Okay, how about THIS for a health care plan for the United States?

[xiphias]

A five-part plan:

1) The government pays for really basic stuff. Basically, if you feel ashamed when you hear about someone dying from a lack of this, it's paid for. If it's cheap and does a hell of a lot of good, that's the stuff we're talking about. Basic checkups without significant tests, tooth cleanings, real basic stuff.

If I hear about someone dying because they couldn't get open heart surgery, that makes me sad, but not ashamed. I'm aware of how expensive that is. Or not getting a transplant -- again, sad, but not embarrassed. So those sorts of things wouldn't be covered.

This would just be a billing code. A hospital or doctor's office could just bill this stuff to the government, and it would be paid promptly.

2) People could form into negotiation blocs who could negotiate lower rates from drug companies, hospitals, doctors, and so forth. If you wanted to, you could sign up for whatever bloc or blocs you wanted to be in, for a small fee (which would basically cover administration and negotiators' salaries), and, if you were a doctor or hospital or whatever, you could sign up for the same bloc which would mean that you'd agree to the rates they negotiated. As a doctor, your benefit would be that there would be a group of people who would count you as a preferred doctor.

Actually, I don't know how necessary this part is. After all, if you were a doctor and WEREN'T part of the bloc, you could still agree to take whatever fee the bloc charged, in order to poach customers. Which would also be fine.

3) There would be health insurance. As in, you pay a monthly fee, and, if something bad happens, they pay whatever your insurance coverage pays for. It wouldn't pay for routine stuff, although the insurance plan could give lower rates for people who demonstrated that they did take care of the routine stuff routinely.

This insurance could be "we pay 80% of your charges, up to a limit, and you pay 20%", it could be, "we pay 100% after a deductible", y'know, whatever. These health insurance plans might be associated with negotiation blocs, but need not be. If they started to pay for routine stuff as well, you begin to run into exactly the same problems we have right now, but, well, if they WANTED to do exactly the things that we have now, sure, they could. Why not?

4) Drug patents would expire seven years after they were approved for sale. That number is somewhat negotiable, if drug companies could prove that they couldn't make a profit in seven years, but whoever was doing the negotiation should be DAMN skeptical.

I mean that we could argue that drug patents should expire ten years, or twelve years, or whatever, as the law. I'm not a financial analyst -- I don't KNOW that drug companies can make a profit, in general, in seven years. But I really, really suspect so. I DON"T mean that an individual drug could be patented longer. Because, if you did that, with negotiations all the time, the negotiators would be corrupt. It just would happen.

5) And the gaps would be filled by private charities. And doctors and hospitals doing pro-bono work. I don't think, in the United States, you could do it any other way. I don't think it would be possible for the government to pay for everything that really ought to be done, and I think that you'd need charity to fill in.

What do people think?

Comments

[pocketnaomi.livejournal.com]

The biggest gap I see in your plan is that it ignores the question of preventive care, which IMO the government REALLY needs to pay for as a matter of basic collective self-interest. It is a hell of a lot cheaper to pay for routine prenatal care than to pay for the care of a badly premature baby, f'rex, or for routine cholesterol monitoring and medications than for the number of cases of additional bypass surgery that would be unnecessary if the problem was caught early. That isn't even counting the overall social, economic and morale benefits of having as low a needlessly-disabled population as possible. I would go VERY far in having the government pay altogether for regular checkups, tests and maintenance, because people who have to pay for these themselves usually just *won't*, and I think it's so much in our interests as a society to encourage that kind of care to happen that it's worth bribing people to do it by making it free.

[kiya]

I would consider "really basic stuff" as noted in #1 to encompass pretty much all preventative care; what of it do you not think wuld be included?

[(Anonymous)]

The other problem is the negotiated rates. When I had cancer and was in the hospital, I only saw one bill. It was for about $22,000; the insurance company paid about $3,500 leaving the hospital to write off the rest. Now something there is out of whack. Did the hospital overcharge or the insurance company underpay? Or something in between? With that much of a discrepancy, it is easy for me to understand why the medical facilities run so tight and toss you out so fast.

