Medicare for everyone proposed

[EMEDPA]

http://www.cnn.com/2014/07/30/opinion/das-medicare-health-care-for-all/index.html?iid=article_sidebar

 

pleasant discussion please. Discuss the merits (or problems) of the idea without name calling, etc.

[MedicinePower]

I've been interested in this for a very long time. A national Medicare plan but allowing people to buy private supplemental plans seems like a fine idea. It works very well for those over 65 and the disabled, I am always impressed with how little money collected is spent on administrative overhead, and the "no pay if readmitted for HAI" seems like a fine idea. I'd be interested in seeing implementation in small groups and going from there.

[rev ronin]

I think he misspelled 'medicaid', because that's essentially what ACA is creating...

[ventana]

my thoughts are simple

 

We have the most expensive health care system in the WORLD, yet we are essentially the bottom of the pile in the health of our citizens.  We spend to much and get to little.  Health insurance companies cost an extra 25% over medicare (their expense ratio - someone has to pay all those executives and all the 'overhead', as well as their profit)

 

>50% of the health care spending is ALREADY done by a miss mash of government programs

 

It should be a right to have basic health care - not a privilege  

 

Medicare does have some issues with fraud, but at a 2-3% expense ratio they can afford it and it is something that can be adjusted (not to throw out baby with the bath water)

 

By simply lowering the medicare age by 5 years every years you would cover the entire country with a basic health care program in about 13 years.

 

 

 

 

BUT

The health insurance industry is a HUGE money making machine, and they will spend $1 short of total bankruptcy to convince every american that a universal payer system is evil -- in spite of the facts saying the exact opposite.  And Americans (who are hung up on sound bites and immediate gratification) just listen to the advertisements and end up agreeing. 

 

 

 

So we continue with the worlds most expensive system that is essentially broke........

 

 

 

 

I liken this argument to global warming - the facts are clear - yet some people just choose to ignore them to further the profiteering motives of huge powerful companies.  

[GetMeOuttaThisMess]

^^^ While they may not make AS much as they currently do, they still have the ability to provide supplemental coverage to those who have the disposable income to pay for same (I agree that they ARE the big elephant in the room financially).  I wonder how this would affect a profession such as ours IF the reimbursement rate were to continue to fall below that of physicians and NP's (aren't the NP's getting same rate as physicians)?

[68W2PA]

Now that we have the individual and employee mandates, I wish we had the option to buy into Medicare - where anybody could pay a fixed premium and be insured through Medicare. If the premiums were set right, it wold be tax neutral. And with the lower administrative costs of the system, this "public option" would probably be able to offer coverage at a significantly cheaper rate than most existing private insurance plans.

 

This wouldn't fix everything, but I like the idea of giving people the extra freedom and choice with this option.

[ventana]

^^^ While they may not make AS much as they currently do, they still have the ability to provide supplemental coverage to those who have the disposable income to pay for same (I agree that they ARE the big elephant in the room financially).  I wonder how this would affect a profession such as ours IF the reimbursement rate were to continue to fall below that of physicians and NP's (aren't the NP's getting same rate as physicians)?

 

I don't think it will effect me at all, in fact if it did it would give me a raise as they are realizing the value of primary care.

 

I 100% agree that the insurance companies will have to switch to a supplemental program for all - just like they do for medicare patients now - and this is a great thing. It allows those that want to pay a lot for extra insurance to do so and we still have some "free market" but at the same time everyone is insured.  in my practice Medicare rates are fine, and all the other "private" insurance companies only wanted to pay me a 10% premium - which I flatly declined as they are such PIA to deal with for all their forms and prior auths...... all of which is geared towards saving THEM money, and wasting MY time.  

 

So a single payer system with the insurance companies doing various levels of supplemental insurance is the answer in my mind (oh yeah and about every other 1rst world county!)

[GetMeOuttaThisMess]

I don't think it will effect me at all, in fact if it did it would give me a raise as they are realizing the value of primary care.

 

I 100% agree that the insurance companies will have to switch to a supplemental program for all - just like they do for medicare patients now - and this is a great thing. It allows those that want to pay a lot for extra insurance to do so and we still have some "free market" but at the same time everyone is insured.  in my practice Medicare rates are fine, and all the other "private" insurance companies only wanted to pay me a 10% premium - which I flatly declined as they are such PIA to deal with for all their forms and prior auths...... all of which is geared towards saving THEM money, and wasting MY time.  

 

So a single payer system with the insurance companies doing various levels of supplemental insurance is the answer in my mind (oh yeah and about every other 1rst world county!)

I had forgotten the previous discussion with regard to peace of mind having a financial cost with regard to not having to deal with private insurers.  Good point.

