this is the U.S. spends the most. Technology diffuses quickly, though, so what ends up happening is that extra money we spend to get it early translates into higher costs for us (knowing that they can get that money from us is why the companies invest in new technology in the first place), whereas your government can then negotiate for much lower prices on the same stuff after some period of time. I'm also NOT saying that other countries don't contribute to medical technology. They contribute a lot. But the fact remains that the U.S. is the unquestionable world leader in producing medical technology. Here's this: <a class="postlink" href="http://www.cato.org/pub_display.php?pub_id=10979" onclick="window.open(this.href);return false;">http://www.cato.org/pub_display.php?pub_id=10979</a> Also, I can't find it at the moment but there's a classic article on why the U.S. spends twice as much as the median OECD country on medical care that's extremely good. The primary factors are Ability to Pay (a high GDP), administrative costs, price (a lack of monopsony power), investment in capacity (what I was just talking about), and one of the most important, unwillingness to ration (we won't tell someone how much they can spend and thus spend more money on expensive treatments with low return). One last point on your Pfizer example: that's basically what the bigger drug companies do according to one of my professors: once they hit a certain point they act more like a bank and invest in small companies they believe have potential to produce profitable drugs. That still boils down to primarily U.S. dollars funding the research (they'll recoup the money they invest in all those different companies by marketing the drugs that do succeed first to us at much higher prices.)
Would it be nice for people to be able to opt-out? Sure. But, as above posters have said, you have to really opt-out. You show up at the emergency room with a sucking chest wound, you'd better have a very substantial amount of blood-soaked cash in your wallet if you'd like treatment. In this society, that isn't going to happen. We're going to treat you anyway. OK, so you happen to be short on blood-soaked cash, and you die. Not a particularly smart decision, but hey, let's say we give you that option. Now your wife has a problem with her part-time job and six kids to support. She lasts about a month (since you were too cheap to buy life insurance either) and she declares bankruptcy and starts getting government aid. So I'm still paying for your opted-out dead ass. For the people who legitimately can't afford healthcare, yeah, I'm willing to pitch in. But remember who ends up in bankruptcy when the chips are down: it's not the people that are living within their means. As I pointed out in my last post on the subject, compared to someone who survives an adverse event without declaring bankruptcy, someone who does: Earns about half as much Has higher mortgage expenses, in absolute dollar amounts Has higher car payments, in absolute dollar amounts Has TEN TIMES AS MUCH CREDIT CARD DEBT, in absolute dollar amounts. If there were a way to write into law a provision that we will triple the fine for anyone that does not have health insurance, but does have a flat-screen TV anywhere in their house, I would be on the streets campaigning for it.
The reason healthcare has become so expensive is due to insurance inflated rates. You'll find that there are two costs of healthcare these days, the insurance cost, and the cash cost. Even the Cash Cost isn't anywhere near the actual value of the services for the reasons I highlighted a couple posts up.
No. The government only pays for drugs administered in hospitals, or under social security type benefits for low income families, old people, and catastrophic drug coverage, just like Medicare does in the States. Otherwise, all drug purchases are private ones made by individuals or insurance companies. I just told you that the PMPRB sets drug prices. Now, the increased amount of government control in health care may play a role, but the PMPRB was only founded in 1987 with the adoption of NAFTA, which stopped compulsory licensing that allowed generic companies to make generic compies of drugs which were still on patent. Some people seem to have the crazy idea (even in Canada) that the government buys every drug sold in Canada, and then rations out those medications to pharmacies. That's not how it happens. Wholesalers buy from the manufacturer, and pharmacies and hospitals buy from the wholesalers. The government only pays for ~ 1/3rd of all drug costs. Most of what I said wasn't directed at you specifically, but at other posters pondering the question of U.S. dollars funding medical research, as well as the accusation that any doctor or scientist worth their salt wouldn't stay in a single payer system, or that single payer systems lose the ability to perform research and innovate. Obviously the U.S. is the largest producer of medical advancements, because it's a very large and very rich developed country. The insinuation from others has been that high U.S. medical costs fuel research and developments for the rest of the world. I'm quite aware that the U.S. pays more than the rest of the world for pretty much every drug, but the suggestion that it's the high U.S. drug prices that allow drug companies to pump out new drugs doesn't hold water, judging by the lack of novelty in the new drug market and the extent to which small startup companies actually produce those promising new drugs. Of course those are still U.S. dollars producing the technology, but the point is that those U.S. dollars aren't being funnelled into research because of the high cost of medicine. There's probably something to be said for the use of innovative new technology and their associated high costs which diffuse at a slower rate to other markets.