[quietann.livejournal.com]

yep, reminds me of my $6000 tubal ligation (which I almost ended up having to pay for out of pocket because student health insurance didn't cover it, but then it turned out that I had the procedure done *2 days* before the COBRA coverage from my husband's employer ran out. That insurance paid $1600 for it and I payed only a $50 copay for outpatient surgery.)

[redknight.livejournal.com]

"Nobody pays list price!" Well, nobody but the uninsured. Medical pricing seems designed to allow for deep discounts for insurers and taking advantage of the people who can least afford to pay list price (the uninsured).

The Wall Street Journal had an article on the subject a few years ago (http://online.wsj.com/article/SB109571706550822844.html?), unfortunately things don't seem to have changed much since then.

[felis-sidus.livejournal.com]

A lot depends on where you live. In some states, if you're uninsured it's easy to arrange a significant discount or free care, because of state statutes. In others, you're on your own.

[vvalkyri.livejournal.com]

Yeah. That's one thing that really disturbs me. For the most part Medicare and some of the other big insurers simply state a price they'll pay for any given procedure, regardless of how much it costs the hospital. ("we don't care if he stays in the hospital 2 days or 20 - we're paying X for that surgery") One of the major ROI on my product is it reminds/guides clinicians into using the 'magic words' to document comorbidities. Medicare etc recognize that the guy who had a heart attack 2 months ago is more likely to be in hospital longer after the surgery. But if you just document "Previous MI" but not "Previous MI w/in 6 mos" you don't get the extra cash.

[wildcard9.livejournal.com]

The only problem I can foresee is people being shut out of the blocs that are the most benefitial. It could be financial (they can not afford it) or societal (i.e. discrimination). I am not sure what you could really do for the financial issue since there are different levels of income across the country. Social exclusure can be avoided via regulation but even that can be circumvented. Either way, not all blocs will give equal treatment, and there-in lies the problem.

[roozle.livejournal.com]

Another reason for shutting people out of blocs might be that they need health care. E.g. exclusions for pre-existing conditions.

[adrian-turtle.livejournal.com]

I would expect a lot of exclusionary blocs based on a perception (maybe mistaken, maybe not) that some group of people has more expensive health care needs. Exclude women of childbearing age and avoid all the expenses associated with having babies. Exclude people over 70 and reduce the risk of having to pay for extended care and multiple illnesses. Those are such big exclusions it's possible to imagine legal remedies. But how about excluding male homosexuals and immigrants, to reduce the bloc's risk of dealing with HIV infection? It may be a foolish tactic, but the Red Cross does it....

[rebmommy.livejournal.com]

Did you see the NECN article about the "Mobile Access to Care" (MAC) Van that is sponsored by the Massachusetts Dental Society and the Boys and Girls Club? It provides free dental care for children from low-income families and gets them connected with dentists who will give them free or less expensive follow-up care. You Papa Tuny (Dr. Norman Becker) is very proud of this program, which he helped to develop. Your cousin Todd (Dr. Todd Belf-Becker) is the featured volunteer dentist in the news article.

[xiphias.livejournal.com]

Yes; that was my last blog post that got me thinking about it.

[happybat.livejournal.com]

I suppose, what I mainly think is that cultural relativity is very interesting - I would be not only ashamed but ANGRY if I heard about a fellow citizen dying because of their lack of ability to pay for open heart surgery.

[xiphias.livejournal.com]

The problem is that it is not possible to pay for the best possible care for all people.

And if it IS possible at one point in time, it's not possible going down the line.

The primary driver of increasing health care, long-term, is increasing technology. The more diseases you can cure, the more expensive it is. People live longer, having disease after disease cured, and that gets more and more expensive.

So you cannot, long-term, cure everyone of everything that can be cured. There just aren't enough resources. Even so, it's shameful if someone isn't cured of something which is easy to cure.

The question is "what is easy, and what isn't?"

[happybat.livejournal.com]

Yes, for sure. I think where you set the limits, though, very much depends on what you currently have and see as normal. I would be outraged to be denied a heart transplant, but able to cope with the idea of paying for my own breast reduction, for example. I suppose what I am arguing is that your current system is so dire (sorry, but it is) that you are prepared to accept far less than I feel you are 'entitled' to...

[xiphias.livejournal.com]

That's exactly it. I'm not talking about a perfect health care system -- I'm talking about one that I think would be possible for the United States.

