So, to be clear, you’re ok with pay for performance/outcomes, but it’s the metrics that you have a problem with. That is an implementation detail, not a fundamental flaw. If clinical studies can correct for a patient’s incoming health, so can CMS. No more gaming the system or being gamed by it. Because, realistically, rejecting or underserving the sickest patients is just kicking the can down the road until it lands at the feet of a caregiver who remembers their Hippocratic Oath.
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What it is, is rationing. And I’m not against rationing as long as we don’t lie about it.
Oh, no shit. It’s a very informative exercise for any parent to trace the chain of command from the school board to the classroom teacher.
Sorry, let me be clear. If you are earning $60K (or perhaps $80K), that’s well over the $34K (last time I checked) average. In other words, we are the wealthy that need to pay for the healthcare of the poor.
Now, also let me clarify. The less health-care will barely budge health outcomes. Americans (who have decent health insurance) aren’t used to longer wait times, being denied expensive and only marginally effective medicines, scarce tests like MRIs, etc. But the important thing is that they barely budge outcomes. In the only cross-border study I could find, Canada and US hospitals had very close outcomes for similar diseases.
But the expensive care that makes you feel that you are paying for something is what has to be eliminated when you want to actually cover the poor.
I’ll say, my realization that a Canadian style system would be unlikely to work in the US was when HMOs first appeared. I expected them to taken up quickly as universal health-care can be thought of as a giant mandatory HMO. I fully expected howls from the right. But I was astonished to find the bigger complaints from those on my side of the political spectrum.
Of course there is denial of care for expensive, marginally effective procedures. Of course, expensive drugs aren’t covered if roughly comparable generics are available. Of course there is limited choice in doctors, wait times for appointments, no direct access to specialists, fewer MRIs, etc.
That’s bloody well how you establish a medical system that’s cheap enough that you can cover everyone. And the statistics prove that the health outcomes are only marginally different.
And yet HMOs were roundly rejected by almost every American of every stripe I know.
Anyway, maybe the medical insurance scheme has become insane enough that Americans (as a whole, of course, there are many who accept the trade-offs) will reconsider HMOs as the way to treat all Americans. But honestly, I don’t see that happening soon.
Which is why, while an appalling mess, ACA and its kin, are probably the only way that America can even slightly edge towards a moral health-care system that truly covers everyone.
(And of course, that said, there’s a never-ending fight to ensure that all Canadians have good access to our universal health-care system. Statistically, being poor, indigenous, or an immigrant means you end up with less access to health-care for a variety of reasons.)
Agreed, but it’s based on effectiveness for price. hence expensive medicines are less likely to be approved. And that’s how it should be.
Also as far an denial of purchase of other treatments. Actually a 2 tier system is one that is unlikely to last. In Canada, you are effectively denied outside treatments. That’s why an incredibly small number of very wealthy Canadians do take treatment in the US, and it’s an advantage we have here. The existence of a rarely taken “escape hatch” means (1) multi-millionaires aren’t incentivized to create a second tier and (2) with no second tier, all Canadians have incentive to keep our system providing decent care.
Thanks for drilling down. The piece violates my internal narrative (although I could come up with some sort of explanation), but I should have looked at it more closely.
Teachers complain about this problem all the time. They are not allowed any autonomy at all by the current regime of teaching to the tests. There is a reason why there is a high rate of turn over among teachers these days.
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I think that depends on where you live. In some places even $34K a year is more than enough to live on, because cost of living is cheaper. In more expensive places, $60K (or even $80K) is barely scraping by. [quote=“tlwest, post:64, topic:102941”]
Americans (who have decent health insurance)
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I have “decent” health insurance that pays for shit, actually. If we were less well off, we would be in trouble. [quote=“tlwest, post:64, topic:102941”]
being denied
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I had to pay out of pocket for a mammogram. Also, if we had the insurance we have now back when my daughter was born, I suspect we would have paid out the nose to have her (a normal, healthy birth, btw). If the GOP gets their way, pregnancies will not be covered.
And for one of these. Out of pocket, it was not covered.
I’m really not sure how a HMO will fix the problems of the current system. The problem is that insurance companies consistently refuse to cover all sorts of things (or charge high deductibles/premiums) for pretty basic coverage. A single payer system and the state actually negotiating would help.
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Actually, a lot of the increase between the 50-60’s and today is the increase in teacher salaries who used to be paid dirt, but now have quite desirable positions (at least if the ratio of # applicants to # of positions is any guide).
Also, schools are a lot more inclusive. I don’t have figures at hand, but I know our local school spent a fair amount on accommodating students who I’m pretty certain would have not been welcome in the school system 50 years ago. (Given one of my sons was among them, I’m rather happy for the change, but I have no illusions about how much if drained from the school system in general for the 2-3 years he needed support.)