It’s not just that the US is the largest developer of drugs and technology; it’s also the ability to get the products to market. Private hospitals have more flexibility to experiment using these technologies. Some may work and some may fail but they are able to take that risk. Single payer hospitals are dependent on the government for their budget and are less likely to purchase expensive equipment that may or may not have the desired effect. As the new technology gains acceptance and other hospitals adopt it, the prices will eventually drop. Once it cheaper and widely accepted, single payer hospitals are then more likely to pick them up. While some quality doctors and scientists are happy to work in a single payer system, I can’t help but notice the US market tends to attract a lot more. Even in Canada, cities that can pay higher salaries tend to attract more skilled doctors. Another problem with the single payer system in Canada is that relies on the provinces to help fund the system. This means in poorer provinces, such as NB or NF, the hospitals are not good as the ones you would find in richer provinces like Ontario. The poorer provinces have trouble attracting doctors and buying expensive technology. Currently in the US you can find outstanding care in some of the poorest states. If a single payer system is implemented I believe there would be a huge discrepancy in the care you would receive from state to state.
Just gonna throw this free e-book in here for anyone who might be interested. Click on the link in the middle for the free e-book. First published in 2002, the numbers are going to be dated, but if you bother to read it, you will see how strong the information presented is, 8 years ago. Yes, I know it's long, but I have found truth here. I have not been sick in over 5 years. Not even a cold. http://www.jonbarron.org/book/ First exposure to holistic and preventative medicine was here: https://www.herbdoc.com/index.php?option=com_frontpage&Itemid=1 I really don't like the way this guy sells, but he is a proven herbalist. Two years into just taking the ECH+ and Super Tonic product from October through December and not getting sick, I began to believe, and expounded upon the supplements I take. I am not affiliated in anyway with any of these companies. I am only a customer, who actively seeks to be responsible for my own health and health care. An ounce of prevention? You actually have more control than you think.
To add, slightly, to the example of the Canadian with terminal brain cancer jumping the border and paying for his treatement: Did he live? I doubt he survived because the news here would've picked it up. Neuroscience is cutting edge and sadly most brain cancers are terminal or highly dangerous. GBM for instance is one of the most common and deadly brain cancers, at one point it's not even worth it to cut the tumor out. If it's in the cerebellum, I'd rather die than potentially become a psychotic, machine-dependent mess. That's probably why the board elected that he doesn't undergo expensive and needless radiation, gamma-knife and chemo. I think the materialistic culture in the US (and Canda) is really blinding people from the true needs in life: health, education and happiness. Lets go buy some more flat-screen TVs and iPods though.
Effective research does occur elsewhere in the world such as the one noted in the UK Diabetic study. However most of the journal articles I read involve technological advances or research that is found within the United States. Studies are generally performed by pharmaceutical companies that have something to gain by creating a niche treatment for their drug. This is why there are no new studies performed on the effectiveness of 1st generation drugs as compared to newer generation drugs. To become licensed in the United States as a physician you must retake ALL your boards not just your actual specialty board. You will have to repeat USMLE steps 1-3 along with the USMLE CS. Then you will have to reapply for a residency and perform 3-7 years of residency. For a physician to actively pursue this option they would have to have a real legitimate desire to endure all of this. Also most residency programs are very anti international medical graduate unless of course they blow the USMLE out of the water with a 270+ score.
