Universal Healthcare

[cat_in_the_hat]

No, not trying to create equal outcomes, just the equal opportunity for outcomes. That kind of comes under the equal protection clause of the 14th amendment.

Article 1, Section 8 of the Constitution clearly gives the government the power to tax people to provide for the common defense and general welfare. Providing healthcare for all certainly falls under that heading IMHO.

We've been down this road before, but I will travel down it again. You hang your hat on the common good language in Section 8, yet if you follow that to its logical conclusion, then there would be no restrictions on the power of government. Clearly, the founding fathers intended to severely limit the power of the federal government. If government can tax for anything they feel is in the common good, then there are realistically no limits on the power of the federal government. The dissenting opinion in the ACA case pointed this out. The logical interpretation of the common good language, since the founding fathers went out of their way to limit the power of government, is that the authority to tax cannot exceed the powers already granted the government in other sections. In other words, the government cannot use taxation to expand its powers beyond what is specifically granted it in the other sections of the Constitution. But that interpretation does not suite the purposes of people who want big government.

In my opinion, this comes back to what I said before. The Constitution is only as good as the people enforcing it. It is not difficult for people in power to appoint folks who will interpret the Constitution in a way that allows for passage of things they want to get done. Supreme court decisions have used Adam Smith's Wealth of Nations as the basis of the decision, which obviously has nothing to do with anything. FDR manipulated the court to get things passed that today is thought of as normal, but back then was thought of as unconstitutional. Unfortunately, once you open the door to the expansion of government power, it's virtually impossible to close it again.

 

[Deeeefense]

You hang your hat on the common good language in Section 8, yet if you follow that to its logical conclusion, then there would be no restrictions on the power of government.

If think they choose that kind of vague language for a reason. They are letting future generations of government debate and come to their own conclusions about what is/is not in the "common good" of people, notwithstanding other language elsewhere, that may provide for limitations

It is not difficult for people in power to appoint folks who will interpret the Constitution in a way that allows for passage of things they want to get done

Again I think this was the wisdom of the founders. They WANTED issues to be open ended enough to be debated, not the opposite. For every argument in favor of the government doing something there is likely an argument against it.

 

[cat_in_the_hat]

If think they choose that kind of vague language for a reason. They are letting future generations of government debate and come to their own conclusions about what is/is not in the "common good" of people, notwithstanding other language elsewhere, that may provide for limitations



Again I think this was the wisdom of the founders. They WANTED issues to be open ended enough to be debated, not the opposite. For every argument in favor of the government doing something there is likely an argument against it.

I think that is the interpretation you want because you see government as something that should solve problems for the people. I don't think the historical picture of the founding fathers supports that view. You are ignoring that our founding fathers did not see government that way. They saw government as a necessary evil. They did not trust government. They thought power corrupted government and it ultimately would turn that power against the people and strip away liberty. Their major concern was protecting individual liberty. Your view is not consistent with how our fathers viewed government. In my opinion, the clause merely states that government should act according to common good and not in it's own self interest or the interest of a few powerful people. In my mind, there is no way they intended to expand the power of government through that clause, or they would not have gone through the trouble to limit it like they did. Your interpretation just makes no sense, in my opinion, in the context of how they thought about government and what they were trying to do.

 

[Deeeefense]

I think that is the interpretation you want because you see government as something that should solve problems for the people. I don't think the historical picture of the founding fathers supports that view. You are ignoring that our founding fathers did not see government that way. They saw government as a necessary evil. They did not trust government. They thought power corrupted government and it ultimately would turn that power against the people and strip away liberty. Their major concern was protecting individual liberty. Your view is not consistent with how our fathers viewed government. In my opinion, the clause merely states that government should act according to common good and not in it's own self interest or the interest of a few powerful people. In my mind, there is no way they intended to expand the power of government through that clause, or they would not have gone through the trouble to limit it like they did. Your interpretation just makes no sense, in my opinion, in the context of how they thought about government and what they were trying to do.

