Single payer health care questions

[bilby]

That is a risk. The main problem with any kind of UHC system in America is that it would be run by Americans. These are the people who voted Trump to be President. One cannot trust them to do things.

Exactly my fear.

I too have to subscribe to this brand of American Exceptionalism; Just because every other country that tried it has made it work far better than the existing US System on every single measure, doesn't mean that the USA won't be able to fuck it up beyond all recognition.

 

[Loren Pechtel]

If I believed it would actually work as it's supposed to I would vote for it in a heartbeat. I'm opposed, though, because I would expect the same thing we always see--too much corner-cutting.

That is a risk. The main problem with any kind of UHC system in America is that it would be run by Americans. These are the people who voted Trump to be President. One cannot trust them to do things.

I consider it not merely a risk but a near certainty. UHC puts the same agency in charge of the spending and in determining what is proper to spend it on. This is a major conflict of interest that history shows is almost certain to go bad.

 

[Toni]

That is a risk. The main problem with any kind of UHC system in America is that it would be run by Americans. These are the people who voted Trump to be President. One cannot trust them to do things.

I consider it not merely a risk but a near certainty. UHC puts the same agency in charge of the spending and in determining what is proper to spend it on. This is a major conflict of interest that history shows is almost certain to go bad.

Honestly, it's not much difference than what happens now.

 

[bilby]

That is a risk. The main problem with any kind of UHC system in America is that it would be run by Americans. These are the people who voted Trump to be President. One cannot trust them to do things.

I consider it not merely a risk but a near certainty. UHC puts the same agency in charge of the spending and in determining what is proper to spend it on. This is a major conflict of interest that history shows is almost certain to go bad.

That's simply not true. Under at least some, perhaps all, worldwide UHC systems, a government department is in charge of spending; while the decisions about what to spend it on are made by boards with significant professional medical representation (hospital boards, regional health boards, medical councils, etc.).

In any sane health system, the money men DON'T have a say in what the money is spent on - only on how much is available to be spent. The major failing of the current US system is that the insurance companies sit in both seats, creating EXACTLY the hazard you warn against - although you seem to labour under the delusion that the risk disappears if the people in power are not a part of 'government'.

What, exactly, renders people immune from corruption when they are safely protected from any democratic influences, I do not know; but I am really looking forward to seeing you try to explain it.

 

[Horatio Parker]

It bears pointing out once again that the US spends far more for worse results than the rest of the developed world.

 

[ksen]

Every extra dollar spent is an extra unit of freedom, liberty and apple pie.

 

[Toni]

How are end of life issues handled under UHC systems?

For some geographical areas and in some families, it is seen as a duty to 'do everything possible' to extend life because failing to do so means you don't love the patient, or you are 'giving up.' This is an enormous cost driver in the US.

Other cost drivers are frankly, addiction issues, and the health issues that go along with addition, including children born addicted or prematurely or with serious medical issues that will likely persist for years, as well as prematurity and attending health issues born to mothers mostly in poverty but not entirely, again sometimes with long term and expensive medical needs.

The narrative goes that poor women should not have children. Of course they should also not have access to birth control which is affordable. For example. Prenatal care should not be provided at no or low cost. Instead, it is important to attach shame to being poor and to make recipients of medicaid and WIC jump through lots of hoops, which isn't at all stressful and does nothing at all to contribute to increased risks of prematurity, maternal or fetal death or morbidity. (irony here in case anyone has any doubts)

Almost everyone I know of any age would prefer to die at home; few people in the US die at home.

 

[bilby]

How are end of life issues handled under UHC systems?

For some geographical areas and in some families, it is seen as a duty to 'do everything possible' to extend life because failing to do so means you don't love the patient, or you are 'giving up.' This is an enormous cost driver in the US.

Other cost drivers are frankly, addiction issues, and the health issues that go along with addition, including children born addicted or prematurely or with serious medical issues that will likely persist for years, as well as prematurity and attending health issues born to mothers mostly in poverty but not entirely, again sometimes with long term and expensive medical needs.

