Matthew Yglesias (July 02, 2007) - Counterintuitive! (Domestic Policy)

I take no variant of "let everyone join the VA system" is practical?

Posted by rilkefan | July 2, 2007 2:18 PM

In fact, this is exactly Howard Dean's plan, scaling Medicare to cover more and more people, and I believe it has been his goal since his Presidential run. So even MORE counter-intuitive, the Shrum-Yglesias-Kaus-Dean-Kucinich approach.

Posted by dday | July 2, 2007 2:20 PM

Kaus should have been at the far right of that list ...

Posted by otto | July 2, 2007 2:22 PM

I agree with the general thrust of Medicare for All, but there are problems urgently needing repair if the program is to be extended:

- Medicare Part A (Hospital fees - all paid by the government after withholding from income during the working years - but not including Doctor Fees) was designed when people mostly went INTO the hospital for a few days. It doesn't fit 'same day surgery' very well, and it doesn't cover post-op care at home or elsewhere at all.

Medicare Part B (Doctor's fees - paid by patient with an monthly premium withheld from Social Security) does not adequately pay physicians so many MDs do not participate.

Medicare Part D (Drug Costs - funded like Part B) has the 'donut hole' with no insurance. Currently Medicare can't negotiate volume discounts - but the VA can - and therefore the costs of Part D insurance are way too high.

MedicAid is a federal/state program for some qualifying low income people. It needs to be incorporated into a federal-only Medicare for All. Retirees heavily depend on this program for near-end-of-life assisted living programs (nursing homes, etc.), but the current program requires that essentially all of their assets be spent down before they can qualify.

My point: lots of changes need to be made just for current Medicare recipients. Lots more will be needed when dealing with non-retirees.

Posted by JimPortlandOR | July 2, 2007 2:36 PM

So if we did this, how much higher would the medicare tax rate have to be?

Posted by henry evans | July 2, 2007 2:42 PM

This is quite the working vacation, Yglesias (emphasis on the former); lots of good posts to keep those of us stuck in the office today from actually working, so much appreciation.

Posted by Ben Cronin | July 2, 2007 2:43 PM

Question to follow up with henry evans': Are medicare payroll taxes capped in the same manner as social security taxas? Is so...lift the cap!

Posted by trza | July 2, 2007 2:52 PM

General principle is right, but starting point should be "Medicare for Kids."

(1) Kids are cheap to insure. Plus you're paying for very cost-effective preventive care instead of hugely expensive end-of-life care.

(2) Americans are more likely to accept an expansion of the welfare state if it's "for the children."

(3) The political dynamics are awesome -- once people start reaching the age limit of the program, the pressure to extend it upward will be almost irresistible.

Posted by lemuel pitkin | July 2, 2007 2:54 PM

tzra

the medicare payroll tax was uncapped by Clinton, so, no extra money there.

my back of the envelope says that a payroll tax of about 7.5 percentage points would be necessary to fund Medicare for All (currently, SocSec + medicare take a 15.3 tax, so, this raises the existing rates by about 50%).

of course, no need to do it with a payroll tax, necessarily, but, that's what it would cost in those terms.

i'm still unsold on the usefulness of the yglesias-atrios-shrum-kaus idea, but, i am impressed at the grouping...

Posted by josh bivens | July 2, 2007 2:56 PM

Are medicare payroll taxes capped in the same manner as social security taxas?

Nope, they're collected on all income.

Posted by lemuel pitkin | July 2, 2007 2:56 PM

What Henry said. How do we pay for all this? Seriously. What we're already on the hook for in terms of health care entitlement costs is totally unaffordable. It would take a sizable tax increase for everyone, not just the rich, along with spending cuts elsewhere, and some fairly strict and penurious cost controls on the part of government. You could borrow the money, or try and mix and match the above. But it still means hard choices that voters and the congressmen who represent them don't want to make.

I'm afraid that "Medicare for all", or "healthcare for all", or whatever you want to call it, may be a concept that's about thirty years too late.