I think you are partial correct to some extent. Contrary to what some think, the states invented the federal government not the other way around. And fresh on the minds of the founders was the tyranny of the British Crown. The states were fearful that a central government could take on a similar role so in fact they did want restrictions and they went out of their way to protect some of the autonomy of the states. However where I disagree with you is, in their wisdom they did not intend to set a fixed, non flexible course for the future. They had no way of knowing nor could they that this country would evolved into a super power with 350 million people, a $14 Trillion economy and weapons that could destroy the entire world several times over. Therefore they left some space in what became the law of the land. Obviously, a country of this extraordinary magnitude and complexity needs something more than a group of passive bystanders in DC that defer to the states in all matters.

I think to some degree you are attempting to divine the intent of the founders without specific words to confirm your point of view - that's just my opinion.The very fact that folks can debate what is and isn't the roll of government within the context of the words , without one side or the other being absolutely confirmed is evidence that this was the intention. Again, that's just my opinion.

IOW I'm not saying your wrong, you have opinions and you should continue to express them, that's what we do in this country, but so should others that have different opinions.

 

[Bill@ModernThirst]

Fair enough...but there are no perfect systems. They all have flaws.

You say... "There's a problem here- we have 300+MM people spread over a continent. We'd need exponentially more facilities (and therefore doctors) to provide those services to our population with any semblance of accessibility."

More facilities? why? We have more doctors and facilities per capita than any country on earth...hence part of the reason for our high costs. Facilities in rural areas have been closed because they aren't as profitable or because they lose money because a high percentage of patients seen had no insurance and could not pay for services.

Did you read my post about how costs are controlled in a universal system, largely by restricting supply? Restricting supply means restricting access.

If accessibility is the issue, then geography is paramount. In the UK, it's very hard to be more then a couple hours drive from London, Edinburgh, or Liverpool. The whole island smaller than Wyoming. So location matters- you need surgery? You can be driven in an ambulance to London or Edinburgh from nearly any place on the island between 8AM and lunch. Hence, the government in a universal system can build a few mega facilities in key population centers and service the entire population at a fraction of the cost that would be needed in the US- because we'd have to have countless facilities spread all over the continent unless we're going to pay to airlift people all over the country. So the end result is that there are geographic limitation as well as political and cost limitations that make all national programs more difficult for the US than most European nations. If the government is going to be responsible for providing that service, they have to be able to provide that service. It's not a matter of "same cost per person should get us the same system" that many want to argue.

If we want to emulate another country's system, it's going to cost us far more to do it.

I don't think Medicare expansion with private insurance as a supplement as the primary tool is necessarily a bad approach. But that doesn't always solve the accessibility issue either. If the care from private insurance is better- that means those who pay still get the better care, and those who can't still get the shaft.

 

[fuzz77]

Did you read my post about how costs are controlled in a universal system, largely by restricting supply? Restricting supply means restricting access.

If accessibility is the issue, then geography is paramount. In the UK, it's very hard to be more then a couple hours drive from London, Edinburgh, or Liverpool. The whole island smaller than Wyoming. So location matters- you need surgery? You can be driven in an ambulance to London or Edinburgh from nearly any place on the island between 8AM and lunch. Hence, the government in a universal system can build a few mega facilities in key population centers and service the entire population at a fraction of the cost that would be needed in the US- because we'd have to have countless facilities spread all over the continent unless we're going to pay to airlift people all over the country. So the end result is that there are geographic limitation as well as political and cost limitations that make all national programs more difficult for the US than most European nations. If the government is going to be responsible for providing that service, they have to be able to provide that service. It's not a matter of "same cost per person should get us the same system" that many want to argue.

If we want to emulate another country's system, it's going to cost us far more to do it.

I don't think Medicare expansion with private insurance as a supplement as the primary tool is necessarily a bad approach. But that doesn't always solve the accessibility issue either. If the care from private insurance is better- that means those who pay still get the better care, and those who can't still get the shaft.

Taking your last paragraph first...I agree which is why I would prefer a single payer national health service with private care only for elective procedures. I just think that the Medicare expansion + private insurance is the gateway to get there. That said, wealth will always have privileges and that's ok.

The people in Montana that live 50 miles from anywhere have issues with access today. People who live in rural areas have issues with access today because their hospitals are being closed because the people that use them are less likely to have insurance and/or are on Medicare/Medicaid. Whereas in urban areas there is an abundance of care and facilities because that's where the profit is.