And we here in the US are more willing to accept our fellow citizens dying than we are to accept paying for their care.

Actually, we're more willing to accept our fellow citizens dying than we are to accept being required to pay for their care. You'll find plenty of people who are willing to pay out of charity, but not out of taxes.

Although you'll find far, far more who are willing to SAY that they'll pay out of charity. . .

[happybat.livejournal.com]

I really spot my socialist heritage when I shudder at the thought of people's lives depending on the charity of others...

[the-siobhan.livejournal.com]

I feel much the same way. I don't think survival should have to be a popularity contest.

[ashnistrike.livejournal.com]

The problem is that it is not possible to pay for the best possible care for all people.

Of course it is. We don't make our military go around with inferior technology.

...Okay. We didn't until the current administration. And we correctly think of that as embarrassing. I'm American, and I think it's embarrassing if a fellow citizen dies because of a lack of ability to pay for open heart surgery. I think it's embarrassing when a fellow citizen has cavities because our health care system is broken. The problem isn't resources, it's distribution. Every other civilized country on Earth manages this, and some even seem to do it well. "Embarrassing" is a very good word for our inability to do so.

[felis-sidus.livejournal.com]

Actually, speaking as someone who sees what things cost on a daily basis, it really isn't possible to pay for the best possible care for everyone. Nor do I know of any other nation that does that. What is possible is to pay for adequate care for everyone, and there are nations doing that, depending on how you define adequate. The most common problem I've seen in most countries with national health services is the amount of time you have to wait for services that are necessary but not urgent. This can mean that what would have been an elective procedure instead becomes an emergency situation. (Not that we don't also have that problem in this country.)

My own proposal is even simpler. Lock a group of doctors representing all specialties in a room until they come up with the single most important health care benefit to provide to everyone. Now lock a similar group of economists, accountants, and financial analysts in a room until they decide how much it would cost to provide that care to everyone you intend to cover. (Not getting into the citizen versus non-citizen thing at this point.) Okay, everybody gets that. How much money is left in the national budget? Lock the doctors up again, and make them find the second most important health benefit. Repeat until we run out of money. Whatever's left over would be the province of the insurance companies.

Think this wouldn't work? Think again. We did something like it years ago in Massachusetts. It was spearheaded by the doctors in the state. All their professional groups got togther, surveyed their members, and agreed on a set of Relative Value Units that ranked medical services across specialties based on a combination of factors. Then they all agreed to accept a certain payment per relative value unit. It worked. Health care costs, while not cheap, were a lot more affordable than they are today. What happened to this system? The federal government decided it constituted price fixing, and outlawed it.

[the-siobhan.livejournal.com]

Speaking as s complete outsider, one of the flaws that I see in your system is just how much everything costs. Doctors and hospitals have to pay insane amounts of money for malpractice insurance, the cost of filing paperwork to multiple insurance companies, advertising (because mediciine is free market there), chasing down patients for payment and of course, getting stiffed by patients. Not to mention chasing down insurance companies for payment, I have a friend who is still harrassing companies for payment eight months later, and she has bills to pay in the meantime.

All those things substantially increase the costs. You could afford to spend so much more on actually treating patients if you took all those factors out of the equation.

[ckd]

I say we just reduce drug patent lifetimes by 1 month for each month in which the company does any direct-to-consumer advertising. (So if you have 5 years left in January, advertise every month and by next January you'll have 3 years left.)

[xiphias.livejournal.com]

I like it. . .

[teddywolf.livejournal.com]

Ohh, I *like* this!

[adrian-turtle.livejournal.com]

This is very clever.

[yardlong.livejournal.com]

I agree entirely with happybat, and of the things you mention should be provided, I'd say that the routine dental care should top that list. That does do a hell of a lot of good, but whatever else you mean by basic care without extensive/expensive testing is of questionable value. Illness needs to be diagnosed and treated. Check-ups that do not provide a product (treatment, cure) are a waste, but it is not known until after the fact. Full care should be provided to every citizen, definitely to include heart surgery which is an expensive cost but often not a continuing and repetitive cost for one patient. Two people in our family have died for lack of heart-related medical care, and I fear for my husband because he can't get preventive treatment before things get to a very threatening level.

