Yes, I know you guys like the phrase. Go ahead, I'll indulge you for a moment - just roll it around in your mouth and taste its sweetness. Horror buffs among you may it aloud a time or two if you like, just to feel the eerie, goosebump-raising chill it sends into your marrow. You can say it in conjunction with "Democrats" or "Obama" if you like, and surrender yourself to the sweetness of the electoral hell-raising you can do with this nuclear option of political discourse. I wouldn't recommend saying it more than a couple of times, though - you might be too distracted to pay attention to the rest of this little screed.

The question will be at the end, but first a little exposition. I'm not sure whether you are aware of the fact, but there is already a form of socialized medicine in the United States. No, I don't mean that everyone has health insurance, heavens no. What I mean is that for those who don't, there are still hospital bills to be paid, bills those people usually can't pay, and the buck has to stop somewhere. Currently, that "somewhere" is, indirectly, at your wallet.

When an uninsured person shows up at an emergency department, there is no option for the hospital - that hospital is obligated to treat the patient as long as the personnel and equipment on-site is adequate for the task. The hospital generates a bill, er...bill and charges just as it would for any patient who actually had insurance. For most of us, these bills go first to the insurance company so that somebody in a cubicle can work on ways to avoid paying for what the company promised you it would, at least until four o'clock - because that's time for happy hour, when he can drink his conscience into submission and show up the next morning for another go at it. For the uninsured person, this bill goes directly to their home address.

Now, the Venn diagram depicting uninsured people and people without enough money to pay the bill for even a minor hospital intervention has some pretty significant overlap. In fact, the first group almost fits within the second. So is that bill going to get paid? Hell's bells, no. And, as disappointed as I know you are about the fact, debtor's prisons are not as widely employed in such circumstances as was once the case. So what happens? The hospital eats the cost.

I can tell your sympathy for the hospitals is not necessarily stimulating your lacrimal glands at the moment. Well, a while back the federal government decided it was a bit unfair to simply mandate that hospitals give care to those who couldn't pay for it, so it reimburses hospitals that treat significant numbers of uninsured patients for their expenses. And that money comes from whatever Uncle Sam can dig out from under fingernails bloodied by clawing at your paycheck.

I've got your (admittedly limited) attention now, I can see. Good. The problem with this setup is that care of uninsured people in the ED is by nature inefficient use of health care money. People who do not have insurance do not go to their primary doctor for the preventive care that might help them avoid a major illness (that pesky "no money" thing again); the result is that uninsured patients are, on average, sicker when they arrive at the ED, because they tried to tough it out at home eating Mom's chicken soup, using leeches...oops, I mean leeches, sacrificing goats, or whatever other home remedy they have heard of. Correspondingly, their care more often requires hospitalization and more intensive treatments, and it is therefore more expensive. And much of it might have been prevented in the first place had there been affordable primary care available to them.

So for any good conservatives out there, this surely should raise your hackles a little bit, shouldn't it? I mean, the Republican Party is the party of fiscal responsibility, efficiency, and all that, right? If you're going to be on the hook paying for these mouth-breathers, don't you at least want to know that it is being done with the absolute minimum amount of money necessary?

Well, I've been procrastinating on my long-promised Sawbones Plan for Awesome New healthKare, but I'll lift my skirt and show a little leg for a second here. Eliminate the middleman. Insurance companies, I mean. Take the money that has been deducted from your paycheck for healthcare premiums, and send it directly to the Medicare budget, where it will be spent more efficiently than in any HMO. The money saved in administrative costs and decreased hospital days, treatments, etc. will help to defray the extra cost of covering the uninsured, and the feds will be able to use their negotiating power to contain costs better than HMOs could anyway. It's not the full fix, but it's a start. You still get to go to your same doctor, you won't pay more money, and the healthcare you receive won't be compromised. The only extra cost I can see would be the alcohol subsidy we would have to pay the insurance guy in the cubicle when he transitions from drinking because he screwed everyone else over to drinking because everyone else returned the favor.