In a single payer system those rural hospitals would be reimbursed for their services and therefore could stay open. And because reimbursement rates would be standardized across the country hospitals could alter their models to adapt to those rates.

Universal model systems limits of access are for non-emergency care. Priorities for care and care access are given for emergency care followed by preventive care...then elective/non-emergency care.

People in areas with abundant care facilities today would see a decline in the numbers of those facilities because frankly, there is a lot of duplication of services. People in rural areas would likely see better access than what they have today.

The US has a population density of 35.14 people/sq mile. Australia has a population density of 3.1 people/sq mile and they make single payer work. Canada has 3.9 per sq/mile... Yes, we have a low density...drop Alaska from that calculation and the number climbs pretty quickly. We have a handful of states with low populations and large land masses. Over half the people living in Alaska live in Anchorage. Kentucky is a pretty rural state and its density is 121 sq/mile.

Today there are 13 hospitals in the state of Alaska, 94 in Kentucky, 27 in Wyoming, 28 in Nevada, 19 in Idaho...

Bill, you're against it and just throwing crap against the wall to see what can stick. All these other countries spend 40% less on care than what we spend. What if we just save 25%? That's a lot of money and that covers everyone instead of leaving 20 million people with no coverage and more with coverage they can't use because they cannot pay the out of pocket costs.

 

[backbeatcat_rivals376595]

It also, in many cases, it's truly, COMPLETELY inelastic. For anyone with a traditional "copay" plan, the cost for many services is fixed, regardless of what the actual bill is. An MRI could truly cost anywhere between $400-$2000+, but their share is set at, say, $250. Can't get much more inelastic than that.


It's a crying f'ing shame there isn't a single politician in Washington that's actually concerned about lowering healthcare COST. That should be the single most important point in this entire discussion, not how to shift around who's pumping in the money into an already broken system.

This. The suppliers of machines, consumables, drugs, services (i.e. doctors...), space (hospitals, clinics), implants etc..etc...etc... have the same type of control over Washington that the defense industry has had for years. Lowering costs is not good for their bottom lines. Government subsidies that flow ultimately to their revenue streams IS good for their bottom lines.

 

[Bill@ModernThirst]

The US has a population density of 35.14 people/sq mile. Australia has a population density of 3.1 people/sq mile and they make single payer work. Canada has 3.9 per sq/mile... Yes, we have a low density...drop Alaska from that calculation and the number climbs pretty quickly. We have a handful of states with low populations and large land masses. Over half the people living in Alaska live in Anchorage. Kentucky is a pretty rural state and its density is 121 sq/mile.

85% of Canada's population lives within 75 miles of the US Border. Despite huge land mass, their population is somewhat densely distributed. Almost 80% of Australia's population lives in greater Perth.

Russia is the closest thing to us (maaaaaaaybe canada, whose system is not good anyway). It's a huge hurdle in terms of logistics, and a huge hurdle in terms of cost. The countries in which universal (Canada's is not single payer) systems work and work well are smaller geographically, with extremely more concentrated populations; France, The Netherlands, Britain, Germany, etc.

And they do it by restricting supply. Restricting supply means limiting the number of facilities, limiting what procedures you can have and when- even non-elective, and restricting the number of doctors. Those are BARRIERS to accessibility. So take all the current statistics of how many facilities and doctors we have and do away with them- they have to become meaningless in a universal system or the universal system doesn't work.

I agree that something needs to change, and if a universal system is what works, I'm for it. I'm against half ***ing it by trying to make our current system operate like a tightly controlled universal system in some ways. It can't. It makes it worse.

This nation needs to make a hard decision. Healthcare cannot, by nature, be a "right" because it is a service, not an innate condition. But it can be a common or public good that we value enough to provide to all. Or it can be a service in which suppliers compete for business like any other good or service. But it is very difficult, and very inefficient for it to be both.

On one hand you have high quality, innovation, and choice- but those with the fewest means don't have access to much of it. On the other you have mostly universal access, but less responsive, less innovative, care with fewer options (that doesn't mean it's not good, just comparatively). At some point, we need to pick and commit.