The narrative goes that poor women should not have children. Of course they should also not have access to birth control which is affordable. For example. Prenatal care should not be provided at no or low cost. Instead, it is important to attach shame to being poor and to make recipients of medicaid and WIC jump through lots of hoops, which isn't at all stressful and does nothing at all to contribute to increased risks of prematurity, maternal or fetal death or morbidity. (irony here in case anyone has any doubts)

Almost everyone I know of any age would prefer to die at home; few people in the US die at home.

These things are handled in various ways, according to the local medical norms and both hospital and wider societal culture; They are in no way tied to the funding model, so there is no one 'UHC' way to approach them. These things define what a society sets as the minimum expectation for their health care system. The success or failure of the funding model (Single payer; Centrally funded service; Private insurance; Regional funding; Charitable donations; or a combination of two or more of these) at the point of use determines whether they need to compromise those objectives set by societal expectations or not. So for example, a patient in the USA might reasonably expect that a hospital will treat his cancer with the latest and/or most suitable chemo drug, but if his insurance won't pay for it, his expectations won't be met. This can also occur under UHC; The major difference being that the rules are uniform - either the system pays, and anyone can get the treatment; or it doesn't, and only the wealthy can get it (as compared to the bizarre US situation where two people of similar means might be treated completely differently, because one happened to work at a company with a different insurance plan to the other).

Typically, UHC is equivalent to everybody having the same insurance plan, with nobody uninsured or under-insured. How good that plan is depends on the implementation of the UHC system. Most UHC systems provide excellent coverage, driven by expert medical opinion on what is best, rather than by marketing and the averaged opinions of the general public.

Almost all UHC systems have better outcomes overall than the US system, by all reasonable measures.

 

[Toni]

How are end of life issues handled under UHC systems?

For some geographical areas and in some families, it is seen as a duty to 'do everything possible' to extend life because failing to do so means you don't love the patient, or you are 'giving up.' This is an enormous cost driver in the US.

Other cost drivers are frankly, addiction issues, and the health issues that go along with addition, including children born addicted or prematurely or with serious medical issues that will likely persist for years, as well as prematurity and attending health issues born to mothers mostly in poverty but not entirely, again sometimes with long term and expensive medical needs.

The narrative goes that poor women should not have children. Of course they should also not have access to birth control which is affordable. For example. Prenatal care should not be provided at no or low cost. Instead, it is important to attach shame to being poor and to make recipients of medicaid and WIC jump through lots of hoops, which isn't at all stressful and does nothing at all to contribute to increased risks of prematurity, maternal or fetal death or morbidity. (irony here in case anyone has any doubts)

Almost everyone I know of any age would prefer to die at home; few people in the US die at home.

These things are handled in various ways, according to the local medical norms and both hospital and wider societal culture; They are in no way tied to the funding model, so there is no one 'UHC' way to approach them. These things define what a society sets as the minimum expectation for their health care system. The success or failure of the funding model (Single payer; Centrally funded service; Private insurance; Regional funding; Charitable donations; or a combination of two or more of these) at the point of use determines whether they need to compromise those objectives set by societal expectations or not. So for example, a patient in the USA might reasonably expect that a hospital will treat his cancer with the latest and/or most suitable chemo drug, but if his insurance won't pay for it, his expectations won't be met. This can also occur under UHC; The major difference being that the rules are uniform - either the system pays, and anyone can get the treatment; or it doesn't, and only the wealthy can get it (as compared to the bizarre US situation where two people of similar means might be treated completely differently, because one happened to work at a company with a different insurance plan to the other).

Typically, UHC is equivalent to everybody having the same insurance plan, with nobody uninsured or under-insured. How good that plan is depends on the implementation of the UHC system. Most UHC systems provide excellent coverage, driven by expert medical opinion on what is best, rather than by marketing and the averaged opinions of the general public.