How about it, true-believer conservatives? Socialized medicine, and it hardly has to make you feel icky at all. At least, any ickier than you usually feel at being confined on this planet with the rest of us.

sawbones:

didn't someone think of that one already? And didn't the Chamber of Commerce, employers, insurance companies, Reagan dems, and fiscally responsible repubs nix it? And didn't the AMA modify their position on it? And didn't much of Congress and others fear-monger amongst the constituency to create an atmosphere of lost benefits and freedom? And wasn't much of this insurance cost covered by a lower employer based contribution than what exists today?

We played politics with it and here we sit today free in our own laissez faire environment, free to make a choice of having insurance or not having insurance. It is agreat country.

For the record, the contributions in this country by gov and incurance companies for heathcare cost are evenly split with the remainder cost of 16-17% being "out-of-pocket" or your premiums and deductibles. Not many believe the gov has such a huge part in healthcare costs already.

run75441:

sawbones:

didn't someone think of that one already? And didn't the Chamber of Commerce, employers, insurance companies, Reagan dems, and fiscally responsible repubs nix it? And didn't the AMA modify their position on it? And didn't much of Congress and others fear-monger amongst the constituency to create an atmosphere of lost benefits and freedom? And wasn't much of this insurance cost covered by a lower employer based contribution than what exists today?

We played politics with it and here we sit today free in our own laissez faire environment, free to make a choice of having insurance or not having insurance. It is agreat country.

For the record, the contributions in this country by gov and incurance companies for heathcare cost are evenly split with the remainder cost of 16-17% being "out-of-pocket" or your premiums and deductibles. Not many believe the gov has such a huge part in healthcare costs already.

yep.

This particular idea hasn't been floated, as far as I know. There is no doubt that various entrenched interest groups instinctively resist any reform of our medical system, but previous approaches to the subject have been severely wanting. HMOs were a nice thought, but really little more than Neosporin on a sucking chest wound. The healthcare proposal floated during the Clinton administration was simply birthed upon the public, like Athena from the mind of Zeus - hardly a surprise that those threatened by a change in power dynamics would resist it. But time is our ally as well as our enemy on this issue. Sometimes in medicine, a diagnosis is not immediately evident from the facts available; in those instances, we typically try to exclude by testing or empirically treat the most serious and immediate threats to life, buying us time to look deeper. And sometimes it is only by the passing of a half hour, a few hours, or a few days that enough symptoms present to make the answer clear. I think that time may finally be making obvious to a sufficient number of people that our medical system is in need of something more than "take two of these and call me in the morning."

I think the ideal would be to create a national health care system in one fell swoop, but the system of government we have does not lend itself to rapid, radical change (a feature that has been to our advantage in countless situations). I have vacillated in recent years between believing that we should follow a British model of governmental change (consulting and co-opting the various power-holders involved to arrive at an incremental change that is at least somewhat tolerable to all) and a less cooperative model. But I fear that we may be approaching a point of real collapse very soon, so I lean increasingly toward the second option: pick them off one at a time. With this proposal, isolate and wipe out the insurance companies. Big Pharma, the AMA, and the trial lawyers will have their day as well. One thing at a time.

Sawbones:

and help kill it in the end because they were sold a bill of goods as to its effectiveness. I think we are in agreement as to what is needed in the end; but, we came very close in 1992 and two years later, it was dead.

The WSJ did a survey in the nineties as to Universal Healthcare. It achieved a 70% approval rating. One you tied a name to the very same plan, it dropped to 40%. While the support for the plan failed, it was still more positive than any other plan. We were in the hay-day of the "laissez faire" philosophy as sold to us by Reagan and supported by Greenspin. 16 years later and the market place still has not come to the table with a solution. Although today, I buy my own major-medical at $126/month with a 70-30 coverage, discounted medicines, and a $1000 deductible (BCBS).