 

[Deeeefense]

85% of Canada's population lives within 75 miles of the US Border. Despite huge land mass, their population is somewhat densely distributed.

Yea a board that's 4000 miles long! That's a lot of space to stretch their population out over and the 15% that isn't along the boarder still has to be served by health care.

It's a huge hurdle in terms of logistics, and a huge hurdle in terms of cost. The countries in which universal (Canada's is not single payer) systems work and work well are smaller geographically, with extremely more concentrated populations; France, The Netherlands, Britain, Germany, etc.

Canada's plan is near universal. It doesn't cover prescription medication and a few other things, but OTOH the cost of most medical services is covered with no, or a very low co-pay. The plan is paid for through tax revenue instead of premiums and is slightly more than half the per capita cost of health care coverage in the US which is non-universal.

I can understand your point about smaller countries with more concentrated populations being able to run a bit more efficiently due the lower number of facilities required. But it's really hard for me to accept that that accounts for anything more than a small portion of the difference in cost between some of these countries and ours. And also consider that 80% of the US population lives in a metro area.

 

[cat_in_the_hat]

I've said this before, but comparing the cost of healthcare in a universal system and ours is like comparing apples and oranges. We spend more on healthcare because we can. We have much more freedom to spend than people do in universal healthcare systems. We are also the richest county on earth, which means we have the resources to spend more on healthcare, to accomplish what ever it is we are trying to accomplish, than the countries we are comparing ourselves with.

 

[Deeeefense]

I've said this before, but comparing the cost of healthcare in a universal system and ours is like comparing apples and oranges. We spend more on healthcare because we can. We have much more freedom to spend than people do in universal healthcare systems. We are also the richest county on earth, which means we have the resources to spend more on healthcare, to accomplish what ever it is we are trying to accomplish, than the countries we are comparing ourselves with.

That's true and it's a big part of the problem. But despite the fact that we spend more per capital then any other country we have poorer overall results. So that "freedom to spend" is not resulting in healthier people. The cost issues were articulated by several other members in this thread. Right now we incentivize the prescribing of treatments and drugs, instead of incentivizing results. As long as we do that there is built in economic pressure to spend more not less.

 

[cat_in_the_hat]

That's true and it's a big part of the problem. But despite the fact that we spend more per capital then any other country we have poorer overall results. So that "freedom to spend" is not resulting in healthier people. The cost issues were articulated by several other members in this thread. Right now we incentivize the prescribing of treatments and drugs, instead of incentivizing results. As long as we do that there is built in economic pressure to spend more not less.

Keep in mind that healthier people and the healthcare system are two different things. Having access to quality healthcare does not change eating, exercise, and lifestyle habits. Those are what make you healthy. There is no question that some other cultures live healthier lifestyles than Americans, and therefore, will have longer life expectancy, among other benfits.

As far as medical results go, it depends on what you are looking at. There are many things we excel at. We have much higher survival rates for many cancers than the universal healthcare systems you favor.

We have much higher access to treatment for chronic diseases than many other universal healthcare countries. For example, we have a much higher percentage of people who could benefit from them, taking statin drugs than the Germans, Swiss, Dutch, and Briton.

We have much higher screening rates than many of the universal healthcare systems. For example, our screening rates for mammograms, pap smear, PSA tests, and colonoscopy are higher than in other countries.

We have better access to new technology. In fact, many of the important medical developments happen in the USA.

We typically have access to new drugs before other countries and have access to wider range of drugs than those countries.

Americans rate the quality of their personal care higher than Canadians do.

Canadians wait much longer for treatment than Americans. That includes emergency treatments. I read a story about a Canadian woman who had a blood cancer that could only be treated by a stem cell transplant and was told her wait time to receive treatment was 8 months. After 4 months, she came to the United States to get treatment. By then it was too late and she died shortly afterward. It's a myth that Canadians only wait for treatment that is not life threatening. When there is no market at all, the supply of a service or product will not keep up with demand. This woman had very few options for her treatment and they did not have the capacity to treat everyone who needed it.