Posted by Claudius | July 2, 2007 3:03 PM

It could work (at least theoretically) if the achievable costs savings were larger than the additional costs associated with extended coverage to those who are not currently covered. Does anyone know if they are? Then it's just a problem of making sure that the median tax payer sees that his or her bill has not gone up (and quality has either improved or remained the same).

But if the available savings are smaller than the costs of extending coverage, it's a tougher political equation.

Posted by henry evans | July 2, 2007 3:13 PM

You should check out HR676, which has all the details for funding with about a 4.5% tax plus inclusion of all the existing funding that is paid. I haven't run the math myself, but it makes sense that if you put everyone on it, eliminate all the administrative costs (well, at least to the Medicare level of 1-3%, cover everything, and pay the medical workers (including physicians) adequately, that you can pay for it and make it work.
The only thing they seem to have forgotten is specific mention of alternative modalities, but that should come out at the hearings (if they ever have them) and can be added.
The key here is that if you take the administrative costs and the profits out of it, we are already spending enough money. The trick is in how it's raised--right now paid by employer. If we had this system and my employer gave me a 5% raise, the employer would be ahead from not having to pay for my insurance, and I would not see my paycheck change at all, but the 4.5% tax would be paid.

Posted by Earwicker23 | July 2, 2007 3:13 PM

What we're already on the hook for in terms of health care entitlement costs is totally unaffordable.

Almost, but not quite. What we're already on the hook for in terms of health care costs is (arguably) unaffordable, but entitlements as such aren't the issue. Private spending is rising even faster than public. Shifting some current spending from the private to the public sector doesn't directly affect the cost issues one way or the other, but it has lots of advantages starting with, you know, increasing the number of people with health coverage.

It also seems to be entirely normal and desirable that as we get richerwe devote more of our resources to health care. For folks who say that health costs growing faster than the economy is by definition a crisis, I'd like to know what they think is the correct share of health care in GDP is and how they arrived at that number.

Posted by lemuel pitkin | July 2, 2007 3:22 PM

"If we had this system and my employer gave me a 5% raise, the employer would be ahead from not having to pay for my insurance"

But you would absolutely have to mandate the raise. Think about how gas prices have stayed well above where they were even as the price of a barrel of oil returns near its previous levels.. Many employers will not voluntarily pass their savings onto the new bearers of the burden..

Posted by Trevor | July 2, 2007 3:32 PM

Henry Evans is right that its a tough political equation but I think that framed properly, as Matt suggests, or by a campaign of "all of America deserves what I have" (brought to you by the Greatest Generation) or something, this can be overcome.

Earwicker 23 hits several important funding points. Especially the "trick is in how it's raised--right now paid by employer. If we had this system and my employer gave me a 5% raise, the employer would be ahead from not having to pay for my insurance, and I would not see my paycheck change at all, but the 4.5% tax would be paid." You would pay income tax on the raise, but that's not a big amount.

Costs would also go down some withot any effort because the population that would be newly covered would be healthier than the population presently covered. The rest depends upon how healthy we want to be.

Posted by Peter Driscoll | July 2, 2007 3:39 PM

I'm down for the Kids First approach, myself. Intuitively, there's no reason why children ought to be held hostage to the employer-based system--who'd gonna argue that children should be punished if their parents can't find a job that includes health care? And if you let 18-year-olds keep their coverage permanently, you can gradually ramp up into a universal system.

Attacking the problem this way seems easier than trying to gradually expand Medicare/Medicaid. Though I like the idea of V.A. Health for all. Aren't we, in our own ways, veterans of the Global War on Terror?

Posted by jlw | July 2, 2007 3:41 PM

Even if an employee got the full raise, it would translate into less than the monetary value of the benefit currently provided due to the changes in taxation as the expense passes from a business expense to wages. There is a somewhat interesting question lurking here -- how much would be collected in additional personal income taxes if all employer spending on employee health care were converted to wage income? This amount could be used to partially offset increases otherwise needed in the payroll tax.

Posted by henry evans | July 2, 2007 3:43 PM

Obama and Edwards and Clinton have health care plans that are designed to sound SERIOUS, and make them look like the really CARE, but are too complicated to ever be understood by anyone so they will never get enacted. This is intentional.

