Welfare in the US

[Marston]

@Wonkish1

You really seem to love the expression briefly and succinctly, as you use it in each of your posts...
FYI: It refers to MY question, which I didn't want to expound in more detail. Got it?

Alright, so you want a detailed discussion of healthcare policy?

Not quite. Chiefly, I want to know why so many (not most) Americans have a such violent aversion to something that is not worth discussing at all in every other industrial nation.

Okay, lets start off with the fact that most Americans are fairly content with the current system since most of the premium cost is "payed" by their employer and healthcare cost is payed by an insurance company and they essentially have close to limitless demand of the highest quality drugs, procedures, doctors, etc. they want with little personal expense relative to its cost. They don't want that to change.

Second, many Americans are scared of government imposed cost containment most commonly materialized in conversations about the "waiting lines" in other countries for expensive, but often times life saving expenditures. A fear that is warranted.

Third, they have a fundamental distrust of governments ability to manage a system that is about 1/8 of our entire economy. Given the disasters of government handling many, many things in the past this to makes sense.

Fourth, they believe in competition and government removes that from the system.

Fifth, they don't want the country more "welfarized" than it already is. I.e. they think the country already has enough transfer payments going on why add more.

Sixth, current public debt totals.

First, as to the OP question, I would recommend John Kingdon's quick read: America the Unusual.  It pretty much sums up why American's, as a collective group, are generally adverse to social welfare and economic redistribution programs compared to other western industrialized nation's.

Now, onto this convoluted mess...

You state that most American's are fairly content with the current system. False. For that to be correct, there would have to be some actual sort of 'system' in place. The United States has no one such system. Rather, multiple subsystems have developed, either through market forces or the need to take care of certain population segments. The satisfaction level varies greatly from subsystem to subsystem.


I will admit that most American's (unfortunately) share your view of supporting market solutions as opposed to government intervention in health care financing and delivery. This experiment will fail us sometime in the not-so-distant future when health care spending rises to such a percentage of GDP that we are finally forced to comprehensively overhaul this "system". However, until this point, we're stuck with this quasi-market mess. Only when employee premiums reach a intolerably high rate and Medicare, Medicaid, CHIP, VA, and Military Health crowd out other needed public expenditures in the budget - only then - will something finally get done.

I feel the need to dispel some of your shameless scare tactics in regards to "cost containment" in other nation's that you claim is "warranted".

1) Dude, we already have cost containment measures in place (public and private). No other aspect of health care policy has received more attention during the past 20 years than efforts to contain increases in health care costs. Look at PPS and resource-based relative value scale for price controls in the public sphere. These have existed since the 1970's and haven't reduced beneficiary aggregate satisfaction levels. Unless you have some recent data that I have not been privy to as of yet.

2) The waiting-lines tactic is getting old. Stop cherry-picking data. Thanks.

You also claim that government intervention removes competition. Again, that would imply that there is competition in the first place. Let's not fool ourselves. The healthcare industry in this country is largely monopolized (the insurance side more so than the provider side). I could get into how government can induce competition in health care but this post is already long enough. If you want, I will expand on this in a later post.
..........

Look, I'm tired and irritable right now. So I apologize for being brash and rude and all that. I suppose I cannot fault you for believing common misconceptions but I just see the same lines trumpeted time and time again by the purist free marketers and it gets old, you know? I don't dispute the fact that most American's probably think the same way you do about this issue and so your reasoning on that front still stands. However, I will take issue when you claim these reasons as warranted and factual. Just a warning.










     

[Marston]

You must be logged in to read this quote.

We could probably find near universal agreement on the problems afflicting the U.S. health care delivery systems. It's the solutions where we might run into some disagreement, I would wager.

You must be logged in to read this quote.

In that case, I would probably wager that satisfaction varies greatly from plan-to-plan. I would suppose that an individual enrolled in a high deductible catastrophic-coverage only plan would probably have a lower level of satisfaction overall than a individual enrolled in one of those heavily lambasted "Cadillac" plans (assuming that the two individuals cited use the same array of health services). As a whole, I'll agree that many American's over-utilize their health services but I am generally wary of generalizations and the people who make them. Just saying.