 

[Bill@ModernThirst]

Canadians wait much longer for treatment than Americans. That includes emergency treatments. I read a story about a Canadian woman who had a blood cancer that could only be treated by a stem cell transplant and was told her wait time to receive treatment was 8 months. After 4 months, she came to the United States to get treatment. By then it was too late and she died shortly afterward. It's a myth that Canadians only wait for treatment that is not life threatening. When there is no market at all, the supply of a service or product will not keep up with demand. This woman had very few options for her treatment and they did not have the capacity to treat everyone who needed it.

That's because in order to keep costs down, Universal healthcare systems restrict supply. They limit the size of medical school classes and keep facilities at a minimum. In Canada, they have things like "summer shutdown" to stay on budget. You pay your own prescription drug insurance (can be either private or public). Canada's wait times for diagnostic procedures is shameful, and even their own government admits it has cost tens of thousands of lives. Free healthcare that is slow, non innovative,and non responsive is not the kind of healthcare accessibility we want.

Again, there are decent universal systems. Canada isn't one of them. So we need to stop using them as an example of a "universal" system that works. Theirs sucks. Focus instead on Britain, France, The Netherlands, Germany, Scotland, etc. Those are good. Let's see if we can't find ways to get the good parts of those and combine them with the good parts of ours.

 

[Deeeefense]

I read a story about a Canadian woman who had a blood cancer that could only be treated by a stem cell transplant and was told her wait time to receive treatment was 8 months. After 4 months, she came to the United States to get treatment.

I can't speak to this person's particular case but most stem cell treatments are still categorized as experimental and not covered by insurance or Medicare. If the treatment was covered in Canada, then at least it was covered. It probably wouldn't be in the US.

Focus instead on Britain, France, The Netherlands, Germany, Scotland, etc. Those are good. Let's see if we can't find ways to get the good parts of those and combine them with the good parts of ours.

I agree with this totally. The ultimate way to handle this issues (which we will never do for political reasons) is to take out a clean sheet of paper and examine in detail the best health systems in the world and note what has worked and what has created problems. Then refine the results and put a task force together to develop a plan based on the best, most economically efficient principals, then pilot test it, refine it again and ultimately roll it out.

 

[cat_in_the_hat]

I can't speak to this person's particular case but most stem cell treatments are still categorized as experimental and not covered by insurance or Medicare. If the treatment was covered in Canada, then at least it was covered. It probably wouldn't be in the US.



I agree with this totally. The ultimate way to handle this issues (which we will never do for political reasons) is to take out a clean sheet of paper and examine in detail the best health systems in the world and note what has worked and what has created problems. Then refine the results and put a task force together to develop a plan based on the best, most economically efficient principals, then pilot test it, refine it again and ultimately roll it out.

I would love to see a clean slate approach, but I agree that it is unlikely to ever happen.

 

[Levibooty]

I have to say I dropped in out of curiosity and was relieved and happy to see this discussion being had in a mature and knowledgeable fashion. Just thought I would share my reaction. I simply wish we could somehow prioritize health of the nation ahead and above health of a few pocketbooks.

 

[Bill@ModernThirst]

I can't speak to this person's particular case but most stem cell treatments are still categorized as experimental and not covered by insurance or Medicare. If the treatment was covered in Canada, then at least it was covered. It probably wouldn't be in the US.

It's actually the opposite (speaking about treatment for cancer in general, not stem cell treatment specifically). Because our healthcare is privately driven, the testing and approvals process from our FDA is exponentially faster than in Canada, and the main driver of Canadians who come to the US (which is not as common as people want to claim, but not totally uncommon) do it for treatment that is approved here and still waiting for Canadian approval. Private companies pay for it, and facilitate it, and the FDA piggybacks on their trials for approvals.

It's most noticeable with Cancer drugs, which take years to be approved in Canada after they're already standard treatment in the US (the Eribtux example I used earlier is apt here). The trend has been for Canadians to come to the US, pay for the drugs themselves, and then sue their public prescription plans to repay the cost sometime later.

They're not coming here for bypass surgery, or emergency surgery. They come here for drugs and cutting edge treatments that take so much longer to be approved in Canada, and even then Canada really usually uses results from FDA trials as a major basis for their approvals. That's a HUGE thing we DO NOT want to lose in a future system.

In other words, new treatments are far more likely to be covered and offered in the US than in Canada.