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About that "World's Best Healthcare System" the U.S. is supposed to have...

CHDeac said:
Theres a lot of opinions on this thread and I applaud you becoming more informed on the system. Ive enjoyed reading some of what you've posted.

I've dedicated 20+ years of my professional and academic life to making the system better. I've worked with CCIO and CMS on cost control demonstration efforts. I've worked with HHS and implementing various aspects of reform from Clinton through Obama. I've worked on the front lines enrolling Medicaid dual eligibles. I've worked with the state of NC and CCNC on developing an improved and efficient Medicaid system. I have the opportunity to work and negotiate with provider systems, ACOs and PBMs. I've worked on creating tools to identify cost/quality metrics to help manage network costs. I work with large employers trying to control their medical spend. I wish I could simply "link" to these experiences and how things really work but I can't. I don't spend a few hours reading about the system on a blog. I work in it 60 hrs a week trying to make it better. You can accept that or ignore it but don't act as if Im uninformed or simply pushing a personal agenda. I'm not.

And I don't disagree its broken. Special interests on all sides (from pharma to AARP) have sway in the process. The whole system is broken, from medicaid to medicare to the unacceptable # of uninsured we have. And based on my experiences, its incredibly naieve to think this country could easily adopt single payer as the panacea. Politics, culture and economics are highly intertwined in this. To suggest otherwise is misguided IMHO.
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All the wisdom and experience you've acquired wasn't necessary to write off a single payer system as impossible simply because of vague "politics" and "economics". America is America, we all get it, that doesn't mean things can't change. The private health care insurance industry is a divisive blight on our society, and its existence only serves our capitalistic pride.
 
CHDeac said:
Theres a lot of opinions on this thread and I applaud you becoming more informed on the system. Ive enjoyed reading some of what you've posted.

I've dedicated 20+ years of my professional and academic life to making the system better. I've worked with CCIO and CMS on cost control demonstration efforts. I've worked with HHS and implementing various aspects of reform from Clinton through Obama. I've worked on the front lines enrolling Medicaid dual eligibles. I've worked with the state of NC and CCNC on developing an improved and efficient Medicaid system. I have the opportunity to work and negotiate with provider systems, ACOs and PBMs. I've worked on creating tools to identify cost/quality metrics to help manage network costs. I work with large employers trying to control their medical spend. I wish I could simply "link" to these experiences and how things really work but I can't. I don't spend a few hours reading about the system on a blog. I work in it 60 hrs a week trying to make it better. You can accept that or ignore it but don't act as if Im uninformed or simply pushing a personal agenda. I'm not.

And I don't disagree its broken. Special interests on all sides (from pharma to AARP) have sway in the process. The whole system is broken, from medicaid to medicare to the unacceptable # of uninsured we have. And based on my experiences, its incredibly naieve to think this country could easily adopt single payer as the panacea. Politics, culture and economics are highly intertwined in this. To suggest otherwise is misguided IMHO.
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Whateve...like you know what you're talking about...
 
CHDeac said:
Theres a lot of opinions on this thread and I applaud you becoming more informed on the system. Ive enjoyed reading some of what you've posted.

I've dedicated 20+ years of my professional and academic life to making the system better. I've worked with CCIO and CMS on cost control demonstration efforts. I've worked with HHS and implementing various aspects of reform from Clinton through Obama. I've worked on the front lines enrolling Medicaid dual eligibles. I've worked with the state of NC and CCNC on developing an improved and efficient Medicaid system. I have the opportunity to work and negotiate with provider systems, ACOs and PBMs. I've worked on creating tools to identify cost/quality metrics to help manage network costs. I work with large employers trying to control their medical spend. I wish I could simply "link" to these experiences and how things really work but I can't. I don't spend a few hours reading about the system on a blog. I work in it 60 hrs a week trying to make it better. You can accept that or ignore it but don't act as if Im uninformed or simply pushing a personal agenda. I'm not.