They are designed to fail but in failing to give them cover as being serious thinkers and caring politicians.

I am sick of them.

Thirty years ago when LBJ signed Medicare legislation into law in the home of Harry Truman he said that starting coverage at age 65 was just the beginning. The plan was to reduce the eligibility age until everyone was covered.

Now that we have a crisis in medical care and the population is ready to embrace strong leadership to finish what was begun thirty years ago we have our Democratic presidential candidates subverting any chance at reform with bullshit.

Posted by ken | July 2, 2007 3:45 PM

Henry -- The additional wages would still be deductible by the employer so no additional revenue there. The raise would be subject to income tax, FICA, and M/M, so there would be some increase in revenue. I am totally guessing here, but I think that employee contributions to their employer-provided insurance would disappear and be available to employees. This might offset, on average, the loss of take home pay. On average may not be good enough however. On the other hand, people would be more able to get new jobs at more money since they would still be covered despite pre-existing conditions. It has no downside that I can see. Take a look at "Its a Mystery" On June 30, below.

Posted by Peter Driscoll | July 2, 2007 4:05 PM

RE the "how do we pay for this?" questions:
It is made a lot easier by the fact that universal healthcare is a free lunch.

Posted by rbl | July 2, 2007 4:06 PM

If kids are covered I think that you can just set it up in a way that everyone born in 2000 or later is covered.

As the children get older they retain coverage. We will have a large donut for the 8-65 year olds but the older groups will then support it seeing that they are left out of a good system.

Funding should be done by at least extending the medicare tax to all income, unearned and capital gains. The cap gains rate would still be less than it was under the Reagan tax cuts.

Posted by stillonmt | July 2, 2007 4:07 PM

If you're going to start giving Medicare to people of all ages, damn the cost, then why not start giving Social Security to all adults? If it's good enough for the geezers...

This is another Dem idea I'm betting isn't going to sound so nice outside of the echo chamber. Medicare costs are spiraling out of control as is, and -- unless you want to risk bankruptcy -- you need secondary insurance anyway to cover what Medicare doesn't. Instead of making that problem bigger to solve an unrelated problem of the 15% Americans who are uninsured (many because they simply don't feel like paying for health insurance), why not just focus on the uninsured?

The 85% of Americans who do have health insurance are going to be wary that they'll end up with something worse under a more socialized system -- and they'll probably be right. I don't think America's ready for the sort of rationing and waiting times prevalent in countries like Canada.

Posted by Fred | July 2, 2007 4:08 PM

Not a bad idea really. You have to wonder why HRC didn't go this route when she had her chance.

It will be hard for opponents to attack the idea without seeming to oppose the existing Medicare program, which is popular.

The corporate cost of existing employer-employee insurance should be remitted back to workers in their paychecks. Since it's part of their pay packages anyway, it won't cost the corporations anymore than they are now paying, and it would allow these monies to become part of the tax base to finance the expanded program.

Posted by kafka | July 2, 2007 4:13 PM

your proposal means both:

"Medicare for the richest age-group"

"Free healthcare and higher for the age group with the greatest productivity, that is also least attached to the labour market"

Posted by Chris | July 2, 2007 4:21 PM

Chris's ideal society is a forced labor camp where people are valued only for their productivity and are compelled to work by the threat of death. We can't use the firing squad for shirkers in this country, unfortunately, but denying them life-saving medical care is the next best thing.

Posted by lemuel pitkin | July 2, 2007 4:25 PM

I don't think America's ready for the sort of rationing and waiting times prevalent in countries like Canada.

Can we please stop with this? Health care is rationed in the US...by wealth. And the waiting time for a sixth of the population is infinite. Having lived in both countries, I can tell you that I find no better service and more constraints here...not to mention a hell of a lot more stress. The net decrease in freedom (you are way more tied to your job) more than offsets the theoretical increase in choices.

A lot of the wait times in Canada are because it is very sparsely populated, which makes coverage more difficult.

And the Medicare for kids idea is awesome, both politically and actually. I still remember the Mass. plan fondly.