There was a 500 person project team that developed the plan and it passed from congressional committee to committee. Packwood, Dole, Cooper, Wellstone, Chafee, Kennedy, Moynihan, Mitchell, Breaux were all involved in it. If the Senate had 10 more Dems in it, it would have passed. The public never got to see a fair review of it as it was poisoned by Congress. Financing would have come from the same contibutions by Employers (50%) plus contributions from Employees, a tax on cigs, and a tax on high end healthcare plans. It would have covered 240% of poverty (SCHIP - sound familar?) in each state free of charge. All children and those in poverty would have been covered.

I assume you have a distaste for attorneys, well join the club as mine comes from 1 attorney who I will see get sentenced to prison. And I assume you would envision some type of assisted care and/or nursing care to be free of charge for those suffering from malpractice as a $250,000 cap would not cover life time care.

We do need to do something soon along similar lines.

Start by making Medicare available to anyone that can pay the premium. Since its a group rate, it will attract everyone that's currently paying for individual health insurance, which is way more expensive.

One great way to get such a program going would be to offer seniors a 100% coverage option for which they would pay an additional premium out of their SS. It would end up being less than what they currently pay for supplemental-Medicare insurance.

If the Medicare system was offered to anybody that could pay the group rate it would attract many of the working uninsured, who could afford a group policy, but are currently unaffiliated with a group.

It's selling the plan, in the face of concerted and well-funded opposition (including a lucrative industry you propose eliminating) that's the tricky part. It they spent 100 million in 1993 to defeat it, what do you think they'd spend now?

I hope the next president, and a favorable congress, can do the job this time.

1. Medicare and Medicaid today offer patently inadequate coverage. (Virtually no doctors in Alaska will take new Medicare patients.) To achieve your desired level of preventive care, the coverage, hence the costs, would have to be significantly expanded. Moreover, the Medicare/Medicaid eligibility rules would have to be completely rewritten. This would be a political renegotiation on the order of the creation of the World Trade Organization--and it is to be done by that collection of clowns we fondly call the U.S. Congress, who haven't made a hard decision since maybe 1985?

2. Private insurance company assets would have to be purchased by the United States, which is, after all, impairing existing contract rights and condemning a private market that has existed for well over a century. This would be how many hundreds of billions, or trillions, of dollars? The ensuing litigation would keep the trial lawyers happy for at least a few decades.

3. The biggest problem with your proposal is that it ignores the demographic driver of the health care crisis: the relentless aging of the population, pushing health care demand up and at the same time undercutting productivity (which has to support health care) down. Improvements in efficiency can do only so much to counteract this.

The ultimate question is one of allocation: how much for whom? Now, we let an unregulated price mechanism, haphazardly and half-heartedly offset by public subsidies, decide that. Only a paradigm shift will allow us to address that question forthrightly: Baby Samantha lives, because she's an investment in our future. Grandpa Ed dies, because he's had eighty-five years and won't live more than another year no matter what we do. It sounds cold, but our present system is just as heartless; it merely uses rhetoric and other cosmetics to hide the fact that there is help for some and not for others.

In the US, 12.6% of the population is older than age 65. That ranks us 37th in the world - a much smaller percentage than many other industrialized countries, all of whom spend substantially less on health care per citizen than the US. Our median age, 36.6, is relatively low as well. By the same token, our life expectancy doesn't rank all that well either, compared to other industrialized countries (either from birth, or healthy life expectancy) - nor does our infant mortality rate.

Health care dollars are already being allocated - they're just being allocated inefficiently and inequitably.

It's not like we don't have models from other countries we can learn from, as well as models of US government-provided health care (VA hospital system - which fares much better than is often believed, Medicaid - which actually still works pretty well, Fritz, and Medicare, which is already in need of overhaul).

You are right about that difficult transition, however, but it's not like we really do have to put insurance out of business - not if we provide a base level of coverage (which could be privatized, actually), with supplemental policies available (such as in Canada).

It's attainable, provided sufficient political capital. And will.

Bust all the HMOs under the RICO Act, confiscate all assets, take control.