I have a bunch of disjointed tidbits and then an overall analysis, so here goes. A lot of people have been talking about how America is the world leader in new medical technology. Unfortunately, most of the data suggests that this new technology is quite expensive and in the majority of cases almost completely worthless in terms of health benefits. Robin Hanson has been harping on this for months now at overcomingbias. Check his shit out. I have two major concerns about this bill. The first is simple...the budget. Yes, it is projected to be budget neutral or beneficial, but that claim is murky to say the least. Not only that, the number of people requiring health care is set to increase a shitload in the near future as the boomers start retiring. Seriously, the numbers are mind blowing. Read Arnold Kling on Econlog if you want the full treatment. The second problem is the tremendous moral hazard it creates. This ban on filtering due to pre-existing conditions is troubling. While it is good that insurance companies can't dick people over like they could before, the price paid for not having insurance is really fairly low. For a huge number of people, it makes perfect sense to sit on your ass and pay the fine and then grab insurance when a serious illness comes along. The old "heads I win, tails I break even" problem. Also, I suspect that with the coming of greater availability and usage of individual insurance, we will see fewer small businesses providing insurance. The cuts in medicare and medicaid are being lauded for reducing health care costs, but really the benefit is pointless. The curve will simply see a drop and then continue back on its trend. The derivative of the curve remains the same because we haven't come anywhere close to the real problem behind rising healthcare costs which is the divorce between the buyer of healthcare and the cost of healthcare. Even with this bill, people usually don't have a fucking clue how much their health care actually costs and so are incentivised to spend to their hearts content. Given all this, I still support the bill, because quite simply it is the best we could do given the enormous constraints of the political process. True reform is impossible. A lot of changes need to be made to the system and this addresses a few of them. I'm in favor of any Pareto improvement I really don't like this sort of middle road we are forced to take. I would prefer a single payer system to what we have now including the new bill and it really is retarded that Democrats couldn't even seriously suggest the idea given the huge majority they have in all branches of government. My ideal system would be similar to that of Singapore. People there have mandatory health savings accounts which are supplemented by the government for the poor and young. HSA's keep that safety net beneath you without divorcing the individual from the costs. People also have incentive to stay healthier since the cost of their future illness will come from their pocket. They also have incentive to ration their own treatment. There is also incentive for companies to innovate on new technology(ineffective as it may be). The system is far more efficient though a bit less equal than the single payer systems and is certainly better in every way than the clusterfuck we have in America. I honestly can't begin to fathom why it doesn't have more support. Seriously, the market for food works beautifully in our country and food is one of those things that people would consider a basic "right", and the only government role in the market is the provision of food stamps. Over the course of our lives we probably spend as much on food as we do on healthcare, if not more and yet one market works wonderfully and the other is fucked. Mandatory HSA's would fix the only difference between the two products, which is their payment schedule. How does it impact my life? Quite nicely actually. My dad is loaded and gets great coverage from his company and now I can chill under that umbrella for a 4 more years, which gives me enough time to finish up graduate work and get a nice job with its own insurance, without this bill I would have had to get my own coverage probably through the university. Saves me money.
I apologize in advance for not reading this whole thread, so if this has been covered, feel free to ignore. I do feel there is one impact that a lot of people are completely missing here: the overall impact on doctors (and primary care in particular). If you work in the medical field, you know this: Medicaid and Medicare the biggest fucking pains in the ass ever. So, rather than fixing them, and re-evaluating the absolutely retarded regulations both of these plans have, we just throw more tax dollars at it to make it better? No, this is going to make it worse, much much worse. This brings me back to my original point; doctors absolutely hate dealing with this shit. I've gone into a couple different PCP offices to see signs like "I'm sorry, but due to limitations that Medicaid imposes onto giving you the best possible care we can provide, we do not currently accept this plan." With this influx of people onto programs like Medicaid, doctors are overwhelmingly objecting to this (I heard a stat of somewhere around 75%). There's already a huge shortage of primary care doctors in this country, and now you want to hinder them more? I know the goal of this bill is more preventative care, but using this bill as the vehicle will hinder their progress more than help. Oh, and like everyone else has said, when have entitlement bills ever hit their projections? Despite what the CBO says, this will cause a MASSIVE FUCKING DEFECIT. Not to mention, how did they sneak student loan reform into this? I could have sworn this is for healthcare. I'm calling fucking bullshit.