Posted by nolaboyd | July 2, 2007 4:46 PM

"Can we please stop with this? Health care is rationed in the US...by wealth. And the waiting time for a sixth of the population is infinite."

No one is denied emergency medical care in America -- all state-funded emergency rooms are required to provide treatment, regardless of ability to pay. Poor people are covered by Medicaid. They don't wait months for necessary operations or treatment like many do in Canada.

Completely socialized/nationalized medicine ultimately leads to a two-tiered system anyway, where those with money attempt to leave the system to get better/quicker care. For example, Canada now has firms like Timely Medical Alternatives, Inc. (its slogan: "Can you afford to wait?")

Posted by Fred | July 2, 2007 5:08 PM

There might even be a Grand Bargain angle to "Medicare for All" that could get it past 60 votes in the Senate. To-wit: the new program for under 65's (call it "Medicare Prime" or some such) could compel enrollees to accept some kind of managed care arrangement, or at least contain incentives for them to do so. And I don't mean some fraudulent "Medicare Advantage"-type managed care, but a real, government-run managed care program. This would address the "we can't afford runaway Medicare spending as it is" objection. It's also a backdoor to an outcome that most of the entitlement reformers eagerly seek: breaking the fee-for-service paradigm in Medicare for over 65's.

Posted by Knecht Ruprecht | July 2, 2007 5:22 PM

No one is denied emergency medical care in America -- all state-funded emergency rooms are required to provide treatment, regardless of ability to pay.

But the real problem in American health care is the lack of primary and preventative care - to avoid conditions such as obesity, hypertension, and diabetes. Early intervention is the key to a healthy society, not reactive medicine for emergent conditions.

And not to totally whack you over the head, but all state-funded emergency rooms are required to do is "assess and stabilize."

Got a brain tumor? Too bad. Got some other cancer? Too bad. AIDS? So sorry. And just rattle off any common chronic condition, and it's not an emergency room problem.

The emergency room is not a primary care physician.

Posted by MasonMcD | July 2, 2007 5:31 PM

What Medicare for All would cost

How much do you pay right now every month for Mecicare? How does it compare in size to what you pay for every month for your health insurance? The Medicare "bill" is a lot smaller, right? The correct question to ask about costs is not how high your Medicare bill will go, but whether the increase in Medicare will be more than, will even approach, the bill for health insurance that it will replace.

What you pay for Medicare covers precisely those years of your life during which you will predictably have the most need for medical care. Your health insurance, on the other hand, almost certainly does not cover these high-cost years. And even if it, theoretically, covers you up until age 65, in practice, many plans end when you end your current employment. And if your reason for ending your current employment should happen to be an ongoing medical condition, good luck getting onto another plan.

Sure, there are some factors that work in the other direction. You pay for your Medicare, over-65, protection over about 3 years of working life for every one year covered, while private health insurance is year for year. But your insurance is still probably 3 times greater than your Medicare "bill". Yes, to make the coverage universal, there must be some way to pay for those not curreently covered. But this will mainly be addressed by having everyone who works, and their employers, contributing into the system, rather than the present system whereby many people with jobs can't afford to contribute the outrageous premiums the private insurers charge, or they choose to freeload. Those of us with incomes will, it is true, have to cover the indigent. But we already cover them, plus the working freeloaders, either via govt subsidization of free care, or via providers of medical services having to charge paying customers more in order to stay in a business in which they are compelled to treat everyone who can be wheeled through an ER door, insurance beneficiaries or not. It would be cheaper to subsidize the right, preventive, care, for the indigent. rather than the wrong, emergency, care as is now the case.

Posted by Glen Tomkins | July 2, 2007 5:34 PM

Medicare is already a fiscal train wreck in progress. "Medicare For All!" would require at least $1 trillion a year in new taxes, probably much more. Politically, it's a fantasy. Fiscally, it's grossly irresponsible.

Posted by Mixner | July 2, 2007 5:57 PM

"Got a brain tumor? Too bad. Got some other cancer? Too bad. AIDS? So sorry."