And I don't disagree its broken. Special interests on all sides (from pharma to AARP) have sway in the process. The whole system is broken, from medicaid to medicare to the unacceptable # of uninsured we have. And based on my experiences, its incredibly naieve to think this country could easily adopt single payer as the panacea. Politics, culture and economics are highly intertwined in this. To suggest otherwise is misguided IMHO.
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You and I probably agree on more than we disagree. We both agree the current system is broken, and we both agree that Obamacare is a bad idea that will make the current system more broken. I appreciate the conversation.

Respectfully, I think you should consider whether your long experience in the industry has induced a bit of "Stockholm syndrome" or just made it hard for you to imagine the possibilities of radical change. My overall point, as you understand, is not that we should import the British system or the Canadian system or the Austrian system, but that we should try to craft a single-payer system that works for America. I agree that will be very, very hard. In fact, I am not sure that it can be done until we do something to fix the very serious problems we have with our overall electoral system, primarily the extreme gerrymandering of Congress and the extreme influence of monied interests in our politics. Because the simple fact is the only way to get our health cost-to-benefit ratio down to international norms is for a lot of very rich influential people to make a lot less money.

Perhaps where we disagree is the idea that moving toward a more "free market" approach to healthcare will achieve that goal. I just don't think there's anything in the historical record or my personal experience with healthcare that supports the idea that a reasonably well-functioning market can ever happen in healthcare. the knowledge gaps between supplier and consumer are too big to be bridged, especially when the conditions creating the need for the services - sickness and injury - inherently erode the decision-making skills of the customer and his/her family. The serious inefficiencies in the market mean that more "market freedom" is primarily going to result in more profits for suppliers.

The only way for that not to be the case is to reduce utilization by customers - which translates to rationing care based on who can afford it, i.e. more of what we have now. The studies I have cited indicate that in some ways, Americans already utilize services less than some other countries - we see the doctor less, we spend less time in the hospital. Reducing cost by reducing utilization is not a step in the right direction. We need to reduce the cost of the utilization.
 
Deacon923 said:
You and I probably agree on more than we disagree. We both agree the current system is broken, and we both agree that Obamacare is a bad idea that will make the current system more broken. I appreciate the conversation.

Respectfully, I think you should consider whether your long experience in the industry has induced a bit of "Stockholm syndrome" or just made it hard for you to imagine the possibilities of radical change. My overall point, as you understand, is not that we should import the British system or the Canadian system or the Austrian system, but that we should try to craft a single-payer system that works for America. I agree that will be very, very hard. In fact, I am not sure that it can be done until we do something to fix the very serious problems we have with our overall electoral system, primarily the extreme gerrymandering of Congress and the extreme influence of monied interests in our politics. Because the simple fact is the only way to get our health cost-to-benefit ratio down to international norms is for a lot of very rich influential people to make a lot less money.

Perhaps where we disagree is the idea that moving toward a more "free market" approach to healthcare will achieve that goal. I just don't think there's anything in the historical record or my personal experience with healthcare that supports the idea that a reasonably well-functioning market can ever happen in healthcare. the knowledge gaps between supplier and consumer are too big to be bridged, especially when the conditions creating the need for the services - sickness and injury - inherently erode the decision-making skills of the customer and his/her family. The serious inefficiencies in the market mean that more "market freedom" is primarily going to result in more profits for suppliers.

The only way for that not to be the case is to reduce utilization by customers - which translates to rationing care based on who can afford it, i.e. more of what we have now. The studies I have cited indicate that in some ways, Americans already utilize services less than some other countries - we see the doctor less, we spend less time in the hospital. Reducing cost by reducing utilization is not a step in the right direction. We need to reduce the cost of the utilization.
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a-0102.jpg
 
Deacon923 said:
You and I probably agree on more than we disagree. We both agree the current system is broken, and we both agree that Obamacare is a bad idea that will make the current system more broken. I appreciate the conversation.