[UpRegulated]

I've been interested in this for a very long time. A national Medicare plan but allowing people to buy private supplemental plans seems like a fine idea. It works very well for those over 65 and the disabled, I am always impressed with how little money collected is spent on administrative overhead, and the "no pay if readmitted for HAI" seems like a fine idea. I'd be interested in seeing implementation in small groups and going from there.

 

Then you will still have a two-tiered system - those with Medicare and the "wealthy" who can afford to add private supplemental, which would become yet another political wedge.

[UpRegulated]

my thoughts are simple

 

We have the most expensive health care system in the WORLD, yet we are essentially the bottom of the pile in the health of our citizens. So we continue with the worlds most expensive system that is essentially broke........

 

 

 

 

I liken this argument to global warming - the facts are clear - yet some people just choose to ignore them to further the profiteering motives of huge powerful companies.  

 

As for having the most expensive system in the world.  Our expense is higher because of the widespread use of technology in healthcare and the high salaries of health care providers compared to other countries.  Which of those are you willing to reduce and to what degree?  

 

 

As for being "the bottom of the pile," among industrialized nations -- we have among the highest percentages of minorities of all industrialized nations.  Health disparities among minorities are well-documented, and many have little to nothing to do with either a lack of insurance or a lack of access.  Also, an often cited statistic is infant death rates and low-weight births. Many countries count their rates differently than we do.  See also point #1.  Finally, if healthcare is so poor here, then why do we lead the world with medical and pharmacological innovation, and why do so many from single-payer countries come here to receive their care?

 

Lastly, on global warming (what that has to do with anything I'm not sure).  Maybe you are more well-versed on the matter than me, if so, perhaps you can tell me why temperatures have remained flat or even cooled over the last 15 years, despite 15 years of increased CO2 emissions.  Perhaps you can explain why a few years back NASA was caught red-handed placing temperature probes in the hottest places they can find (e.g. on airport tarmacs, on roof tops, etc.).  Perhaps you can explain the well-documented fact that climate researcher after climate researcher has been caught fudging data.

[UpRegulated]

So a single payer system with the insurance companies doing various levels of supplemental insurance is the answer in my mind (oh yeah and about every other 1rst world county!)

 

Most 1st world countries DO NOT have a single payer system.

[GetMeOuttaThisMess]

Most single payer systems as I recall from a Morgan Spurlock story involve much smaller countries/population bases making such an option financially viable (nordic countries).  Canada would be an exception to this.

[68W2PA]

Most single payer systems as I recall from a Morgan Spurlock story involve much smaller countries/population bases making such an option financially viable (nordic countries).  Canada would be an exception to this.

 

I don't see how having a small country would necessarily make having a single payer system more affordable in terms of per capita spending. If anything, the smaller the country, the lower the aggregate risk pool, the higher the necessary per capita costs.

Inversely, the larger the society, the higher the aggregate risk pool, which when coupled with the higher monopsonistic bargaining power, would probably yield even lower per capita costs.

[EMEDPA]

As for having the most expensive system in the world.  Our expense is higher because of the widespread use of technology in healthcare and the high salaries of health care providers compared to other countries.  Which of those are you willing to reduce and to what degree?  

 

I'm ok with less utilization of technology. right now CTs and MRIs are significantly over utilized. not every knee strain needs an mri. not every bump on the head needs a head CT .Last time I checked the city of Monteral , Canada had 2 CT scanners and 1 mri for the entire city. my local mcdonalds has more than that here....:)

The entire country of Haiti has 2 CT scanners and no MRI for 9 million people. The CTs pretty much run 24/7 but surgeons and other clinicians have relearned the clinical skills many of us have forgotten and are willing to say "this is probably appendicitis, I will operate" or " this probably isn't lets watch and wait". Health care in the US was pretty good before 1975 with less technology....

the PCPs need to take back management of common presentations of diseases that are often now managed by specialists. 

[GetMeOuttaThisMess]

More affluent, smaller population based countries w/o diversification of population and inherent variability of diseases (unlike US). Back to my McD's diet 24/7.

[gbrothers98]

Most 1st world countries DO NOT have a single payer system.

True.

Dont confuse single payer with universal coverage, they are different.

Most countries that provide health care coverage do so through a variety of levies and taxes along with administration by various local, state and federal entities.

While there is a federal medicare system in place in the US, the larger system is state run medicaid which is then greatly overshadowed by private insurers broken down along state, regional and employer lines. 