Please. If you're destitute you will qualify for Medicaid and get treated for any of those conditions.

"But the real problem in American health care is the lack of primary and preventative care - to avoid conditions such as obesity, hypertension, and diabetes. Early intervention is the key to a healthy society, not reactive medicine for emergent conditions."

So why not mandate that everyone at least have limited insurance to cover the costs of preventative care? Limiting the insurance coverage to preventative care would make it much cheaper. Most prudent folks would keep their current health insurance policies, or, pair the preventative care insurance with a high-deductible policy to cover catastrophic costs. As for those who didn't -- we're already on the hook for their catastrophic health care now anyway.

Another idea -- since low-income Americans tend to be disproportionately represented among patients of type-two diabetes and other preventable diseases -- would be to tie their receipt of cash benefits (e.g., EITC, welfare, etc.) to positive behaviors such as getting their kids vaccinated, etc. Like Brazil does and like Bloomberg is proposing. We don't all need a nanny state, but some of us do.

Posted by Fred | July 2, 2007 5:59 PM

The buzzword should be "Medicare reform".

Posted by John Emerson | July 2, 2007 6:20 PM

Re: Are medicare payroll taxes capped in the same manner as social security taxas?
Nope, they're collected on all income.

Not quite. It is collected on all wage and salary income, but not on unearned income.

Re: No one is denied emergency medical care in America

Nor is anyone demniend emergency medical care in Canada and there are no waiting lists for it. With the additional benefit that it is paid for and no one goes bankrupt as a result.

Re: They don't wait months for necessary operations or treatment like many do in Canada.

Oh good grief, there are waiting times in America and please don't try to claim otherwise. They are not, on the average, as long as wait lists in Canada, but they do exist and for some people they can can in fact stretch into months. You are apparently very isolated from the American healthcare system.

Posted by JonF | July 2, 2007 6:22 PM

How to pay, how to pay. Hmmm. Well, we have four times as many aircraft carriers in commission as the rest of the world combined. Maybe a few more than we need. Also, we have a costly war that's doing us no good.

I'm sick of Democratic candidates who intend to keep dishing out the gravy to the war machine, and offer smoke-and-mirror health care plans.

The President, of course, cannot enact legislation- that is a job for the Congress. So it is entirely appropriate for a candidate to say he will try to extend Medicare to all.

And that "he" is intentional. I believe Clinton is honest- when the drug companies and insurance companies have bought her, she will stay bought.

Posted by serial catowner | July 2, 2007 6:43 PM

Ha ha, Fred is all "Poor people should exercise more" today. But put up a post about how Americans should drive less and he'll be all "Driving is good! Nothing wrong with being fat!"

It is amazing the brazenness with which the rightwing trolls will proclaim that everybody already has all the medical care and drug therapy they need. Let's hope they keep talking like this because it shows the silent majority just how out-to-lunch the rightwingers really are.

Of course, I know they must also spend time insisting there is no global warming, the glaciers are actually getting bigger, and besides, the ice cap on Mars is melting (as it does in every Martian summer) so the global warming that isn't happening is actually quite normal.

It's a busy life if you're a troll. Hope they are at least paid well.

Posted by serial catowner | July 2, 2007 6:52 PM

How to pay, how to pay. Hmmm. Well, we have four times as many aircraft carriers in commission as the rest of the world combined. Maybe a few more than we need. Also, we have a costly war that's doing us no good.

The entire military budget is only a fraction of the money that would be needed to fund "Medicare For All!"

When you've put together a budget proposal for funding "Medicare For All!" that is politically realistic and fiscally responsible, get back to me.

Posted by Mixner | July 2, 2007 6:57 PM

mixner

you're way overstating this.

the defense budget is just a shade under $500 billion, while the sum total of what US employers pay for health care (and which presumably would be taken up by "medicare for all" in a swap for single-payer instead of employer-provided care) is just a shade over $500 billion.

both are, of course, enormous sums of money, but, neither is "just a small fraction" of the other.

