Public health care

[Storebought]

I've been thinking about what a public health system that didn't rely on any kind of nationalized health insurance, paid for by some new payroll tax, would look like.

Suppose, instead of some nationalized health care, we have locally-funded emergency care only, in which we treat ambulance service and the emergency wards of hospitals like a local public service, such as a police or fire department.

All of the residents living within the closest approach to an emergency wing would pay property and/or sales tax for the upkeep of the day-to-day costs of catastrophic health care; the going rates can be obtained from local insurance policies (which, necessarily, will no longer offer catastrophic coverage)

For nonresident consumers of emergency services, the patient will be charged the hospital's sales tax on his bill.

I will be the first to admit that this is, well, still half-baked. But I wanted to start a debate on this topic that didn't fall into the typical "single-payer" sloganeering that has poisoned the older threads.

[○∙◄☻¥tπ[╪AV┼cVê└]

The problem is that different places would have different levels of funding. Long Island has some very poor school districts right next to some very rich school districts. It would make more sense to have the funding not be so local. Also, property and sales taxes are rather regressive.

It is important to note that the primary reason why emergency room visits are so expensive for patients is that they have to treat everyone, even people who can't pay. Obviously a universal health care system would make that system be less crazy.

[Tetro Kornbluth]

The problem is that different places would have different levels of funding. Long Island has some very poor school districts right next to some very rich school districts. It would make more sense to have the funding not be so local. Also, property and sales taxes are rather regressive.

It is important to note that the primary reason why emergency room visits are so expensive for patients is that they have to treat everyone, even people who can't pay. Obviously a universal health care system would make that system be less crazy.

That would depend on what sort of system you wish to apply.

Btw the Irish experience has shown that a singular health bureocracy based (usually) around the main city is generally not really a very good idea (though it should pointed out that this is a relatively recent issue; Ireland was much more decentralized until recently in towards health) and this is in of course a country much smaller than many US states.

I quite like Storebought's idea actually (well the first half of it; also there needs to be some sort of cross-ward insurance for travellers, people moving, etc). But I would extremely doubt it's feasability. It must be said here that Health is not my major political issue though.

[Bono]

Not a good idea, especially if it doesnt allow for competing private sector. As any other state company, it's prone to inneficiency.

[Storebought]

The problem is that different places would have different levels of funding. Long Island has some very poor school districts right next to some very rich school districts. It would make more sense to have the funding not be so local. Also, property and sales taxes are rather regressive.

It is important to note that the primary reason why emergency room visits are so expensive for patients is that they have to treat everyone, even people who can't pay. Obviously a universal health care system would make that system be less crazy.

In my own plan, I insist on sales and property taxes because even transients pay them, unlike income tax. Since accidents are statistically speaking just as likely to strike them as lifelong residents, it doesn't seem quite fair that residents pay all of the hospital operating costs for emergency care though local income tax.

Yes, hospital emergency wings are required by federal law to admit patients regardless of their ability to pay. And for truly indigent ... well, society already pays for them, badly, today. I am pretty convinced that we will never recover payment from them under any plan. They are a permanent loss.

I wanted my plan to reduce some of the overhead (and then some) that the hospital charges for the patients that can pay, whether insured or not.

[Storebought]

Not a good idea, especially if it doesnt allow for competing private sector. As any other state company, it's prone to inneficiency.

That' just it: my *plan* only applies to ambulance service and emergency wings of hospitals -- in other words, public health. In no way does it apply to clinics (which are private institutions) or to long-term care, etc.

But I'd certainly like to hear alternatives that are based around localities/communities.

[opebo]

Why on earth cover only emergency room care?  What a waste.  Provide a full health package that keeps the people as healthy as possible and you reduce the expensive emergency room visits.  Mainly poor people need regular doctors visits, and treatment and medications for chronic ailments.

[Bono]

Not a good idea, especially if it doesnt allow for competing private sector. As any other state company, it's prone to inneficiency.

That' just it: my *plan* only applies to ambulance service and emergency wings of hospitals -- in other words, public health. In no way does it apply to clinics (which are private institutions) or to long-term care, etc.

But I'd certainly like to hear alternatives that are based around localities/communities.

So, you want the parts that need more efficiency--those where care must be delivered in an error free and precise way, to be the most inneficient, and to have no private competition whatsoever?

[Ebowed]

As any other state company, it's prone to inneficiency.

Agreed.  We should privatize libraries, fire stations, and the military.

Otherwise there wouldn't be any private sector competition, and that just kills a good economy

[opebo]

'Public' bureaucracy is often just as efficient as 'private' business.

[Ebowed]

'Public' bureaucracy is often just as efficient as 'private' business.

If not more so, since private business puts its own profits far ahead of the welfare of the patient.

[John Dibble]

'Public' bureaucracy is often just as efficient as 'private' business.

If not more so, since private business puts its own profits far ahead of the welfare of the patient.

The reverse of that is politicians often put their own personal interests (political profit, etc.) ahead of the welfare of their constituency (the patient in this case), which makes the public system more inefficient. I'm not saying there's no validity to your point, but that those who would be running a public system wouldn't always be philanthropists.