I’ve heard the plausible, if not proven, hypothesis that education managed only because smart intelligent women had no other career opportunities in the 50-60s, and the education system took advantage of that by paying them very little and thus had the ability to provide high quality educators at a cost the government could afford.
I don’t know if I believe it, but it does make a good story.
Agreed. I live in a very expensive city and scraping by is pretty much how everyone feels (I suspect that changes at > $250K, but I don’t know). But that doesn’t mean the province charges me a lower tax rate. I pay my nearish 50% marginal rate just as if I lived in a place with 1/5 the housing cost. No matter how you slice it, I am fortunate to be making an above average salary, and I need to be paying for the medical care and everything else to support those who aren’t.
HMOs work exactly the same way as the government does - negotiating power. Now obviously the government is the biggest HMO, but the principle is the same.
If the seller isn’t willing to price the item/service so that the benefit/cost ratio is within the predetermined acceptable grounds, then you don’t buy. That’s why there are bunches of medications that have improved outcomes that just aren’t available. That’s why you only get to use these sets of doctors and if they’re busy for a few days, that kind of sucks. Likewise, yes, there may only be one MRI clinic in the area that you can use, so you may have to wait a month or so (for my mother it was 2.5 months).
But it keeps prices down.
There is no magic bullet - just bargaining power.
It’s also why HMOs have to be big enough to wield power.
(I agree that co-pays are bad - they discourage the use of needed medical facilities by the poor. But all that means is that I pay the co-pays for me AND the “other poor household I pay for” in my taxes. The co-pay money is going to go in the system. The only question is whether it goes from a flat-rate basis, or whether it goes in a progressive basis where I pay more because I have an above average salary.)
That depends on where you are, how much tenure you have, etc. Again, younger teachers are paid on the lower end of the scale, work “off the clock” quite a bit, have more benchmarks to meet and much less autonomy in the classroom. Yes, people are paid more, but cost of living is much higher and the issues outside the classroom are quite different than 50 years ago?
Do you mean because of integration? Or because of kids who have special needs (I’m guessing this, since you mentioned you’re own little one as a point of reference)? One point that links this back to the health care discussion (see! Back on topic, us!), is that medicaid funding is often part and parcel of helping kids with special needs at schools (and at times, at home as well). Much of that $$$ is about to evaporate. And of course, privately run schools can reject kids who have special needs.
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I don’t disagree and in fact, I’d much rather have that come out of our taxes, as opposed to paying a private, for-profit corporation that has the right to deny many things I might actually need. [quote=“tlwest, post:68, topic:102941”]
HMOs work exactly the same way as the government does - negotiating power. Now obviously the government is the biggest HMO, but the principle is the same.
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Sure, I’m getting what you mean here. But again, that doesn’t mean there aren’t problems with the HMO system (or with a government run, single payer system, of course). But we have worse outcomes and higher cost than pretty much the rest of the developed world, despite having some of the most world class health care in the world (if you can pay, of course).
I think that’s something we can agree on here! In this case, I think it means making politicians make hard decisions. I have little faith in them to do so, at this point. I do think that part of the reason for lack of public hearings, etc, as the senate hashes this out (and no townhalls, either once they go on break) is because they are well aware that what they are doing is generally unpopular (especially if the CBO projects on this are similar to the ones from the house).
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Honestly, I cannot see how, if the Republicans dismantle ACA, this isn’t going to bite the Republicans really, really hard in about 3 years. Now just maybe the number of people without health problems who were annoyed at mandatory insurance will outnumber voters either have health problems or are terrified about having health problems, but I really don’t think so.
Especially since Republicans tend to skew older (i.e. with more health problems). If nothing else, it should bring a few million more Democrats out next election.
Still, since this particular Republican bonfire will be made out of the suffering of others, I’d prefer they not throw the torch onto the pyre. But if they choose to do so, I cannot imagine that they’ll escape paying the price.
Of course, I couldn’t imagine Trump winning, so my prediction may not be worth much :-(.
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Absolutely! If lots of their constituents, and especially the ones who vote for them, lose their coverage, or lose family members to easily preventable illnesses, it absolutely could.
The only thing that prevents that is the continued hardline divisions that have grown up over the past few years. There are not too few “anyone but a democrat” voters out there (some who are “anyone but a republican” too). And the idea that the core of Trump/GOP voters are working class is somewhat of a myth. Much of the white working class has just stopped voting altogether, because they see nothing changing. I’d say that much of their base (especially the Tea Party/Trump base) are sort of upper middle class small/medium business owners, who disliked the ACA because of the mandates for businesses to insure their workers (although businesses with less than 50 employees were exempt, I think). They feel like they “pulled themselves up by their bootstraps, so why can’t all the poors!” [quote=“tlwest, post:71, topic:102941”]
Still, since this particular Republican bonfire will be made out of the suffering of others, I’d prefer they not throw the torch onto the pyre.
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Amen!
They will and we’ll see if they do.
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