Almost all UHC systems have better outcomes overall than the US system, by all reasonable measures.

I would like to correct something: insurance or type of insurance or ability to pay privately, or lack of any of these can act as a gate keeper to a medical practice. At one point, our insurance company changed because of a choice my husband's employer made and our pediatrician's office did not accept the new insurance. We had to choose between paying out of pocket ourselves or switching practices. Medicare (insurance for older Americans) has limits on procedures it will/will not pay for; if a provider wishes to provide a procedure not covered for the Medicare patient, the patient either signs a waiver agreeing to pay him/herself or else the provider cannot provide the service or provides it with no charge. The last is strongly avoided.

However, doctors do not treat patients on Medicaid (insurance for poor people) or on the most gold plated plan available differently. Doctors WILL do their best to proscribe treatments that will save patients money by being covered by their insurance whenever possible. At least some practices will help patients in need of financial assistance find that assistance. But say, a homeless guy has appendicitis and a wealthy guy has appendicitis and both show up at the same ER: both are treated and both are treated exactly the same, although the wealthy guy is more likely to be offered a private room if he has to stay overnight. The homeless guy might be offered generic pain meds or antibiotics if needed as would anyone with an insurance which would only pay for generics..

 

[TSwizzle]

How are end of life issues handled under UHC systems?
Almost everyone I know of any age would prefer to die at home; few people in the US die at home.

In the case of cancer, it's quite typical that towards the end the patient is put into a hospice for palliative care. A lot of the hospices in the UK are supported by charities. I think it is less common that people take up hospital beds during the end of life these days. My father received palliative care at home and passed away in his bed. I think it depends on the patient and the family as to where the patient is placed.

But the NHS are getting a bit too carried away with the DNR (do not resuscitate) policy. Seems now if you go into cardiac arrest, they may just let you slip away. Just my experience.

 

[bilby]

How are end of life issues handled under UHC systems?
Almost everyone I know of any age would prefer to die at home; few people in the US die at home.

In the case of cancer, it's quite typical that towards the end the patient is put into a hospice for palliative care. A lot of the hospices in the UK are supported by charities. I think it is less common that people take up hospital beds during the end of life these days. My father received palliative care at home and passed away in his bed. I think it depends on the patient and the family as to where the patient is placed.

But the NHS are getting a bit too carried away with the DNR (do not resuscitate) policy. Seems now if you go into cardiac arrest, they may just let you slip away. Just my experience.

Your experience??

When did the NHS allow you to die rather than resuscitate you?

As far as I'm aware, DNR orders in NHS hospitals are initiated by the patients; in the absence of an explicit request from the patient, resuscitation is attempted wherever possible.

Do you have any evidence that this is not the case?

 

[Alcoholic Actuary]

Do you know the costs of procedures under UHC or single payer systems? Because I think that would be a tremendous advantage. It seems like the costs in the US go something like this:

You "How much for an MRI?"
Doctor "Why don't you tell me how much you/your insurer can afford and then we'll send the bill"

https://www.forbes.com/sites/kateashford/2014/10/31/how-much-mri-cost/#304b4bf48485

It seems like an MRI shouldn't cost between $800 and $2400 within the same zip code. I'm a property and casualty actuary, not a health actuary. But the fact that it is easier for me to predict the range of outcomes of a liability settlement from a slip and fall accident in a restaurant than it is to predict the range of costs for a knee replacement surgery from the exact same accident is ridiculous.

And before I hear the "medicare doesn't cover the costs" refrain, that is an easier fix than the current attempts at getting the medical community on board with standardizing prices.

aa

 

[fromderinside]

I've a pacemaker with electrodes left and right and a defrib feature. Billed insurance 232k, Medicare and medigap paid less than 60 k. System wrote off loss with big tax benefit. Range for such run from mid 50s to almost 300k. Not standardized, but, complaint meaning everybody can interpret outputs but everybody also needs proprietary equipment to read. The device is mainly software which is proprietary and coded to thwart mass production. Private insurance may have had to foot the whole bill for those under 55.