[opebo]

I meant more in a structural sense.  I think the emphasis placed on 'incentive' in selling us on the design of institutions/organizations in capitalist society is really over done. 

In fact what motivates most people in an organization is 1) security and 2) fear (of getting fired/caught/yelled at).  Very few people in even a 'private' organization have significant opportunities for financial gain.  No, the cogs in the machine, whether nominally 'public' or 'private' - are kept in line with a combination of penal threats and 'assurational' security - alas in our particular society mostly the former and very little of the latter.

Anyway the point of this is that the balance is a bit better in a government bureaucracy - the cogs have more security and a little more defense against abuse.  Contrary to capitalist rhetoric this means they are enormously happier.. whether this translates into better functioning of the organization I don't know.  But in neither case does incentive in the sense of irregular or performance-based reward above salary have much to do with said better functioning.

Of course the big argument in favour of 'private' incentive is innovation..  but what we demand from most of the institutions that make up our health-care system is care, and in fact care of a rather basic nature.  Housing people, giving them already-designed treatments, drugs, cleaning them, etc.  Yes, the doctor on the ground has to diagnose, but I would still argue that this is a more bureaucratic function than entreprenourial.  As Ebowed points out the profit motive can be counterproductive in basic care situations - I shudder to think that the persons caring for me in my old age and/or infirmity will be motivated by reducing costs. 

It seems to me that the only areas in which the 'profit' motive might lead to a better functioning of the health care system would be development of new drugs and treatments. 

[Bono]

What you're neglecting is that in a market where there is free competition, the consumer is free to penalize bad services by simply going somewhere else, whereas there is an incentive to provide good care. In a government monopoly, there is no incentive whatsoever since the patient has no alternatives, the only incentive is to perform a bad service so there will be problems and funding will be increased.

[opebo]

What you're neglecting is that in a market where there is free competition, the consumer is free to penalize bad services by simply going somewhere else, whereas there is an incentive to provide good care. In a government monopoly, there is no incentive whatsoever since the patient has no alternatives, the only incentive is to perform a bad service so there will be problems and funding will be increased.

And I'm afraid what you're neglecting is that fifty percent of americans cannot afford any health care, and thus are not 'free to penalize bad services by simply going somewhere else'. 

The government 'monopoly' will provide better service than the the 'private' one does, for the very large number of people who get no service at all currently.

[Gabu]

What you're neglecting is that in a market where there is free competition, the consumer is free to penalize bad services by simply going somewhere else, whereas there is an incentive to provide good care. In a government monopoly, there is no incentive whatsoever since the patient has no alternatives, the only incentive is to perform a bad service so there will be problems and funding will be increased.

Only thing is this: what of the people who couldn't afford what the private providers were charging?  While the free market might provide competition, one thing that it doesn't do, and was never intended to do, is to provide goods or services to those without adequate money for them.  The free market might maximize financial utility of consumers and producers, but that's as far as it goes.  If a company's main goal is to turn a profit, which is the goal of all private for-profit companies that sell a product, what possible incentive would they have to provide their service to everyone?

From just about everything I've seen, people's arguments in favor of a public health care system have less to do with how well the system runs and have more to do with the idea that health care is a right that everyone in the entire country should have access to, whether or not they're capable of paying what a private company would charge.  As such, what you're arguing is largely irrelevant, even if it's true.

[Јas]

What you're neglecting is that in a market where there is free competition, the consumer is free to penalize bad services by simply going somewhere else, whereas there is an incentive to provide good care.

Though, in this scenario, many consumers won't be able to penalize bad services because they can't financially afford to do so.

In a government monopoly, there is no incentive whatsoever since the patient has no alternatives, the only incentive is to perform a bad service so there will be problems and funding will be increased.

Even if there may be no significant financial incentive to provide good health care, there are surely other incentives at play to provide such health care depending on who exactly in the system one is considering.

[David S]

The fundamental problem with health care in America is that its too expensive. Even huge companies like GM are struggling under the weight of health care costs for employees and retirees. The reason it is so expensive is that it doesn't operate as a competitive free market. Fix that problem and the costs will come down by themselves. Then it will be more affordable for everyone.

[opebo]

The fundamental problem with health care in America is that its too expensive. Even huge companies like GM are struggling under the weight of health care costs for employees and retirees. The reason it is so expensive is that it doesn't operate as a competitive free market. Fix that problem and the costs will come down by themselves. Then it will be more affordable for everyone.

Is that really the reason?  It is the sort of thing that is just not going to be all  that cheap, given the training and technology involved.  I suspect the main reason it costs a lot in the US is patent enforcement.

[David S]

The fundamental problem with health care in America is that its too expensive. Even huge companies like GM are struggling under the weight of health care costs for employees and retirees. The reason it is so expensive is that it doesn't operate as a competitive free market. Fix that problem and the costs will come down by themselves. Then it will be more affordable for everyone.