I would say, however, that there has been some success controlling costs through cost-sharing (in regards to MCO's, not FFS) while maintaining good access to primary care, preventive serves, and health promotion activities. Despite anecdotes, individual perceptions, and isolated stories propagated by the news media, no comprehensive research to date has clearly demonstrated that HMO's and other MCO's have expended the quality of care delivered. Actually, the quality of care under HMO's has improved over time through early detection and treatment - which is more likely in an HMO. The pressures you cited do not lead to significant changes in physician behavior because under capitation a physician takes full responsibility for a patient's overall care. Also, HMO's and non-HMO's provide roughly equal quality of care as measured by a wide range of conditions, diseases and interventions. At the same time, HMO's lower the use of hospital and other expensive resources. Hence, medical care delivered through HMO's has been cost-effective. Of course, there has been evaluations that have indicated lower access and lower enrollee satisfaction rates for some HMO plans (particularly for-profit). So, it's a mixed bag. I'm just warning against generalizations again. HMO doesn't necessarily equal bad and unpopular. Like so many things in health care, it varies from case to case and from plan to plan.

You must be logged in to read this quote.

It was just an assumption. A pretty apt assumption at that, it seems. As per your request, the HMO Act of 1973 is a prime example. I don't know what you mean by "meaningful" exactly but it cannot be dismissed. It did, after all, kill Ted Kennedy's push for universal health care in the 1970's.

You must be logged in to read this quote.

Relatively speaking, you're right. Compared to some countries, we must look like a libertarian utopia. I just wanted to state the fact that cost-containment practices do exist in the United States.  

You must be logged in to read this quote.

Careful with the generalizations!

It really varies country to country. There aren't many "typical government run universal healthcare systems", I'm afraid. For example, Canada is primarily FFS plan so they contain costs by limiting access for non-medically necessary cases. (Incidentally, these elective cases are where most of your wait-times are seen). Germany, through the Socialized health insurance system, has more of a managed competition approach. The NHS has global budgets. Others have play-or-pay rules, employer mandates, double mandates, high risk pools, etc.

I, myself, am particularly fond of the principles of managed competition. Maybe intrigued is a better word - but that's for another post.

You must be logged in to read this quote.

I don't necessarily disagree with this assessment. In fact, it's probably more true than not.

You must be logged in to read this quote.

Ah, do we have a healthcare professional in our midst? Perhaps someone in a clinical practice profession? Nah. You seem not nearly arrogant enough. Healthcare administration? IT? Public Health?
  


 

[Marston]

First, I have to say, Wonkish, that you seem to have some semblance of understanding of healthcare policy but you kind of shoot that credibility to hell when you resort to petty name calling. That kind of stuff turns a lot of people off.

Now, onto the discussion at hand.

You must be logged in to read this quote.

Yeah, I know. We've kind of strayed off of that path a while ago, didn't we?

You must be logged in to read this quote.

First, I don't think people "shun" HMO's as much as you may think. Sure, there was a point in time (80's and 90's) where HMO's were widely but, like many things in the healthcare continuum, they evolved. Now, the HMO's I think you're talking about are the staff model types. The staff model exercises a great degree of control through paid, fixed salary physicians and control over practice patterns of their physicians. Hence, it is easier to monitor utilization. Enrollee's in this type of HMO might be somewhat upset do to their limited choice of physicians and all that. So, it's not a surprise that the number of staff model HMO's has declined over recent years.

Now, group model and network model HMO's vary in their popularity and each has its own attributes and disadvantages.

However, Independent Practice Association Model HMO's (IPA) have been very successful in terms of constituting the largest share of HMO enrollments. The IRA model provides an expanded choice of providers to the enrollees and also allows small groups and individual physicians the opportunity to participate in managed care and to get a slice of the revenues. So, you see that HMO's aren't the mean unpopular bully they're made out to be. You really have to define what type of HMO you're talking about before we can have a reasonable discussion on the merits of that model.

You must be logged in to read this quote.