Respectfully, I think you should consider whether your long experience in the industry has induced a bit of "Stockholm syndrome" or just made it hard for you to imagine the possibilities of radical change. My overall point, as you understand, is not that we should import the British system or the Canadian system or the Austrian system, but that we should try to craft a single-payer system that works for America. I agree that will be very, very hard. In fact, I am not sure that it can be done until we do something to fix the very serious problems we have with our overall electoral system, primarily the extreme gerrymandering of Congress and the extreme influence of monied interests in our politics. Because the simple fact is the only way to get our health cost-to-benefit ratio down to international norms is for a lot of very rich influential people to make a lot less money.

Perhaps where we disagree is the idea that moving toward a more "free market" approach to healthcare will achieve that goal. I just don't think there's anything in the historical record or my personal experience with healthcare that supports the idea that a reasonably well-functioning market can ever happen in healthcare. the knowledge gaps between supplier and consumer are too big to be bridged, especially when the conditions creating the need for the services - sickness and injury - inherently erode the decision-making skills of the customer and his/her family. The serious inefficiencies in the market mean that more "market freedom" is primarily going to result in more profits for suppliers.

The only way for that not to be the case is to reduce utilization by customers - which translates to rationing care based on who can afford it, i.e. more of what we have now. The studies I have cited indicate that in some ways, Americans already utilize services less than some other countries - we see the doctor less, we spend less time in the hospital. Reducing cost by reducing utilization is not a step in the right direction. We need to reduce the cost of the utilization.
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Good post. My beef is that there is a lot of misinformed hyperbole on this thread posted out of idealogical populism rather than on how the system works or you know, good old facts.

I agree we have a cost issue but I think its more than just a per unit cost issue. Medical trend in the US historically is driven by a lot of discretionary care, not to mention an aging population that simply needs/wants more care. We need to control both. I love the notion posted here by someone who yells at insurers for controlling utilization yet pushes for single payer. Um, you do know how single payer works right?

I also agree we need innovation. I think you tackle it from a supply side, Id argue we need it from a supply & demand side. I think the american health care consumer, is part of the problem. One small example: We've seen countless cases of "I need my brand since the generic don't work" gibberish.

I think we agree there's no change single payer could pass or even work in the US given our history. Think about it. We passed reform largely on the promise of "if you like your doc/plan you can keep your doc/plan". Many of us knew this was a huge distortion and it hit the fan last fall. Can you imagine if we actually did have that sort of change?

Last, I can't let the stockholm syndrome question go ignored. Sure, we all have our institutional biases. No doubt. I work with people who still think the ACA will get repealed. But I also work more people who understand the system and have great ideas on how to fill some of the chasms you refer to…Cost quality treatment tools that let you research alternatives from your phone. Telemedicine that allows docs to do "real" physicals hundreds of miles away using incredible (and cheap) technology. Innovative models that pay docs for doing outcomes cheaply. Incredibly predicative modeling that allows us to help guide interventions before they are even needed. We may win the war incrementally and without a whole sale system change. At some point we will have to as the feds (and consumers/employers) won't be able to continue to afford to finance our health care (as a side note, the average ACA premium gets a 75% tax subsidy and that will only go up as trend grows faster than wages).

I suppose I hold out hope in the market since I have such little faith in how the feds manage health care, based on what Ive seen over the past 20 years and in particular over the past 5. Its been that bad IMHO. And sure the Pubs have been obstacles but the deems and regulators have done this so poorly and with such little expertise. Hobby Lobby is a great example of this, but thats a post for another day.
 
bobknightfan said:
Thanks for posting.

This is just one more example....out of millions....documenting how screwed up our healthcare system is in this country today. It is a bureaucratic mess.
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Did you happen to read anything else on that site? Interesting stuff about personal liberty, health care and role of gov't in messing it all up (not an endorsement just a summary).
 
Thanks for that post. Appreciate your experience.

I will mention a couple things. First, one of your paragraphs seems to indicate that you don't think people could choose their doc in a single payer system. This is untrue in most countries. In most single payer systems like France and Canada you choose your own primary care doc that is your medical home. I don't know the extent you are allowed to choose a specialist. Maybe bad can weigh in on the Austrian model.