HMOs were formed by criminal conspiracy. In 1973, Kaiser Permanente approached Bob Haldeman, Nixon's right hand man, offered him a bribe, sold him on a scheme to defraud medical consumers by restricting access to medical care and choice, and by denial of claims for spurious reasons.

Industrialist Edgar J Kaiser established the precursor to HMOs to cover workers at the Grand Coulee Dam, and later warship workers, and it worked so well at minimizing costs (to the detriment of those "covered") that when a suitably corrupt government came along, he pushed it as a national plan, and Voila!, HMOs.

Better, Nixon framed it as "socialized medicine", thus convincing Ted Kennedy to champion it, a move Kennedy has regretted ever since. Nixon didn't come upon his nick "Tricky Dicky" by happenstance.

I think the criminal conspiracy which established HMOs as a cancerous blight upon your great nation falls well under RICO jurisdiction.

This post is not entirely tongue-in-cheek; just a little, given revealed fact (google the Nixon/Haldeman HMO phone transcripts. They are decipherable with just a little practice.)

LOL! Oh Poor old Tricky Dick. He gets blamd for everything. But, your historical background regarding Kaiser and The Grand Coolee Dam workers is so true. And HMO's have been more of a curse than a blessing in so many ways in the ensuing years.

I'll give this top post a thumbs up too just for bringing a very important issue to the fore. However there is so much there to take issue with in it and against it's suggestions, but, I see several posters already have.

Suffice it to say I too think we are moving towards a popular view towards Socialized System and I know you love yours in Canada, Dr. No, and believe it's nothing but a blessing.

I agree we need to get everyone covered in America.
but one very imporatant facor that always gets lost in this argument and it is this:

The 37Th rating among all the rest of the countries in the world, is not a rating regarding' quality of care'. It is a rating that refects the fact that so many people are left out of the system or forced to utilize services that are sub quality in nature due to lack of funding,in impoverished areas of the country.

Because the USA rates on top as far as Quality Care,as does France.

The 37th rating takes into account those left out of the system and therefore have to rely on sub-quality services, like walk-in clinics in poor areas or no services at all.

But for those with means the USA has the best in quality health care.

The richest people in Europe and from all third world countries around the globe come here to get care when they have a catastrophic illness.

This is the place to get the best possible Health/Medical/Surgical/Oncolo­­gy Care on this earth.That's the misnomer that gets lost in this argument.

The reason the USA has the best quality care(if one can afford access to it) is precisely because we currently do not have a Socialized System of Medicine.

We live in a Capitalistic Competitive for Quality Service Country where say if a Cardiologist is brilliant at his craft,.. here, in America the sky is the limit as far as how much money he can make and charge for his service in his own private practice.

This competitive nature of the system is what contnues to keep America on the cutting edge of being the country with the great innovative nature to compete, to rise to be the best, in whatever field of endeavor one chooses.

As much as it is clear we must do something about the serious problems with the HMO's and the lack of quality health care availability for all, it is also clear we shouldn't want to lose that competitive edge..

We might consider that if went strictly to a completely socialized system we do risk certainly losing our competative cutting edge on excellence.

All of life is a trade-off of sorts..but be careful what you wish for at times,too.

We don't want to lose what's best about America as we move for new and sweeping changes to a flawed current system.

The one thing curiously that I liked about Obama and his plans was that his Health Care proposal is not a total mandated Health Care Plan.

His does leave some wiggle room to work out plans for individual choce. And that is very important,imho.

I just believed that Hillary was more competent to get at least some sort of plan up and operating as she has already been through the crucible of trying to get through that muck and red tape before. She knows the pitfalls and blocks she is facing.

At the end of the day, because of the many issues cited in these threads none of this will come fast or easy. But it's really important to never lose sight of what makes America strong and unique as we try and find our way through the byzantine road to providing Health Care for all without losing that competitive aspect of the health care system.