There may be something I'm not aware of, but free mammograms for women who can't get care for breast cancer makes me question the purpose. But then, I did go for one myself, and was sent a bill for over $800.

[mightydoll.livejournal.com]

Sounds somewhat similar to Canada's plan. Though we don't cover teeth or eyes, for reasons I can't fathom.

As far as drug patents go, I like it in theory, but what I would be worried about is drug companies using addictive additives to "hook" people before their patent ran out. Kinda like Effexxor does. They claim it's so you won't forget to take pills...and it works in the capacity, if I forget a day, I get SICK!!!

but that's not really nice when I'm somewhere where I can't get access to these precious (and expensive - - my dosage is about $3 a day) little red pills.

That said, here in Canada, as long as a drug company holds a patent (before the generic version of the drug comes out) the company has to make available "compassionate doses", which is how I get my drugs, free, through my doctor.

Since Effexxor is about to go generic, I'll probably do what I did when Zoloft went generic and switch to something newer and less well tested...just call me a working class guinea pig.

[msmidge.livejournal.com]

Really, Effexor does that? I think I have a friend who was trying to go off of it recently and her life became a total wreck so she just went back on it. I wonder if that's why.

[mightydoll.livejournal.com]

yup, sure does. It's an evil little drug.

severe nausea, headaches, chills, body aches, petit mal seizures, irritibility (though that's to be expected if you go off an SSRI), sweats, dizzy spells, tunnel vision, disorientation, short term memory loss...

Zoloft was bad, when I went off that, but nothing compared to Effexor. I used to "joke" going off Zoloft that I felt like an extra from Trainspotting.

Thing is, I'm one of those folks who actually DOES have a neurological reason to take SSRI's and for as evil as they are, they're a damn sight better than the alternative (lithium, etc.)

[linenoise.livejournal.com]

All of the SSRI class of drugs, which includes most of the popular anti-depressants (Prozac, Paxil, Effexor, etc) come with some nasty discontinuation symptoms. Some of the really nasty ones can actually cause long-term damage to the nervous system if you try to go cold turkey from a higher dose.

Anyone that's undergoing treatment with psychological medications should always consult their doctor before stopping treatment, and you should never go off them cold turkey if you've been on them long enough to reach theraputic levels, unless you're in the middle of an allergic reaction and the consequences of discontinuation is the lesser evil (and if that's happening, you should definately be calling your doctor, if not heading to the hospital).

[the-siobhan.livejournal.com]

Sounds somewhat similar to Canada's plan.

The big difference is that if something is expensive or high-risk like heart surgery, it's still offered to everybody equally. Under this proposed plan, you still have more options if you have money. (Not that rich people don't have more options here as well, but at least access to the actual procedures is equal.)

We may get ourselves into a position where we have to do triage on certain medical procedures due to rising costs, but I dealy hope (and intend to vote) that acess to those procedures is still provided to everybody.

Though we don't cover teeth or eyes, for reasons I can't fathom.

By the time doctors figured out how much teeth affect the rest of your health, we were already facing a funding crunch.

[linenoise.livejournal.com]

Do you have any evidence that Effexor is actually adulterated to cause that?

I know for a fact that all of the SSRIs are incredibly *physically* addicting, by their very nature. Which doesn't mean that the drug companies did anything to make them that way. It just means that your body gets acclimated to them in such a way that stopping treatment or missing a dose can have nasty consequences.

I've heard anecdotal evidence to the effect that Effexor is particularly nasty to discontinue, but this is the first time I've ever heard it alleged that that is at all deliberate. And I've done a fair bit of my own research on psycho-pharmacology.

[rarkrarkrark.livejournal.com]

woah woah woah woah, addictive *additives*? Every source I've ever seen says that it's the med itself that causes physical dependency, but if you've got a source that says different, I'm interested.

[vvalkyri.livejournal.com]

Oddly enough, someone randomly responded today to something from a year or so ago in my journal (http://vvalkyri.livejournal.com/616246.html) that reminded me about your post here.


I think you've got a lot of good ideas, and I like your way of stating, "if it's embarrassing for it to happen" - my way of putting it had been in terms of it being shameful.