This herd of cats along with the corporate and specialty interests abundant in this country will place significant obstacles in the way. The reality of pivoting a trillion dollar monster and the displacement of associated jobs including some whom contribute to this forum cannot be ignored. We are in the midst of slow grinding change whose result will be seen and felt decades from now. The system will never be to the whole satisfaction of everyone involved but it will overall improve on what currently exists. 

Involvement of PA specialty, state and national organizations is needed now more than ever. A perfect example is the treatment of PAs as compared to NPs in the language of the ACA concerning EMR implementation and meaningful use leading to improved reimbursement. PAs should not have been excluded and how this was missed on a national level is beyond me. 

Regards

G Brothers PA-C

[UpRegulated]

I'm ok with less utilization of technology. right now CTs and MRIs are significantly over utilized. not every knee strain needs an mri. not every bump on the head needs a head CT .Last time I checked the city of Monteral , Canada had 2 CT scanners and 1 mri for the entire city. my local mcdonalds has more than that here....:)

The entire country of Haiti has 2 CT scanners and no MRI for 9 million people. The CTs pretty much run 24/7 but surgeons and other clinicians have relearned the clinical skills many of us have forgotten and are willing to say "this is probably appendicitis, I will operate" or " this probably isn't lets watch and wait". Health care in the US was pretty good before 1975 with less technology....

the PCPs need to take back management of common presentations of diseases that are often now managed by specialists. 

 

Not sure if I would be touting Haiti as a model. ;)

 

But I largely agree.  Many things, however, contribute to the per capita spending on health care in this country.  Use of technology (and overuse), highest salaries of health care workers of any industrialized nation (PA's and NP's make more here than MD's do in many countries), a large and rapidly growing minority population, heavy ED utilization (by the insured and uninsured alike), poorer lifestyle habits (obesity esp, poor diets, tobacco, etc.), a ridiculous malpractice system, and layer after layer of red tape from Medicare, Medicaid, JCAHO, state health departments, EMTALA, and innumerable legislative and regulatory acts layered on top of one another by the federal and state governments.

 

99% of what I described above would not be solved by a single payer system.  The idea that private insurance causes high health insurance costs is a total myth. Do you know what the average profit margin is for major insurance companies?  4%.  Those greedy, evil, private insurers are really cashing in, huh? Fix what I mention above and health care costs would be halved.

[EMEDPA]

I agree Haiti is not a model of efficiency. Turkey is actually pretty good. They have a system where you work your way up from village clinicians to local clinic to community hospital to regional medical ctr so the folks who get to the big ctrs have already been through a few layers of primary care and specialists and really need to be there.

We have a lot of smokers, a lot of obese citizens(now 66% of the US adult population), and a lot of issues related to being a developed nation that are not seen in other nations to the same extent.technology has planted many folks in comfy chairs all day long at work or on their couches at home. I would be surprised if the average american between 18-50 could run a 15 min mile without becoming short of breath. we are a nation of fat slobs.

we hop in our cars to go a mile to the mini-mart. There are certainly many issues at play.

[GetMeOuttaThisMess]

Good, I'm over fifty and excluded. "Honey, could you pull into In/Out for me? I'll take a side of atorvastatin with that, please."

 

OK, in interest of full disclosure, BMI is 27.

[EMEDPA]

Good, I'm over fifty and excluded. "Honey, could you pull into In/Out for me? I'll take a side of atorvastatin with that, please." OK, in interest of full disclosure, BMI is 27.

I'm at 22.5, the same as the day I graduated high school. highest ever was 25.8.

at 17 it was easy. I ate anything I wanted, at 30 a bit harder. now in my mid-40s it is a lot of work and self denial. no seconds at dinner. rare deserts. salad or a side not salad and a side.

I let myself go a bit on vacation and usually gain 5 lbs in a week on vacation but have it off a week later. I skip a lot of lunches and snack a lot on small things like fruit and trail mix.

[GetMeOuttaThisMess]

I will probably drop off 10 pounds, hopefully fairly quickly, once I unglue my bottom from the sofa and get back into the game. Psychological stress of dealing with others needs doesn't help..

[EMEDPA]

I will probably drop off 10 pounds, hopefully fairly quickly, once I unglue my bottom from the sofa and get back into the game. Psychological stress of dealing with others needs doesn't help..

I'm sure you can do it. when I was at my heaviest it was because I was working 220 hrs+/mo at 3 jobs and was associate chief of a community emergency dept. I was always either working or in meetings. I never exercised. I ate like crap. pictures of me taken during that time don't look anything like I look today. some of my long time friends don't even recognize those pix as me as all the extra weight seems to migrate to my face....:)

one of the wake up calls for me was almost being denied life insurance due to cholesterol issues...(now normal with exercise, weight loss, and lots of supplements).