Utilization is an interesting thing. The data is scanty, but I think there is reason to believe that our system encourages over utilization of the wrong things (name brand drugs, end of life desperate measures, elective surgery) but rations good things (like primary care and hospital stays) in the name of cost control. It appears that some single payer systems control cost by restricting the former and encouraging the latter. Again, it is undeniable that these systems do a better job on cost control.
 
I don't get how anyone thinks ACA will get repealed and not be vetoed. Obama would certainly veto any repeal. Hillary wouldn't allow it to happen.
 
Deacon923 said:
Thanks for that post. Appreciate your experience.

I will mention a couple things. First, one of your paragraphs seems to indicate that you don't think people could choose their doc in a single payer system. This is untrue in most countries. In most single payer systems like France and Canada you choose your own primary care doc that is your medical home. I don't know the extent you are allowed to choose a specialist. Maybe bad can weigh in on the Austrian model.

Utilization is an interesting thing. The data is scanty, but I think there is reason to believe that our system encourages over utilization of the wrong things (name brand drugs, end of life desperate measures, elective surgery) but rations good things (like primary care and hospital stays) in the name of cost control. It appears that some single payer systems control cost by restricting the former and encouraging the latter. Again, it is undeniable that these systems do a better job on cost control.
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Not making any specific suggestions here. Just calling out that we as Americans love our health care our way. Obamacare was sold on this. Single payer, in a broader sense, could completely hinder this.

The irony is managed care did the opposite (lots of PCP access, limited access to specialists) yet was villified...
 
olddke said:
I am sure this will really help things if it stands. http://www.cnn.com/2014/07/22/politics/obamacare-subsidy-ruling/index.html?hpt=hp_t1
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This in all reality could kill Obamacare. Without subsidies the law is completely dead. In order to change the law (and this allow subsidies to be granted to federal exchange enrollees) it will have to pass through the House. The law pretty clearly states that subsidies come for those enrolled in the state exchanges (at least that is what I have seen - perhaps someone else can shed some light on that). So it would be a huge over reach for the judicial branch to essentially change the law (even if it seems like a common sense solution).
 
I couldn't really glean this from the CNN article, but is this just an oversight in the wording of the ACA?
 
TownieDeac said:
A lot of good insurance, health care, and outcomes discussion the past couple pages.

I wanted to bump the thread this morning because there's a bill that's going to go in front of Congress early next week from Senator Harkin, the chair of the Appropriations subcommittee, about funding biomedical research.

The association I work for has a lobbying arm in Washington that sent this email out to the board of directors, heads of cancer centers around the country.



Essentially, this is the fight faced when trying to get more NIH money. You gotta try to get bipartisan support, and it typically means cutting from other programs.

Biomed research means funding cures and creating jobs, that should be both parties' line.
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If you had not sent me all those nasty, foul-mouthed negreps I would probably let this go, but as it is I have to ask what is wrong with your lobbyists? If they are having trouble turning a claim to be doing "biomedical research" into a big Washington, D.C. cash payday they need your help, Townie. Are they sleeping with the right people? Who exactly have they been paying off? Get it in the game, Townie! Go to Washington; suck somebody's dick.
 
DeacinBama said:
I couldn't really glean this from the CNN article, but is this just an oversight in the wording of the ACA?
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I think it was an intentional move in order to 'force' states that might be hesitant to set up exchanges to set them up. So it wasn't an oversight it seems strategic. Unfortunately (or fortunately depending on your political lean) this move has been countermoved and it seems as though unless the courts overstep their limits, this could be a major problem for Obamacare. I don't think this is something that Obama can presidentially override, although if he can I am sure he will. That may be what the pubs are baiting him to do anyway.
 
If that's the case, then that's a horrible gamble, particularly if the law already permitted the establishment of the federal exchange.

I'd still appreciate some input from our local law scholars. I imagine that intent matters here to some degree, even if the text of the law is incomplete or inexact.
 
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