That's what I was referring to when I mentioned the British model. For most of the major reforms I've read about over there, the limeys seem to take pains to get all of the stakeholders involved early and give them a chance to get their say on the matter. In this instance, that means the doctors and nurses, the drug companies, the HMOs/hospitals, the trial lawyers, and the insurance companies. It doesn't make for quick policy fixes, and it certainly doesn't lend itself to ideal solutions, but it maximizes your chance of getting everyone on board for at least an incremental improvement. Over time, if you string together enough increments, you get to where you wanted to be in the first place. I think if the Clintons had done more of this when crafting the health care proposal, they would have had a better chance of passage; instead, they presented it fully formed, and the stakeholders revolted. I believe it was the insurance companies who came up with the "Frank and Doris" (or whatever the actual names were) ads that started turning public sentiment against the plan. That's why I think co-optation and cooperation is better for this kind of thing in general, because it only takes one motivated stakeholder to shout the right buzzwords and make the public lose confidence.

Ultimately, it doesn't matter, because that reform didn't really address some of the biggest cost drivers in medicine. I wouldn't mind seeing the next president give Hillary another swing at it, because we are approaching the time when solutions will be forced on us instead of chosen. And the solutions in moments like those are never pleasant or ideal.

For the record, I don't really have any distaste for attorneys, as my mother, father and brother are all lawyers - the only family I know where I could be the black sheep by becoming a doctor. But that doesn't make them any less fun to rip on.

I didn't envision this as a general fix, merely as a logical first step that would only piss off one of the major heavyweights involved in the equation. The insurance companies were in the vanguard of defeating the proposal fifteen years ago, but they were only successful because the other interest groups - doctors, pharmaceutical companies, etc. - either quietly agreed with them or offered no public support of the plan. You're right that Medicare/Medicaid as currently formulated would not be acceptable to most doctors as a universal payor - you would have to adjust payment schedules, etc. to make treating Medicare patients somewhat better financially - but it wouldn't increase costs as much as you might think. Don't underestimate the amount of time and personnel involved in jumping through the various hoops that insurance companies erect for doctors wanting reimbursement. If each office no longer has to have one or two employees for the sole purpose of chasing insurance reimbursements, that frees up quite a bit of money and makes the increase in payments necessary quite a bit smaller.

You're also right about the legal aspect of driving an entire industry out of business. To be honest, I'm not sure how to get around this, but the reality is that we will do so someday by one route or another. We will eventually reach a fork in this road at which the healthcare system will either be subsumed into the federal government, or it will splinter and crumble, leaving behind a system of allopathic care for a small slice of the population with a lot of money, and faith healers for everybody else.

As for the aging population as a cost driver, you are partially correct; but as FB pointed out, other countries are managing this without bankrupting themselves. And this is in large part due to that dirty little concept of restrictions. If you have centralized authority, you have the ability to assert that you're not going to cover a medication that costs twice as much for only a 10% improvement in effectiveness. You have the power to say no, not every person who has a seizure gets an MRI and EEG after the first episode. This leverage over the pharmaceutical and medical-testing aspects of the racket is potentially the biggest cost-saver, although I don't know if leverage would be sufficient to obviate an eventual need for central control of that as well. And of course, this whole thing would get Big Pharma in a lather, so you'd only bring it up after picking off the insurance companies.

Your point at the end kind of dovetails with this concept, and I find no choice but to agree. I don't know how one would go about setting the sliding scale for who gets treated and who is deemed not worth the cost, but I don't have much doubt that someone is going to have to step in as the voice of cold reason in these matters. My ninety-four year old grandmother has had a long and full life, and I don't see that obtaining optimum control of her blood pressure a worthwhile endeavor - if her heart hasn't killed her by now, it's probably not going to do so anytime soon. Obtaining volunteers for that particular job won't be easy, although you'd have some unemployed insurance people who might just be a natural fit.

I think I might run this one by my father - he used to prosecute racketeering cases on a semi-regular basis, although I'm not sure if any fell under the RICO law (as I understand it, the changes to the law in the 1990s made it somewhat more difficult to apply in a lot of situations). If it were possible, however, that would circumvent one of the thornier problems that Fritz pointed out with my off-the-cuff proposal.