Face it. There are only a few aspects of the device that can't be programmed by a first your student at a bad CC. The tech who advised the doctor who put it in my chest tried to arm wave the battery as the reason for the cost. It is a new generation battery, but, it is a standard lithium ion battery from the technical stuff to which I have access. My estimate of custom, one off, cost to produce this system is about 40-50 k presuming one has to tool jigs and custom design and program SW.

So why? Because they're all like that idiot who's now being tried. Hell, even retired 15 years I know enough about humans and microprogramming (assy) heart related SW that with about three months study I could do the task myself in less than a week up to to all existing codes. Not rocket science.

The system is so corrupt that those in the professions involved actually believe they can get away with most anything.

I say bring down the level of care to exclude devices that cost more than 2 k and scanning procedures that cost more than 500 dollars. Negotiate the rest with very intrusive actuary and process inspection and control then set process suited to patients not to investor bottom lines.

Yes, single payer.

 

[TSwizzle]

Do you know the costs of procedures under UHC or single payer systems? Because I think that would be a tremendous advantage. It seems like the costs in the US go something like this:

You "How much for an MRI?"
Doctor "Why don't you tell me how much you/your insurer can afford and then we'll send the bill"

I know my insurers have to pre-approve things like an MRI. I've never had an MRI for years and can't remember what went on. But any time I see the billing for healthcare it looks like the treatment is billed @ $1,000, i.e. the insurance company received a bill for $1,000, then there is some sort of discount for being "in network" of providers, so the amount goes to $600 then shenanigans and the insurance company says "here, there's $400". A weird set up.

I've a pacemaker with electrodes left and right and a defrib feature. Billed insurance 232k, Medicare and medigap paid less than 60 k. System wrote off loss with big tax benefit. Range for such run from mid 50s to almost 300k. Not standardized, but, complaint meaning everybody can interpret outputs but everybody also needs proprietary equipment to read. The device is mainly software which is proprietary and coded to thwart mass production. Private insurance may have had to foot the whole bill for those under 55.

Face it. There are only a few aspects of the device that can't be programmed by a first your student at a bad CC. The tech who advised the doctor who put it in my chest tried to arm wave the battery as the reason for the cost. It is a new generation battery, but, it is a standard lithium ion battery from the technical stuff to which I have access. My estimate of custom, one off, cost to produce this system is about 40-50 k presuming one has to tool jigs and custom design and program SW.

So why? Because they're all like that idiot who's now being tried. Hell, even retired 15 years I know enough about humans and microprogramming (assy) heart related SW that with about three months study I could do the task myself in less than a week up to to all existing codes. Not rocket science.

The system is so corrupt that those in the professions involved actually believe they can get away with most anything.

I say bring down the level of care to exclude devices that cost more than 2 k and scanning procedures that cost more than 500 dollars. Negotiate the rest with very intrusive actuary and process inspection and control then set process suited to patients not to investor bottom lines.

A bit off topic but it's the same with cars and their software. A new transmitter for the keyless entry system, $800 ! WTF, where did they get that number from ?

 

[southernhybrid]

Until now, I've avoided this thread because after working as a health care professional for 42 years, I could write a book on what's wrong with health care in the US. I'll just mention one of my pet peeves, my biggest one is the ordering of tests and procedures that are not always needed, especially when it comes to older adults who already have very poor quality of life and are expected to have poor outcomes. The tests and procedures come with their own risks, which are rarely discussed with the patient or POA.

I have a 94 year old patient in the late stages of dementia that has been put through several tests this year to evaluate her circulation. The woman is totally confused, incontinent, and totally dependent. She sits in a w/c most of the day talking to herself. She becomes easily agitated and is at risk for skin breakdown, so why does the PA keep refusing to consider a hospice referral, which would provide her with comfort care and a daily aide? It always seems to me that there are two many doctors and PAs who can't come to terms with the fact that their patients are facing death in the near future, no longer have any quality of life and it would be in their best interest to provide palliative care.