 

Again, like I said, you have to specify what type of HMO you're talking about. I would probably join right alongside you in stoning to death the Staff Model HMO but I would defend IPA HMO's vigorously in terms of patient satisfaction of care and cost-effectiveness.

You must be logged in to read this quote.

What would you call it, then?

You must be logged in to read this quote.

Just so I'm clear, I will not be baited into defending 3rd-World countries healthcare systems. Corruption is rampant in many of these countries and it infects their healthcare systems to the maximum. Utilization review is not used as intended and there is a gross mismanagement of funds at the administrative levels. You cannot equate Costa Rica's healthcare system with Canada's or the United Kingdom's simply because they're government-run. That would be a big and naive mistake. I know that's not what you're trying to do. That was just a general statement on my part and why I have little to actually say in response to your statement on that.

You must be logged in to read this quote.

I think Germany' system does have its advantages, to be sure. However, it of course it not without its faults. It suffers from insufficient or inappropriate care, shrinking revenue, and an aging population - to name a few problems. I think there are certain aspects we could look at adopting from it, however.

You must be logged in to read this quote.

Ha. I admire anyone that decides to study health policy for fun. We're few and far between.

As for myself, I'm finishing up my double-majors in Health Science and Public Administration. I'm going to apply for a health education position in the Peace Corps to gain some practical experience before going for my MPP with a concentration in health policy.  

 

[Marston]

You must be logged in to read this quote.

Yeah, that's what I was referring to. It just comes off as somewhat arrogant in a sense, at least from an observer's viewpoint. Of course, we're all guilty of that kind of stuff once in a while. It's just best not to let it become habitual.

You must be logged in to read this quote.

No. I'm saying that we've crossed the line of generalizations a long time ago in this thread. For better or for worse, we've definitely strayed a long way from the OP's original question. Thus, it's kind of 'late in the game' to be still engaging in generalizations (especially when you and I decided to discuss a litany of issues pertaining to health care access and delivery domestically and abroad). I'm not sure if that makes sense. Regardless, it really doesn't matter now as long as we're not still rehashing old generalizations and stereotypes.

You must be logged in to read this quote.

Well, network model HMO's are really well suited for metropolitan area's where large group practices are located but that's besides the point. If we're to focus on staff model HMO's, I suppose you could make an argument that they are similar in some sense to national universal health insurance systems abroad but there's also some key differences. First, many staff model HMO's are really limited in terms of access. You really cannot compare on regional staff model HMO to an entire country in terms of access. That's a false comparison. I could make a case linking PPO's to some universal systems abroad but I won't because that's also a false comparison. You can find linkages between almost anything but it doesn't mean you should pursue them. HMO's are a uniquely American solution to cost-containment and utilization review issues. I don't really think they should be taken out of that context and compared to non-native health systems abroad.

You must be logged in to read this quote.

Yes, but it's market-based bureaucracy.  

You must be logged in to read this quote.

....

You know that can very well happen here, don't you? One of the few similarities between the U.S., UK, France, etc. is the fact that quality varies greatly among provider's. There are some state-of-the-art hospitals and outpatient centers in Europe. There are some really crappy ones, as well. The same applies for us here in the U.S. God knows I've told my friends and relatives which hospital I want to be taken to if I need acute care.


Look, I fear we're probably very close to going around and around in circles about HMO's and comparability and all that. So let me just say this:

The United States is plagued by two major issues: increasingly unaffordable cost of health care and a lack of insurance coverage for a relatively large segment of the population (we'll see how well the ACA does in tackling the second issue). We've been at the cutting edge of technological innovation. By affording the full cost of research and development for technology that other countries later adopt and use, we've indirectly subsidized the cost of healthcare in other countries. We also subsidize the care of a large number of illegal immigrants in the South. Other countries don't really have to contend with this - at least not at the same scale we do. Thus, I would say that any solution in the future is going to have to be uniquely suited to our problems and will probably not end of being a mirror image of Germany's system, the UK's, Canada's, etc.