Posted by josh bivens | July 2, 2007 8:16 PM

Josh Bivens:

Huh? We spend about $2 trillion a year on health care. Roughly half of that comes from the government. So if "Medicare For All" cost no more than we currently spend on health care altogether, it would cost an extra $1 trillion on top of what the government spends now. $1 trillion is over a third of the entire federal budget.

But wait! There's more! "Medicare For All!" would cover the 45 million people who are currently insured as well as all the people who are currently covered by private insurance or government programs. So it would likely cost even more than an extra $1 trillion per year.

Posted by Mixner | July 2, 2007 9:09 PM

Huh? We spend about $2 trillion a year on health care. Roughly half of that comes from the government. So if "Medicare For All" cost no more than we currently spend on health care altogether, it would cost an extra $1 trillion on top of what the government spends now. $1 trillion is over a third of the entire federal budget.

No. We're in this mess because our healthcare is too expensive for a number of reasons, one of which is that it's been hijacked by a for-profit health insurance industry, which coincidentally degrades the health of the country by denying care.

Other industrialized nations spend half of what we do and get superior results.

We can do that too. Everyone getting relatively inexpensive primary and preventative care, saving us from paying for more costly chronic care and quadruple bypasses in the future.

This isn't rocket science. Health care *insurance* shouldn't be for-profit. That makes no sense. I don't know how we fell for it.

Posted by MasonMcD | July 2, 2007 9:32 PM

MasonMcD,

No. We're in this mess because our healthcare is too expensive for a number of reasons, one of which is that it's been hijacked by a for-profit health insurance industry, which coincidentally degrades the health of the country by denying care.

Here we go again. What does "hijacked by a for-profit health insurance industry" mean, exactly, in clear, empirical terms? Are you sure it wasn't the for-profit health care delivery industry?

Other industrialized nations spend half of what we do and get superior results.

No, they don't get superior results. They may score slightly higher on some aggregate health indicators, but that's not the same thing as getting "superior results" from their health care system, because so many other things have a much greater impact on health than the health care system.

Health care *insurance* shouldn't be for-profit.

Why not? Should home insurance be for-profit? Car insurance? Life insurance? Mortgage insurance? Renter's insurance? Disability insurance? Or should those be run by the government too?

Posted by Mixner | July 2, 2007 10:22 PM

Serial Catowner:

"Ha ha, Fred is all "Poor people should exercise more" today. But put up a post about how Americans should drive less and he'll be all "Driving is good! Nothing wrong with being fat!"

I don't think it's unreasonable to expect someone who is dependent on government largess to do some responsible things like getting her kids vaccinated. If advocating that makes me a troll in your book, so be it.

Not sure exactly what you are groping toward with the driving example. Walking isn't a realistic alternative to driving for most people who have to drive to work. Driving also doesn't preclude them from eating healthy or hitting a gym after work. Speaking of driving, did I mention I bought shares of Frontier Oil Company at the beginning of February? I must have been Kreskin to know that gasoline prices would go up this summer.

Mixner:

"What does "hijacked by a for-profit health insurance industry" mean, exactly, in clear, empirical terms? Are you sure it wasn't the for-profit health care delivery industry?"

Good points. One of the reasons health care is expensive is that health care providers in American are very well paid. Physicians average $200k+ per year (with surgeons often earning several times that). Nurses often make over $100k (my sister is an agency nurse who often works for $60 per hour). There are also more obscure health care jobs (e.g., profusionists) that are similarly highly paid. Of course it's politically easier to rail against amorphous "for-profit insurance companies" than highly paid nurses.

Also, what about not-for-profit health insurance companies? It's not like they don't exist.

Finally, what about the wellness/prevention efforts of for-profit insurance companies? Last year, I was offered a job with the investment company subsidiary of a major insurance company. New hires got an orientation from an R.N. on staff about the free company gym, personal trainers, free flu shots, health screenings, free visits to the company's staff M.D.s, etc. As an insurance company, the management knew it was in their interests to keep their employees (and insureds) healthy. Isn't this the kind of prevention we should want to promote?

