beyond 140 for @lewmoorman

Good point, Lew. This brings up quite a bit of questions about our preparedness and our willingness to face difficult ethics questions.

One of the biggest issues that no one *ever* discusses anymore is the omnipresent pre-existing condition clause. People with even minor routine problems are denied coverage regularly - even if they can pay. I would bet this is responsible for far more of our nations uninsured than simple poverty.

Many of those people then spiral downward, until a life-threatening catastrophe requires the state to step in (with Medicare or another program). Only then it costs taxpayers FAR more than treating the initial issues.

The first step to assessing our nations true health insurance status is to require equal access to care for everyone by eliminating medical discrimination and pre-existing conditions clauses.

Great point Allison. I will add that one to the list of big questions as I learn more.

Good article referred to in twitter comment:
http://www.whitehouse.gov/omb/blog/09/04/20/TheCaseforReforminEducationandHealthCare/

Highlights how our need to spend so much on healthcare is hurting our investment in education.

The only groups that benefit from the current system are insurance companies, their lobbyists, and the politicians that the lobbyists pay. Everyone else pretty much gets the shaft.

Thus, the problem will be ignored or deflected with "Look at our health care system? What are you, a SOCIALIST?" until past the point where it's fixable.

Here's an interesting link that might help explain #1: http://bit.ly/WZvjs

I will jump out on a limb and respond to each of your questions. These are just my opinions, mind you - as someone who has worked in health care, Been in the Military, been a Civilian Government Employee, a beneficiary of the Veterans Administration, and someone currently using "public health care, _with_ insurance). I have some basis for an at least educated opinion.

1. Why do we spend 2 times more than Europe per capita but live slightly less?

Well, certainly our diet and "fast everything" lifestyle has a lot to do with it. I also think that as a nation we have an odd aversion to spending much on preventive medicine of any type - yet we shove a substantial part of our budget into Medicare/Medicaid. One example of pushing debt forward.

2. What value do insurance companies add to the equation?

The same value that friends of mine think they have when they fins out I don;t have a credit card - "What! I wouldn't go anywhere without my credit cards - that's security". Suuuure it is! These are the same people running up 30-49K credit card debts. What kind of security is that? Money in the bank - THAT is security!

Insurance offers the same (mostly false) sense of security.

Again, not living within our means - pushing debt forward.

3. How does the legal system contribute to the costs?

I blame the Lotto :) Everyone expects to "get rich quick". Guess what, folks, it rarely happens that way, and when it does, it often ends pretty ugly. You don't respect money you don't earn (and over time you don't respect yourself). This is why the W.P.A. was successful - people actually EARNED the Government "assistance they received. They learned to work, and to earn.

A quick lawsuit makes everything ok - it's like winning the lotto.

4. How do we deal with the ethical issues around treating very old members of society (e.g. heart surgery for a frail 90 year old)?

This one is really tough. First, we should invest more in preventative medicine now (and bring PE back to every school!) so that the 90 year olds of 2090 are in better health. This is one of those things where society bites the bullet, and after someone has gone through their savings (yes, drain their savings), steps up and helps. We certainly can't ignore them.

5. Where are we overspending or over treating (ie where can we save)?

First, let's not exempt either Government of Government Officials from any law everyone else must follow. That must be costing some money, or they wouldn't do it (and, dammit, it is just unfair!).

Second - flat tax - no more loopholes. I don't care exactly how it works as long as everyone pays the same percent of what they make. Include corporations in that.

We need a line item veto and a President with the cajones to use it.

6. How do we create incentives to ensure preventive care?

Mandate it, at least through college - and pay for college. Better educated people will earn enough, and be better educated about how critical preventive care is. We mandate health care for our military now - do it for everyone receiving Federal/State monies.

7. Is the system of creating supply for doctors flawed?

The system of training them is - spend damn near a decade learning stuff that is useless 3 years later. And, again, create preventive health care clinics in rural areas and inner cities - and pay (honest and quality) doctors to run them. It will be much cheaper in the long run.

8. How do we trade universal healthcare needs with incentives for invention?

Invest the most in those diseases that cost the most. Seems brutally unfair to those with uncommon diseases, I know. But you pay these debts in the REVERSE order of personal debt - in personal you pay the least debt first, regardless of interest rates - because the compounding won't affect you like it will the trillion of debt we accrue as a nation.

Health care needs tackled from the opposite direction. Actuary tables sound cruel, and they are. They are also effective.

9. Do we know how well our treatments work? Is the default to act misinformed?

The lack of accountability in health care is pretty astounding. How many multi-million dollar studies have we seen that show the complete opposite of another multi-million dollar study? How can that happen? I'm not sure, but I am sure it makes no sense.

