Not really Lloyd, it is a lot of work and not much fun at all to argue endlessly for something as fundamentally right and necessary as universal health care only to be stymied by public apathy and the enormous lobbying ability of the corporations that control this issue.

You can cop out and think that you are letting “Washington” decide this but it is the electorate that ultimately allows the industry to maintain this control and the electorate is us.

It would be interesting to see how well a public option competed with a private one. I would fully support such a plan if we could ensure a fair fight between the two but I’m not sure how such a thing could be done. Would you support an apples to apples, no holds barred cage match that pitted my private systems reforms against your public system reforms? (We could never do this but what’s the harm in theorizing, right?)

Here are the rules I’d propose to make this a fair fight.

1.) IF an employer pays for their employees healthcare that healthcare is taxed at the normal income tax rate. (Meaning Employers would have to declare exactly how much they pay out in health benefits per employee. In this way the level and cost of service becomes a negotiating point for both parties and the state is provided additional money for the under-priveledged’s vouchers.)

2.) IF an employer does choose to pay for healthcare, while their employees will have that healthcare taxed as income, they would be able to deduct the cost of that healthcare (along with the entire wage paid to said employee) from their quarterly tax bill.

3.) IF an employee chooses not to take the company plan (in which case employers should be expected to pay out the sum that would be spent on their health insurance, or if no company plan is offered employers would still be required to help facilitate withholdings that could be directed to the plan of the employee’s choice.

4.) Any out of pocket money spent on healthcare (copays, hospital visits, monthly premiums would be tax deductible.

5.) Employees would be able to choose between any insurance carrier in the country including any state’s public plan.

6.) Both private and public plans must be funded in the same way (on premiums) though those premiums may be paid by needs based state vouchers.

7.) The federal government can not interfere by creating a plan of its own or attempting to regulate any state’s private or public plans.

8.) States can not use their powers of regulation to impede the private plans and any regulation on said plans would apply to the public plans as well.

In the Right Corner we have the For Profit Private Plans that market directly to the consumer and are no longer able to hide their costs or their profits. They must stand on their own and face the pressures of competition from by consumers that are no longer in a captive market because they can shop outside of their state.

In the Left Corner we have the Not For Profit Public Plans that also market directly to the consumer and must compete with the private plans as well as other state’s plans (should they wish to offer them). They cannot dip into the public coffers to more service at a lower rate because that would be breaking the rules set above.

The contest is to see who can best provide the service, education and care necessary for a healthy populace at the most affordable price. The winner will be the consumer.

Sound like fun Ron? Frankly I wouldn’t care who won the battle. If the public plans were required to be self sufficient, I might even find myself rooting for (and buying from) them. I just want a fair fight and I want apples to apples benchmarks. If they can assure us of that I;d buy in. Unfortunately all our reasonable discussions are for nought because Washington is about ready to decide all this for us. Oh well. It was a fun mental excercise.

I would say that I would not advise something less than a single payor system but I would support a public option that competed directly with private insurance if that is what it takes to convince people that profit driven insurance is more costly. I believe that this is a back door approach and it will prolong the inevitable because it will soon be obvious that this is the most cost effective solution.

Conservatives wonder where the money will come from. I am an administrator in a business that pays 100% of the costs of it’s employees health care. For twenty employees that is $320,000 in premiums and HSA contributions plus short and long term disability insurance, FICA, and workers comp insurance. That is an enormous pool of money for such a small number of relatively healthy employees and their families. In addition to that cost, our business and my employees pay taxes that support the current government contribution to health care payments. I haven’t taken the time to determine what the total sum that my business and my employees ultimately contribute but you can see that it is substantial. That is where the money would come from. Since, as a nation, we pay over 16% of GDP for health care, the money is already there. The problem isn’t where the money will come from but how the money is spent.

If you read my comments to DTM earlier, you can see that in the case of workers comp, much of the waste is in denial of treatment, delay of care, unnecessary litigation, and lost productivity. That is only one small segment of the problem. The original post here about direct marketing by pharmaceutical companies points out another area where marketing trumps reason and science and increses the cost of care without commensurate benefit. With the private insurers, the most costly problem is that they pass risk to the government programs and allow the costs of uninsured care and inadequately reimbursed public care to be cost shifted in the Hospitals and passed on to the employer based programs and private policies. They allow this because it forces more money to be funneled through them and their income is derived from that flow of money. The more that comes in and the less that goes out the more they profit. That is why they have shown little interest to date in tracking the outcomes of care and why they tend to favor payment for costly intervention rather than cost effective prevention. This cost is an enormous hidden tax on all of us.

If your interest lies in quarterly profits derived from the health care industry as it exists today then you would want to maintain the status quo. If you are fiscally conservative and believe that universal access to health care is a long term benefit to society and the costs of the system should be commensurate with the value derived from it then you would ultimately support a single payor system. Based on the experience of all of the other industrialized economies and even some of the less industrialized ones, it is clear that we can offer universal coverage with better outcomes for much less than the cost of the current system. If we are content to continue to spend over 16% GDP then we can be the envy of the world and make everybody happy in the long run.