Posted by Fred | July 2, 2007 11:32 PM

Why not? Should home insurance be for-profit? Car insurance? Life insurance? Mortgage insurance? Renter's insurance? Disability insurance? Or should those be run by the government too?

Because only in the case of health insurance is necessary, routine care, and necessary routine remediation absolutely unavoidable, yet the industry's only recourse to make a profit is to avoid that which can't be avoided.

Crashing your car happens, but it's not an inevitable statistic. Neither is a disability, or a tree through your roof. Actuarial tables pretty accurately predict the incidence of accidents or "acts of nature," and rates can be tagged to risk factors, but they fall woefully short in predicting what is necessary for "good health."

Should you get that colonoscopy? Blood pressure screening? How about an angioplasty vs. bypass? MRI vs. a couple of Tylenol? Actuarial tables are poor at valuing preventative medicine, or certain medical interventions, but we know from medical studies that they are absolutely key in preventing more serious conditions.

The doctor and patient relationship, and *outcomes* should drive healthcare, not per-treatment probability assessments.

Posted by MasonMcD | July 2, 2007 11:34 PM

MasonMcD,

Your statements about the possibilities of different kinds of hazard are patently false. Just as anyone can become sick, anyone can become disabled in an accident. Anyone can be involved in a car wreck. Anyone can have their home burn down or their possessions stolen. All of these things can happen to anyone. So why should health insurance, and only health insurance, be removed from the "for profit" market? And why health care insurance, but not health care delivery? Or are you proposing to nationalize the latter, too?

Posted by Mixner | July 3, 2007 12:40 AM

Dear Matt,
Please pay for your own visits to the doctor and stop trying to suck on everyone else's tit for your every need. Isn't it time that the left considered weening?

Posted by RW | July 3, 2007 8:30 AM

Your statements about the possibilities of different kinds of hazard are patently false. Just as anyone can become sick

Health insurance isn't only about (or shouldn't be about) getting coverage when you're sick, but also coverage for staying healthy.

Auto insurance doesn't cover tune ups, homeowners insurance doesn't cover re-shingling the roof, but health insurance needs to be about regular office visits, preventative care, a building good habits.

An additional twist is that everyone's house doesn't crumble, and everyone's car isn't totaled, but everyone dies. The vast majority of health care dollars in this country are spent in the last year or two of life.

That's an inevitable event - not a "risk" - that needs mitigation resources spread across the population in general, as with Social Security or Medicare. Otherwise, with only a narrow population of "insureds" to draw from, it becomes a huge burden for just that population, particularly when you are also skimming profits off of the top.

Posted by MasonMcD | July 3, 2007 8:36 AM

In my small mind, all forms of insurance are socialism. I pay my car insurance, you have an accident, my contribution goes to help pay for your accident. Who could have a problem with that?

Insurance, however, is also a lot like utilities. The larger the net, the lower the per person cost. The logic of the math forces everyone to participate in the Utility, even the uber-wealthy who can afford to opt out. Anhueser-Busch in St. Louis, has its own water treatment plant, but even they have to buy some of their water from the city of St. Louis (That's socialism, perhaps it's no coincidence, that the City of St. Louis has the best public on tap water in the country).

If we can't get Medicade for all, let's give the another model they understand: The utility model. Healthcare is not a commodity, but health insurance, like all utilities, is.

Use the Bell Telephone model, circa 1979 for starters, and force all the healthcare providers to merge into a single oligarchy, and regulate it the way we do the phone system.

Nobody can say they don't know the system. Then we will have single payer to satisfy us progressives and liberals, but it will also be private to satisfy the troglodyte conservatives.

Everybody gets what they want. CEOs of healthcare companies can't be obstructionist because their shareholders gain something out of selling their shares. The cost of the merger will be paid by the massive savings of the new system.

The regulating board regime, should have representatives from every quarter and every stake holder in health care.

By the way, we are still under the same regulatory regime that we had in 1979, they have just, surgically introduced competition and market forces where they thought they would work.

Medicare for everyone sounds great to me. VA for everyone sounds great for me. But I can live with the Ma Bell model too, at least it is some progress. If we want to, after that, we can just nationalize it or turn it into not for profit or non-profit or whatever. But it would be difficult for Republicans to object to it (but I am sure they will) - because the model works fine for the Telecom industry and most utilities, and it's still private company.