And yes - I realize some of these studies are paid by a partner that has a vested interest in the results - but even supposed "independent" studies oppose each other.

A national ANONYMOUS database of every inpatient/symptoms, every ER patient/symptoms would be helpful to track the spread of diseases, ability of hospitals to cope with them, pockets of cancer, etc. But I don;t buy into a "Federal Database" that contains my medical records. I don't trust our government that much. Or anyone,

minter, this is the main point of my post. there is massive fear in looking at this issue. it is a third rail, sacred cow, whatever. but, we HAVE to. it just isn't working. it does not mean we need the canadian system. there has to be a better way. that is what i want to try to understand.

rcollazo, interesting link. not sure i am ready to give up on the american way :) but, i do wonder how the homicide rate impacts average life span. thanks for the info.

I think you have to solve the problem of it being politically inconvient to talk about before any meaningful evaluations can take place. We're in a bizarre situation right now where people are saying "I'd rather give $20,000 a year to the insurance company for substandard coverage than $10,000 to the taxman and never have to hear the phrase 'preexisting condition' again."

That's not really rational, but the established middlemen in our current setup are quite wealthy, well-connected, and don't want alternatives to even get brought up. The stigma and knee-jerk reactions of Canadian or European style healthcare will have to get taken off the table before an honest analysis of healthcare options can come to pass. Until then, we'll keep putting band-aids on our current sytem, insurance companies will still continue being at the core of health care decisions, people will still go bankrupt due to health issues, and nothing will really change.

I think the only way to get around this issue is to tackle it one little bit at a time. There are too many vested interests that are likely to put obstacles in the way of a complete overhaul of the system. Besides I am not sure the big bang approach really would work.

My suggestion for the initial step would be to provide all American with chronic an catastrophic comprehensive health coverage. This will be paid for in the form of an insurance payment by all. Where a person can not afford it, then the government will have to foot the bill. Because this system exists all insurance companies will be required to provide coverage that is better than what the default system provides for Chronic and Catastrophic cases i.e. the deductibles will have to be adjusted as well as the Maximums.

This will release the bond/fear that we all have of not having insurance and having to go bankrupt if we have a heart attack etc.

Once the system is in place, the national insurer will be able to negotiate and rationalize the costs of the system for Chronic and Catastrophic treatments with the blessing of the insurance companies who will want to reduce these costs as it affects them too.

How we deal with the rest of the problems can flow from that point going forward.

I would love to hear what you guys think of this ?

The best introduction I know of is Arnold Kilng's "Crisis of Abundance: Rethinking How We Pay for Health Care"

We need to untie it from employment. Same with retirement. The problem is since it is part of insurance and benefits it gets all sorts of price jabbing and unbelievable waste. This was fine in the days where people stayed at a company more than 5 years but nowadays healthcare and savings all needs to be individually controlled. When that happens the customer will have more demands on the healthcare industry because we it will be pricing in the open. Right now healthcare pricing is so far from market because of the way it is setup behind employment and insurance walls.

It is amazing to me that healthcare costs this much for nothing. I haven't gotten healthcare when I needed it even having insurance because it is such a mess. We all pay way too much and we get nothing, it is a massive bubble with very minimal product.

PRIVATE FOR PROFIT HEALTHCARE IS AN OXYMORON!

As congress debates fixing Americas current private for profit healthcare disaster, global embarrassment, and national disgrace. The question is not weather we will have a public option. But rather what kind of public option we will have.

America is the only country in the developed world that has a GREED DRIVEN! PROFIT DRIVEN! IMMORAL! UNETHICAL! PRIVATE FOR PROFIT! healthcare delivery system.

As a result, hundreds of thousands of you are needlessly killed by your healthcare delivery system in America every year. And millions of you are crippled and injured. America is the only country in the developed World that does not have a NOT FOR PROFIT, PATIENT PROTECTING, government managed healthcare delivery option for all it's people.

America currently has the most costly health care system in the developed world. And the lowest quality of healthcare in the developed world. And the most dangerous, deadly, and FEARED! healthcare delivery system in the developed world.

America is the only healthcare delivery system in the developed World that does not cover all it's people automatically. And America has the most difficult healthcare system to access in the developed World.

Contact your representative and tell then that a single payer, government managed healthcare option is a must for everyone that wants it. Tell them that you demand that the public option be the finest in the World.

Tell them it should be available to everyone that wants it as a HUMAN RIGHT! Tell them it should be the easiest to access in the entire world. Tell them it should have the highest quality, with the greatest patient protections in the entire world. Tell them coverage should be automatic for everyone that wants it unless they choose to opt out. Tell them it should be the most affordable in the World. And tell them that NO ONE in the public option is to be reported to a credit agency, or driven into bankruptcy for unpaid medical bills just because they got sick, for FREEK'EN SAKES!