Maybe I missed your point, but what do you mean only "government role" is food stamps? The government regulates many things about the food market, from farm subsidies to FDA regulations. There is quite a difference in markets that allows food producers to shoot for the lowest prices and why the market for healthcare goes in the opposite direction. People want the cheapest food, people expect the best healthcare money can buy.
This is an expansion first, cost-savings second approach. I don't hold much hope this will result in any real savings. The CBO numbers are based on the selective information the Dems ask it to review, which includes loads of assumptions about proposed saving measures. The cause of health care inflation is a waterfall of federal money in the system, low reimbursements and a focus on unit sales. The only way to cause a refocusing on value is to remove the middlemen as much as possible. In an environment where all preventative care was out of pocket, as it should be, the rates would drop to meet the purchasers' ability to pay. This, however, would require a lot of irresponsible people to take care of their own health, and maintain limited catastrophic policies for situations where they become seriously ill. Neither the insurers, the govt, nor the average American who wants to be taken care of has any interest in moving to such a paradigm. He says he wants insurers out of the system, but that's not what he really means. What he's actually saying is, "I want insurers to pay for everything I want, no matter the circumstance!" The rest I've said before: I’d decouple benefits from employment. It’s an outdated paradigm from the 50s that doesn’t work in the global economy. And no, I don’t buy the argument that it encourages broader risk pooling, which keeps the costs of benefits lower than it would be if we bought health insurance directly. We’ve never tried it any other way and the structure we have doesn’t work. What’s the definition of madness? Doing the same thing over and over and expecting a different result? The solution should be a total rethinking of the marketplace, with an emphasis on direct purchase – privity between the buyer and seller alone – not a more robust version of what we already have... . . . It would also be nice to see Obama do a press conference defining the word “insurance” for the American public. “Insurance” is something you tap into upon the occurrence of an event you’ve paid to have covered. What we have now is a third party administrator ostensibly paying for every health care service, necessary or not, telling people after the fact whether a procedure is covered. That’s insane. What other industry offers services without knowing whether it’ll get paid? Could you imagine going to your mechanic, handing him a credit card and telling him, “My lender might pay for this service, or he might not. He’ll let you know in three weeks. If he rejects it, send me the bill.” Everything elective should be straight out of pocket. A patient shouldn’t even be allowed to submit it to insurance. Insurance should cover only what’s medically imperative. Preventative care’s a nice idea, but it’ll never cut costs. All that’ll do is encourage more consumption, and more bad debt write-offs for providers. <a class="postlink" href="http://philalawyer.net/2009/08/collectivists-or-capitalists/" onclick="window.open(this.href);return false;">http://philalawyer.net/2009/08/collecti ... pitalists/</a> This bill is going to slow a recovery in employment and offshore more jobs. In the end it will hurt the lower middle class it was designed to bring to the voting booths in droves for Democrats... er, excuse me on that last phrase... I meant, uh, "help." We all know this bill didn't have any hidden political agenda behind it. It was designed purely to help people. Excuse me now, I have to feed my unicorn. She eats the shurbs when she gets famished
Good post. Would you be willing to elaborate more about your opinion on the part that I highlighted? Edit: Or direct me to where you have already done so?
You're right, my bad. There are several aspects of food market the government controls. It only detracts from my point a little though I think. Compared to the healthcare market, the food market is barely regulated at all. FDA regulation are just a basic safeguard hoop that everything must jump through, only affecting costs very slightly if at all. The farm subsidies is a bigger deal and is wholeheartedly retarded, but again, I think the overall market impact is minuscule relative to the regulations on health care. Overall I think my point still survives the criticism, but I've run into heavily skeptical territory now, so I had better be careful.