Another one of my patients is in her early 80s and is in the early stages of dementia. She has numerous other chronic health problems and has told me that since entering long term care, she has no desire to stay alive much longer and would prefer not to have any more aggressive treatment. The PA ordered a test to evaluate her circulation, and made a referral to a GI doctor for further tests because she has had chronic GERD for several years. The GI doc sent her to a cardiologist to see if her heart was strong enough for the GI test which included anesthesia and a contrast dye. After the GI tests, the cardiologist wants her to return for an exam. She keeps saying that she doesn't want all of this done, but unless her son, who is also her POA advocates for her, she is at the mercy of these doctors.

These are just two examples of what I see as a waste of medical resources, and/or a lack of respecting an individual's choice to avoid aggressive care. I myself have refused numerous tests and procedures over the years. I've been misdiagnosed many times, expected to consider absurd things like IV iron infusion due to anemia, which was easily corrected with a low dose of iron for six months. You all have no idea how bad things are unless you've worked in health care for a long time and have seen the system, if you can call it that, go from one based on compassion and the best interests of the patient to one based on greed and profit.

Single payer could work if it was implemented slowly and if aggressive end of life care was kept to a minimum. It's aggressive end of life care that is causing Medicare to fail financially, coupled with over testing and polypharmacy, fraud and abuse. How would Medicare for all be affordable unless people of all ages had more realistic expectations of what can be done when they have difficult to treat chronic diseases or are facing the end of life? Hey! We're all gonna die! Is it fair to spend extraordinary amounts of money to give one person a few extra months of life at the expense of the rest of society? It's problematic. And, btw, I hope you all do realize that the success rate of CPR is generally less than 20%. CPR isn't magic and if done on an older adult, it often leaves nothing but a corpse with a lot of broken ribs.

I'm with you Toni. I don't want aggressive end of life care. I don't want CPR. I want only palliative care if I make it to 85. I don't want to be tortured in my old age. I want to be comforted.

 

[Elixir]

Until now, I've avoided this thread because after working as a health care professional for 42 years, I could write a book on what's wrong with health care in the US. I'll just mention one of my pet peeves, my biggest one is the ordering of tests and procedures that are not always needed, especially when it comes to older adults who already have very poor quality of life and are expected to have poor outcomes. The tests and procedures come with their own risks, which are rarely discussed with the patient or POA.

I have a 94 year old patient in the late stages of dementia that has been put through several tests this year to evaluate her circulation. The woman is totally confused, incontinent, and totally dependent. She sits in a w/c most of the day talking to herself. She becomes easily agitated and is at risk for skin breakdown, so why does the PA keep refusing to consider a hospice referral, which would provide her with comfort care and a daily aide? It always seems to me that there are two many doctors and PAs who can't come to terms with the fact that their patients are facing death in the near future, no longer have any quality of life and it would be in their best interest to provide palliative care.

Another one of my patients is in her early 80s and is in the early stages of dementia. She has numerous other chronic health problems and has told me that since entering long term care, she has no desire to stay alive much longer and would prefer not to have any more aggressive treatment. The PA ordered a test to evaluate her circulation, and made a referral to a GI doctor for further tests because she has had chronic GERD for several years. The GI doc sent her to a cardiologist to see if her heart was strong enough for the GI test which included anesthesia and a contrast dye. After the GI tests, the cardiologist wants her to return for an exam. She keeps saying that she doesn't want all of this done, but unless her son, who is also her POA advocates for her, she is at the mercy of these doctors.

These are just two examples of what I see as a waste of medical resources, and/or a lack of respecting an individual's choice to avoid aggressive care. I myself have refused numerous tests and procedures over the years. I've been misdiagnosed many times, expected to consider absurd things like IV iron infusion due to anemia, which was easily corrected with a low dose of iron for six months. You all have no idea how bad things are unless you've worked in health care for a long time and have seen the system, if you can call it that, go from one based on compassion and the best interests of the patient to one based on greed and profit.