Tell them, none of the requirements above are negotiable. Tell them, that we are prepared to remove them from office. Tell them, we will rain down the political FIRES OF HELL! on any of them that would betray the American people. Or continue to compromise the life, health, safety, and National security of the American people for the GREED DRIVEN, PROFIT DRIVEN! private for profit Healthcare Industry.

TELL THEM NOW! AND PASS THE WORD ON.

God Bless You

Jacksmith — WORKING CLASS

Perhaps this is a useful bit of info:

The US currently spends $2.2 trillion a year on medical care, which amounts to 16% of the overall economy.

Juan Enriquez somewhat discusses this topic in his Ted 2009 talk here - http://www.ted.com/index.php/talks/juan_enriquez_shares_mindboggling_new_science.html. Start at about 4:50. Perhaps he has some good books on the topic.

Overweight & Obese Population
reveals a frighten trend we all know about. I suspect we will hear more debate about personal repsonsibility versus freedom with new laws impinging on the ability to get as fat as you want. It will look like the debate about motorcycle helmut laws

1976-1980 46% (14% obese)
1988-1994 56% (23% obese)
1997 54% (19% obese)
1998 55% (20% obese)
1999 56% (20% obese)
2001 58% (22% obese)
2002 58% (23% obese)
2003 59% (23% obese)
2004 65% (32% obese) *yes seems a big increase?
source: US National Center for Health Statistics

there seems to be a disproportionate amount of vitriol directed at the insurance industry. I am not implying the experience of dealing with private insurance is fun nor neccessarily fair. But it is not anywhere near as profitable nor nefarious as some people seem to think.

the biggest insurer in the USA is a non-profit many of you will recall - Blue Cross Blue Shield. Its goal (through cycles) is to NOT "make a profit".
the next largest nationally are Aetna, Cigna, Wellpoint and United Health. The range of pre-tax profit margins earned by these 4 over the last 5 years is 5-11% pre-tax profit margin. Thus at the high end before paying tax, they earn around 11cents on a dollar of sales (premiums).

Compare this to the 5 year range of these various well known (well respected?) companies.
McDonalds (15-26%)
Google (26-37%)
Microsoft (33-42%)
Apple (13-22)
Cisco (25-32%)
Target (6-8%)
Coke (23-29%)
Johnson & Johnson (22-27%)
Proctor Gamble (17-19%)
John Deere (10-12%)
Harley Davidson (17-26%)
Duke Energy (10-26%) is electricity any more basic.

jothocro, interesting point. i really want to learn more about the insurance piece of it. here is why: what value does this layer add at all? they spend tons of money trying to win customers, deal with claims, etc. it is a competitive business. furthermore, since they can't count on customers for life, it is less rationale to invest in long term health. i just think the whole industry does not necessarily add a lot of value. but, the alternative is government control which has its own set of issues (and is politically impossible).

other stats that might help Lew,

in 2004 the breakdown of a dollar in healthcare expenditure

Hospital Care 30 cents
Other 23 cents
Doctor Service 21 cents
Prescript Drugs 10 cents
Nursing Home 8 cents
Administration 7 cents

I assume insurance is part of "other" along with all sorts of medical technology (hips, knees, heart stents etc)

what stands out to me is the other "villain" of healthcare costs, Prescription drugs, is actually relatively small. If government cut pricing (via regulatory mandate, or by becoming single payor) to the level paid by European/Canadian systems (35-50% lower) it would barely make a dent in overall healthcare costs.

David said...
There are lots of wonderful and insightful comments and graphs regarding the healthcare crisis! More educated people = more critical thinking, that's great!!! What is really missing from the equation is a willingness for people to do work. There are plenty of queens, and not enough worker bees. Most are in it for self advancement. Patient's care seems to be far down the list of priorities. IF this was the top priority, than the other areas, like affordability, efficiencies, and cost, will fall in place. One real world example is rehabilitative therapy. This is an area where private insurers have trimmed costs, and rehabilitative therapy suffers as a result. Little is done within the healthcare profession to change the way it operates.
This is a very visible area in healthcare that gets ignored. This is because those in charge of implementing any type of reform would be only hurting their own self interested financial gains by changing a system that rewards them. If this one example shows us what is occurring, than why is any other area of healthcare (that is less visible) going to be motivated to change? I totally agree with you that it all starts with an efficient healthcare system. My experience, in working with the healthcare industry for 20+ years, is that everyone likes the idea of removing inefficiencies just as long as it is not from their area of practice. Through my own real world experiences, if something as fundamental as helping people walk again is met with much resistance, then how can the many of the unproven processes that are proposed going to be implemented? It comes down to implementation by the people willing to do work, who are already benefiting from the inefficiencies. Those people are not going to cut off the hands that pay them!