[MedicinePower]

Then you will still have a two-tiered system - those with Medicare and the "wealthy" who can afford to add private supplemental, which would become yet another political wedge.

 

Sorry, I think I wasn't clear when I presented my position. I would like to see a system where the existing Medicare Advantage/Medi-Gap coverage could be bought by anyone. Many people go with Original Medicare, others go with Medicare Advantage, and some go with Medigap. Advantage and Medigap are private plans that cover a bit more than Original Medicare. There are not presently two-tiers (rich vs poor) in Medicare as some of the Advantage plans have a $0 premium (you get more but have a smaller network and have to ask for authorization). If you don't like it then the next year you can switch out during the open enrollment period.

 

I think extending this to the entire US populace is a fine idea.

[gbrothers98]

Not sure if I would be touting Haiti as a model. ;)

 

But I largely agree.  Many things, however, contribute to the per capita spending on health care in this country.  Use of technology (and overuse), highest salaries of health care workers of any industrialized nation (PA's and NP's make more here than MD's do in many countries), a large and rapidly growing minority population, heavy ED utilization (by the insured and uninsured alike), poorer lifestyle habits (obesity esp, poor diets, tobacco, etc.), a ridiculous malpractice system, and layer after layer of red tape from Medicare, Medicaid, JCAHO, state health departments, EMTALA, and innumerable legislative and regulatory acts layered on top of one another by the federal and state governments.

 

99% of what I described above would not be solved by a single payer system.  The idea that private insurance causes high health insurance costs is a total myth. Do you know what the average profit margin is for major insurance companies?  4%.  Those greedy, evil, private insurers are really cashing in, huh? Fix what I mention above and health care costs would be halved.

Technology adds to the spending due to overutilization but also to over demand. I have many patients that wont accept my clinical explanations and reasons on why not to scan and test. We are a nation of doubters and conspiracy theorists. Our overwhelming sense of entitlement contributes to this also.

Given that many healthcare providers are leveraged with student loans and mortgages and have to bear a certain level of living expenses along with more robust contributions to their retirement accounts due to the lack of provided retirement, a certain minimum salary is needed. Comparison to another country cant be done. I would trade for a state sponsored education and pension, decent public transportation, and reasonable living costs in exchange for my education loan payments, a 20 mile round trip work commute and a mortgage in a tenuous but expensive real estate market.

Not really sure if a minority population increases costs. Illegal immigrants seeking better opportunities than available in their home country who dont have access to health insurance may be a better description.

I do think ED utilization is starting to revert. Cost sharing with new insurances is becoming the norm. That sprained ankle that prompted the ED visit that resulted in a $100 copay with another few hundred to cost share will cause one to hesitate the next time the community gets hit with a URI epidemic. Go argue with your PCP about the need for a zpak next time.

That we are fat and lazy is a no brainer. But we encourage a culture of ease and physical comfort. This is a difficult tidal wave to outswim.

Since I have never had to encounter the malpractice system, I actually have a rather benign view of this. It seems that there are geographical areas of this country that greatly contribute to the perception of malpractice being the monster it is.

Agency and legislative red tape do add to costs but at the heart of these are some well meaning intent. Anyone that has had to argue with a specialist about a critical patient can see why EMTALA is a no brainer.

While insurance companies may make a small percentage profit, if the revenue of the 5 largest insurance companies in a year is over 3 billion, doesnt that 4% add up to a rather large amount of money?

Which brings up the real issue. Exactly why do we need health insurance companies? It seems that the original idea was predicated upon if a subscriber was to suffer a catastrophic illness or injury whose costs would outstrip any ability to pay. Then this morphed into simply a better payment intermediary. Rather than writing the check to your dr, the insurance company did. Companies would provide health insurance as a recruiting and retention tool. Now it is an expense that most cannot afford to provide anymore. In the interim, the insurance companies increased staff, increased technology, increased compensation and increased infrastructure to support the payment for a service that should be a function of humanitarian society rather than a revenue stream.

But we are a country of middle men. We get the bulk of our goods and services not from the source but rather from the entities that coordinate and distribute them. We just keep adding layers of complexity to an already complex system wether it be health care, investing, buying our food or our cars and houses.

G Brothers PA-C

[Gordon, PA-C]

If single payer Medicare comes to America, MDs, PAs, and NPs are going to take a HUGE pay cut.

 

Single payer government can set the reimbursement rates by fiat and give providers a "take it or leave it" middle finger.

 

The government would have a lot more pricing power than blue cross/blue shield would.  

 

It's not an accident that providers in single payer countries get paid a lot less than american providers.