Single payer could work if it was implemented slowly and if aggressive end of life care was kept to a minimum. It's aggressive end of life care that is causing Medicare to fail financially, coupled with over testing and polypharmacy, fraud and abuse. How would Medicare for all be affordable unless people of all ages had more realistic expectations of what can be done when they have difficult to treat chronic diseases or are facing the end of life? Hey! We're all gonna die! Is it fair to spend extraordinary amounts of money to give one person a few extra months of life at the expense of the rest of society? It's problematic. And, btw, I hope you all do realize that the success rate of CPR is generally less than 20%. CPR isn't magic and if done on an older adult, it often leaves nothing but a corpse with a lot of broken ribs.

I'm with you Toni. I don't want aggressive end of life care. I don't want CPR. I want only palliative care if I make it to 85. I don't want to be tortured in my old age. I want to be comforted.

Agree 100%
I like my primary care doc. I'm 67 now and in pretty damn good shape, all things considered. Every year, I visit with the doctor and he comes up with a litany of horrors that could descend upon me. We go through them as I ask "If that should happen and I opted to treat it, what would that do to my quality of life and life expectancy, versus what it would be like if I simply ignored it?" At the end of the conversation, I am always amazed at how very very few possible conditions would even make it a hard choice. I'd much rather get sick and die, than get sick and die a horrible, slow, agonizing death, struggling against the inevitable, despite the chance of a few weeks months - or even years - of relative relief before something else (or the same thing) puts an end to it all.
Even less serious conditions that could be debilitating rather than deadly, engender treatments that are worse in the near term than the disease, in most cases.

 

[southernhybrid]

Hey Elixer. You and I are the same age. I'm glad I'm not the only one that wants comfort and quality of care instead of treatment that may give me a little more time at the cost of suffering more. Call me cynical, but it seems to me that too many doctors are only interested in making money while using the excuse that they must protect themselves form lawsuits. In my state, there is a two year limit on suing for medical malpractice and it's very hard to win a case against a doctor or hospital.

I liked the doctor I had for 17 years but she vanished without having the courtesy of telling me she was leaving her practice. I've been to three different providers in the past year and a half because most of the newer medical offices can't keep staff for very long. And, most of the time you see a PA or an NP instead of an MD. I don't mind that. I actually prefer a good, caring open minded NP, but I would like to establish a relationship with one provider so I don't have to constantly tell new people that I'm probably going to refuse at least half of the things they want me to do.

 

[Loren Pechtel]

These are just two examples of what I see as a waste of medical resources, and/or a lack of respecting an individual's choice to avoid aggressive care. I myself have refused numerous tests and procedures over the years. I've been misdiagnosed many times, expected to consider absurd things like IV iron infusion due to anemia, which was easily corrected with a low dose of iron for six months. You all have no idea how bad things are unless you've worked in health care for a long time and have seen the system, if you can call it that, go from one based on compassion and the best interests of the patient to one based on greed and profit.

I think a lot of it comes down to them not having been close enough to an end-of-life decision to understand that sometimes continued treatment isn't a good thing.

 

[TSwizzle]

I've known one person who reached 100 years old and she was in pretty good shape. After she turned 100, which seemed to be a goal for her, it was a few months later she died. She lived at home until she was about 96 I think. With support of course but she did pretty well. Had a couple falls and had to go into a home. Same with my neighbor, died at 98 I think at home. Took a fall, banged her head and died not long after but she was still driving occasionally in her early 90s. If you look after your health when young I think you will do better as you get older.

 

[southernhybrid]

I think genetics has as much to do with health in later life as anything else might. You can live the healthiest life style known, and still end up with many serious diseases in old age. It seems like a crap shoot in some ways. Of course, those who live very unhealthy life styles are at a higher risk of serious diseases, but there is no guarantee that any of us will remain healthy well into old age.