Posted by Tim | July 3, 2007 10:16 AM

mixner

$1 trillion is half of $2 trillion, so, you've got something right.

but, of the half that is private money, almost a quarter is out-of-pocket spending, and, of the $700 million spent on insurance, employees pay almost 30%.

so, this means, as i said, something like medicare-for-all could pick up every single dollar that is currently spent by employers in the private sector on insurance by raising a bit over $500 billion.

maybe you think medicare-for-all advocates think that nobody should ever pay a penny out of pocket for either health care or premiums. maybe some do. but, most people think of medicare for all as an alternative to the employer-based system, and, to replace this, you need about $500 billion.

you have a point about the uninsured, and, most studies say you'd have to pay about $25-30 billion to cover them, so, call this a round $550 billion convservatively.

bigger than the pentagon, but, still a lot smaller than you make it out to be.

Posted by josh bivens | July 3, 2007 10:25 AM

you have a point about the uninsured, and, most studies say you'd have to pay about $25-30 billion to cover them, so, call this a round $550 billion convservatively.

Don't forget savings from eliminating administrative overhead, both in the insurance industry, and in doctor's offices, hospitals, and clinics.

Also, you need to factor in savings due to preventative and interventionist procedures, as opposed to emergent care.

Posted by MasonMcD | July 3, 2007 10:42 AM

As a physician the prospect of Medicare for all is truly frightening. Medicare has a notoriously complex and low fee structure. I treat very few Medicare patients as I lose money on those visits. Needless to say if my reimbursement on all patients were at the Medicare fee I would be bankrupt in no time. So would most other healthcare providers. My office is also completely electronic. It saves me the cost of a full time employee. I have truly cut all I can from my overhead and Medicare reimbursements still do not even come close to break even.

Posted by Cfranch | July 3, 2007 12:07 PM

I treat very few Medicare patients as I lose money on those visits. Needless to say if my reimbursement on all patients were at the Medicare fee I would be bankrupt in no time.

Where are your costs coming from?

Posted by MasonMcD | July 3, 2007 1:58 PM

Once again any conversation about improving our medical "system" devolves into nit-picking, techno-babble, and illogical comparisons. Our healthcare "system" is the most costly, least efficient in the world. It is near the bottom in effectiveness among advanced or industrialized countries by every measure in every widely accepted study of medical outcomes. Who in their right mind defends this result? Why do people continue to support a system that is clearly the worst of all choices? Who are you people? Pick any other system; pick England, Sweeden, France, Italy, Germany, Austrailia, Canada, or any of a dozen others and we would be healthier. There is no downside to changing systems or expanding Medicare unless your are a non-medical insurance employeee or the owner of stock in drug or health insurance companies. In addition, a change in our health delivery system would help our manufacturing to the point where it would be competitive again. I take some solace in noting that the recipients of Medicare are the most satisfied in the country and that is a growing segment of the population.

Posted by Peter Driscoll | July 3, 2007 3:24 PM

My costs are the usual business overhead-salaries, rent, utilities etc... These are not fixed costs and rise each year while I've watched my gross receipts drop for the past 6 years while seeing more patients than ever. As Medicare lowers reimbursement rates so do private insurers. Oh and my malpractice insurance-let's not even go there.

Posted by Cfranch | July 3, 2007 3:53 PM

As Medicare lowers reimbursement rates so do private insurers.

There is a twisted relationship between Medicare reimbursements and private insurance reimbursement.

As efficiencies were squeezed out of the system by the HMO model, Medicare reimbursements looked generous. Private insurance looked at that imbalance and saw it as a way to externalize "excess" payments. The generous Medicare payments were then seen by government as a gift to private insurers.

Medicare and private insurers are in a race to the bottom, it seems. Pull one element - private insurance - out of that death spiral and we can pull out and avoid the crash.

Posted by MasonMcD | July 7, 2007 12:32 AM

Counterintuitive!

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