Is that really the reason?  It is the sort of thing that is just not going to be all  that cheap, given the training and technology involved.  I suspect the main reason it costs a lot in the US is patent enforcement.

There are a few areas of medical care which still operate as a competitive free market. In those areas costs are reasonable or even decreasing. Vision correction surgery is not usually covered by insurance or Medicare so it still operates as a free market. 20 years ago that process cost about $3000 per eye, but today it is frequently advertised for less than $1000 per eye. I understand breast augmentation has undergone a similar price reduction. (You should appreciate that    )

Over the counter drugs are another example. Walk into any drugstore and you see a wide assortment of products for various conditions. Competitive products are displayed side by side with prices shown. And they are all relatively inexpensive. Want pain relievers? If Tylenol is too expensive how about Advil instead? And if that's still too costly how about aspirin? And if Bayer is too much you can buy the generic brand dirt cheap. The thing is that customers can make cost comparisons and pick whatever meets their need and fits their budget. If the manufacturers want to sell their product they must offer it at a competitive price or customers will buy something else. Competition drives low prices. It really works.

[opebo]

The fundamental problem with health care in America is that its too expensive. Even huge companies like GM are struggling under the weight of health care costs for employees and retirees. The reason it is so expensive is that it doesn't operate as a competitive free market. Fix that problem and the costs will come down by themselves. Then it will be more affordable for everyone.

Is that really the reason?  It is the sort of thing that is just not going to be all  that cheap, given the training and technology involved.  I suspect the main reason it costs a lot in the US is patent enforcement.

There are a few areas of medical care which still operate as a competitive free market. In those areas costs are reasonable or even decreasing. Vision correction surgery is not usually covered by insurance or Medicare so it still operates as a free market. 20 years ago that process cost about $3000 per eye, but today it is frequently advertised for less than $1000 per eye. I understand breast augmentation has undergone a similar price reduction. (You should appreciate that    )

Over the counter drugs are another example. Walk into any drugstore and you see a wide assortment of products for various conditions. Competitive products are displayed side by side with prices shown. And they are all relatively inexpensive. Want pain relievers? If Tylenol is too expensive how about Advil instead? And if that's still too costly how about aspirin? And if Bayer is too much you can buy the generic brand dirt cheap. The thing is that customers can make cost comparisons and pick whatever meets their need and fits their budget. If the manufacturers want to sell their product they must offer it at a competitive price or customers will buy something else. Competition drives low prices. It really works.

Yeah, like I said  about the patents.

[David S]

The fundamental problem with health care in America is that its too expensive. Even huge companies like GM are struggling under the weight of health care costs for employees and retirees. The reason it is so expensive is that it doesn't operate as a competitive free market. Fix that problem and the costs will come down by themselves. Then it will be more affordable for everyone.

Is that really the reason?  It is the sort of thing that is just not going to be all  that cheap, given the training and technology involved.  I suspect the main reason it costs a lot in the US is patent enforcement.

There are a few areas of medical care which still operate as a competitive free market. In those areas costs are reasonable or even decreasing. Vision correction surgery is not usually covered by insurance or Medicare so it still operates as a free market. 20 years ago that process cost about $3000 per eye, but today it is frequently advertised for less than $1000 per eye. I understand breast augmentation has undergone a similar price reduction. (You should appreciate that    )

Over the counter drugs are another example. Walk into any drugstore and you see a wide assortment of products for various conditions. Competitive products are displayed side by side with prices shown. And they are all relatively inexpensive. Want pain relievers? If Tylenol is too expensive how about Advil instead? And if that's still too costly how about aspirin? And if Bayer is too much you can buy the generic brand dirt cheap. The thing is that customers can make cost comparisons and pick whatever meets their need and fits their budget. If the manufacturers want to sell their product they must offer it at a competitive price or customers will buy something else. Competition drives low prices. It really works.

Yeah, like I said  about the patents.

I'm not sure if you're trying to make a serious point or just being Opebo.

[opebo]

Yeah, obviously the point was that the US legal system imposes a monopoly which creates extremely expensive drugs.  As you pointed out generic drugs - those upon which patents have expired or never existed - are very cheap.  Of course 'drug development' may cost money, and a system may be required to fund this... but the general point that patents greatly increase costs is a valid one.

[David S]

It can cost as much as a billion dollars to get a drug through the FDA approval process. R & D adds even more to that cost. For a drug company to remain solvent they must be able to recover that cost through sales revenue. Without patent laws a competitor could reverse engineer a drug, and make a knockoff product without having to spend all the development money. They could then sell it for far less than the original product. That's a formula for bankruptcy for the company that developed the drug. Without patent protection drug companies would not develop new drugs.

Rather than eliminate patent rights, a better solution for government might be to streamline the approval process so it doesn't cost so much to get a drug approved. The high development cost is also discouraging pharmaceuticals from developing drugs for rare diseases because they know there are not enough potential customers to recoup the costs.

[opebo]

Rather than eliminate patent rights, a better solution for government might be to streamline the approval process so it doesn't cost so much to get a drug approved.

Is it really necessary to use poor people as guinea pigs just to save a few bucks?