The compromises that I think are sensible and desirable are that the Doctors, manufacturers of devices and drugs, and hospitals should all remain privately held and should compete amongst themselves based on quality and cost. I would also have the pools of money used to pay for health care managed individually by the States so that there continues to be competition for quality on the payment end. I believe that it would be unwise to allow such an enormous pool of money to be managed by a single entity like the Federal Government. It is always a risk to put such power in the hands of a small central group. Federal mandates regarding the scope of care and the standardization of payment processes and reciprocal agreements between the States would be good but one big pool of money wouldn’t.

Over 70% of Americans want serious reform in this system. You really have to ask yourself who benefits from the current system. It is obviously not the majority of Americans.

I do not believe that a public option that included a broad risk pool would need to reimburse at a rate less than what the private plans pay now.

I saw a patient in the clinic today. He was a young Canadian man in his late 20’s. He suffered a herniated disc in a work comp injury. His injury was denied by the work comp insurance carrier and he was forced to get an attorney to fight it. He was fired by his employer because of this injury. This does not relieve the work comp carrier of the ultimate responsibility of paying for his care but that won’t be known for a couple of years because it will ultimately be decided by an administrative law judge. It does send the message though to other employees to think twice before filing a work comp claim. In the mean time, he was bankrupted by the loss of his job so his care is being paid for by the taxpayer through Medicaid. This is an example of how an insurer can deny treatment and place the ultimate risk on the taxpayer. Many people don’t have the energy to fight this and just give in.

If this man’s injury did not threaten his employer or if there was not an adversarial relationship between the insurance carrier and the patient he would be back to light duty by now and back to full employment in a month or two. Because of the delays related to the insurance companies denial and because his employer fired him; preusumably to send a shot across the bow to other employees who might file a claim, society will pay the costs of his care and his unnecessarily protracted time off work. Several years from now some of the lost income and the cost of the care may be recouped by the patient and the taxpayer when this case is heard by an administrative law judge, but only after the lawyers on both sides get their share. This is an extremely inefficient and costly way to practice medicine.

Another interesting point is that he has weakness and numbness in his leg that may be permanent now but may well have been prevented if he had not been forced to wait over a month for treatment by an employer and an insurance company that denied treatment to prevent short term cost and thereby probably contributed to long term nerve damage. This is why it is unlikely that a single payor system would deny or underpay for proper treatment because the loss of productivity and the loss of function by the worker is more costly in the long run than the cost of surgery and rehab.

Finally, as I mentioned, he grew up in Canada. He just wants to get back to work and is completely baffled about how an illness put him into financial despair. He said that he is one of five kids and that he does not recall a single time in his childhood that his family had a concern about health care. He said that in the few years that he has lived here he hasn’t needed health care so he never gave it a thought here until he herniated that disc. Now one relatively simple medical problem has lead to this. I asked him which system he preferred and he just laughed.

I am sorry if this sounds concocted. This all happened today.

One clarifying question — will the public plan impose any restrictions whatsoever on the deliver of care? For example, if, as a doctor, I realized that patients covered by the public plan were causing my practice to operate at a loss, could I stop seeing them? Or would I be mandated to accept them?

As I’ve stated, I’m not sold on the single payer system and I think it’s going to be a terribly hard sell to get it implemented in the forseeable future. There is always the chance but we will likely just be given another porky bandaid plan that will allow everyone in washington to go home and say they did something.

My question is whether you would support anything short of a single payer system. Be it the success of the left’s efforts to educate us all on the greed and corruption of major corporations or my own ability to reason it out on my own, I’m convinced that the current system is “rigged” against the people that need it. I get it. I’m on board for cutting the bastards down to size. (We really do agree on that, don’t we?)

With that said, I realize that those bastards (as greedy as they are) already have the knowledge and infrastructure to deliver healthcare to everyone and even with a full government take over (which no reasonable person is really advocating) they are still going to be involved because of it. Sure they may have more rules to make them accountable to the taxpayer or something but they really aren’t going to change who they are or what they are. Their money has secured them power and their power will protect their money.

Would a fair compromise to a single payer plan not be to remove all the protections that these major companies enjoy? At one point, you almost seemed to agree that the collusion between employers and insurers has more to do with rising costs and lousy service than most anything else. Would it not be a fair compromise to provide tax deductions to families that buy their own insurance and tax credits to those that can’t afford them. The same federal witholding standards could make this easier and it would spur a whole host of new industries designed to deliver care. (Kind of like green jobs for healthcare.) I don’t like the idea of providing tax credits or stipends because there is a tremendous opportunity for fraud and abuse but the fact remains that stuff happens and we you cant remove a safety net for the jumpers without also removing it for the fallers.

Furthermore, if as you suggested earlier, this was done at a state level where the blend of deduction and credit was closer to the people, wouldn’t it be more responsive to the needs of the people it was intended to serve than if it were run federally?

I ask this because I know I’m not gonna get a system where everybody takes care of themselves and they leave me the hell alone. I dont even want a system like and even if I did, that isn’t what are government was designed to do. I’m wondering, if the event that you aren’t able to get would you want (cradle grave coverage under a centrally managed single payer system) would you be willing to ever meet somewhere in the middle - and where would that middle be?