I will say that universal health care remains a worthy goal but it really cannot feasibly be achieved without a massive escalation in total healthcare expenditures. Even then, universal health insurance is not necessarily equal to universal access, as you well know. If we're really going to shoot for universal coverage, we must first concurrently invest in training a multitude of primary care physicians (your gatekeepers), specialists, and nurses.

If we assume that your generalization is correct that most American's are content with their employer-based health insurance, would you be open to a pay-or-play type of system? It would, after all, be the least disruptive to the current system while expanding coverage to all segments of the population. Just curious.

[Marston]

All healthcare systems ration treatment (and not just expensive treatment), the only question is how this is done.

I agree.  This should be obvious to everyone but it seems to be beyond the comprehension of many on the right.  I have never seen any useful asset or service that is not rationed.  The notion that we don't have rationing in the US is absurd.

Really explain to me how candy and cars are "rationed" assuming you understand what the word means?

Those that can afford them get them and those that can't don't.

In more technical terms: rationed via ability to pay.

[Marston]

You must be logged in to read this quote.

Agreed.

You must be logged in to read this quote.

I was more aiming towards the fact that if you reside in a rural area, a network model wouldn't likely be of much use because most network HMO's contract with large group practices that are in traditionally located in large metropolitan area's.

I think you're trying to surgically remove HMO's from the larger context of managed care and unfairly single out and link them to non-native healthcare systems. You see, pretty much 99% of employer-based health plans operate under a managed care type of system. They pretty much all have taken "a bureaucratic approach to limiting expensive treatment". You're more prone to be aware of the Gatekeeping method traditionally used in HMO's because it requires the patient to be proactive in seeking out referrals by the primary care physician in order to gain access to higher levels of medical services.

Don't be fooled, however! Other types of managed care certainly use bureaucratic approaches that are on par or even more "intrusive" than your traditional HMO Gatekeeping method. Look at prospective utilization review, for one. Under this method, the enrollee or provider (depending on the plan and/or case) must call the plan administrators for precertification, that is, approval before certain services are provided. Most of these plans use clinical guidelines to determine the appropriateness of care.

There's also concurrent utilization reviews and retrospective utilization reviews that are widely used in managed care plans outside of HMO's. The point I'm trying to make is that managed care is bureaucratic in nature. And given that managed care has basically taken over employer-based health insurance, I would argue that it's not receiving the amount of backlash that you may think or want to think it has. Hell, I could even make a case that Medicare, which still operates mainly under the traditional fee-for-service reimbursement method, is actually less bureaucratic than your every-day managed care plan in terms of utilization review.   

You must be logged in to read this quote.

Really? I mean, Really?

So you're saying I don't have to worry too much about a proven disparity in health outcomes between, say, an average community hospital and a highly-ranked teaching hospital system like the University of Michigan? Let me tell you, if I had the ability to choose, I would take Michigan every time over the hospital that is located not 10 minutes away from me. I'm not going to argue that the NHS is perfect. But it's inappropriate to discount the fact that they've made great progress in updating their hospitals and outpatient centers since the 1990's. Also, if you're judging the quality of their "product" by way of outcome, I'm unsure how you come to your conclusion.

You must be logged in to read this quote.

You didn't.

You must be logged in to read this quote.

What I was trying to get at, in simple terms, is that if everyone is insured, we don't have the healthcare professionals in place to service the universally insured population.

You can comfort yourself all you want by claiming the U.S. has universal access (I suppose in some perverse way it does). Only about 30 states have high risk pools set-up. The ACA set up a national high-risk pool but the 80:20 coinsurance and the 125%-150% premiums above market averages severely limit the number of applicants with the ability to pay.

You must be logged in to read this quote.

I don't know. Please enlighten me.

You must be logged in to read this quote.

So, would it be safe to assume that you would perhaps prefer Singapore's system to our own?

As for play-or-pay, employers would have to provide health insurance for their employees or pay into a public health insurance program. If the employer chooses to pay, financing is through a payroll tax paid by the employer and the employee, very similar to the way Medicare and Social Security are currently handled through payroll deductions. Because the employer-based system is already in place, it would be the least disruptive to the current system, obviously.