I have never doubted whether I would receive any ordinary medical treatment that I would need*.
Medical insurance and access to medical care has not been a significant factor in any decision in my life**.
I feel that I get good value for my medical payments (direct or via taxation).

No kidding! I hated paying US taxes, since I'll be damn'd if there seemed to be anything coming back for the money spent.

Looks to me like we're gonna get Californicated. I'd get out and fly along, croaking, if there was anyone marching.

I am so discouraged by the sheer aggressive ignorance of the opposition that I don't feel up to pushing back.

I'm reminded about an argument I had in kindergarten with a classmate who insisted that one's eyes were marbles. Her mother told her so, and she wouldn't budge from her position, and got really really angry when I mentioned that I'd felt the eyes of dead fish (fresh from the Long Island Sound) and they certainly weren't marbles.

I get that same vibe from the health insurance lobbyist's Army of Ignorance.

I apparently write a lot of comments that begin with "What I don't understand" so...

As near as I can tell, the main argument waged against the "public option" (can we please get a better name?) is that it will undercut the private medical insurance and provide everyone in the country with cheaper health care. The first time I heard it, I'd wondered if I simply misheard the radio.

Universal coverage. Cheaper coverage. How is this an argument against nationalized health insurance? (Note: Single PAYER, not single provider.)

More importantly, why is this argument working? (Support for some sort of single payer plan has been eroding, IIRC.)

I have an honest question or two. I've heard claims that the British and/or the Canadian systems take longer, sometimes much longer, to handle procedures. Is that true or false? Do you have links?

I'm really curious.

I've repeated this many times, but Brazil, a country with two-thirds the population of the US and *one-twentieth* the GDP, has national health care. And it works pretty well.

Abi, thou art full of win.

Wyman Cooke @5:

I don't have stats or links handy, but I can tell you anecdotally that, at least in the Canadian system, waiting times are both real and not as bad as some folks would have you believe.

Yes, there are waits for some procedures, and yes, sometimes they are long waits. The canonical example is hip replacements. There just aren't enough doctors or enough operating rooms to keep up with demand. There can also be long waits for some kinds of tests and screenings. Yes, wealthy people can often get those tests and procedures done faster by going to the 'States and paying for them.

And yes, emergency room wait times can be long if you're there with something that gets triaged as a non-life-threatening emergency.

But.

If you're a middle-aged man who shows up at the ER with chest pains, you don't wait at all.

And if you've got a cold you can't shake, you don't have to wait weeks to see a doctor -- you can walk into a walk-in clinic, and you'll be seen within an hour or two. (Admittedly, this can be a different story if you're not in a big city)

The Canadian system is not perfect. But it works, and it works well. It could certainly do better, and wait times are one area where it could improve. But honestly, even if wait times are longer overall (and I'm skeptical that they really are), that's a price I'm more than happy to pay in exchange for never having to wonder if I can afford to see the doctor to find out if that cold is really pneumonia.

My average wait time for an ordinary appointment with a primary care doc in Hawai'i is two months.

Health Care in Germany sounds mighty fine, too.

Wyman, Canadian health sometimes takes a little longer if things aren't urgent. If they are, they go to the front of the queue. That's not common. My parents became Canadians thirty years ago, and they love Canadian health care. Now that my sister has died, the thing I am most grateful for is that my parents are in Canada, not here. Not becoming a Canadian when I could have is one of my very few regrets in life.

What can I say? I underestimated US capitalism.

Greedheads claim Michael Moore lies or exaggerates when he talks about health care in other countries. I can't speak to every case, but from my family's stories, I know what he said in Sicko about Canada is true, and from good friends in France, I know what he said about that country is true also, so I'm inclined to trust the other claims.

I won't be able to follow this thread to answer any questions you might have about Canada, but I strongly encourage you to look beyond the claims of the right--including the claims of rightwing Canadians.

Thanks.

John Chu #4: As near as I can tell, the main argument waged against the "public option" (can we please get a better name?) is that it will undercut the private medical insurance

And that's the argument against the "public option"... for the insurance companies! Of course, they have lots of money for advertising and astroturfing, all paid for by our premiums.

Oh dearie me. Waiting for a hip replacement. I waited nearly ten years for a correct diagnosis. Once I was diagnosed (with necrotic degeneration of the hip joint), I was put on the Waiting List. Where I waited nearly an additional year. But I finally got the operation.

When my second hip went bad, catastrophically (it was necrotic degeneration again, this time the bone in my femur simply collapsed, it was so rotten), I was in the emergency room in half an hour, in the operating room in another half an hour or so. Because it was sudden, and therefore an emergency. But I had waited a long time for a diagnosis which I didn't get, dutifully reporting all the symptoms(I won't bore you), and getting nowhere. Because there are some things that even adequate insurance can't make right. And if you can't get the care, it doesn't matter that you can pay for it.

I expect this situation also to improve under Universal Healthcare.

I recently made a mendacious post to another site in which I urged right-wingers to call their representatives and demand a public option -- since surely no public program could successfully compete with private services, and thus it was sure to fail.

I figure they will either change their minds, hold their aching heads wondering what has gone wrong with the world, or else they will actually do it. Win, win, win.

Wyman, Australia, where I live, also has universal health care. Waiting lists are much the same as in Canada, particularly waiting lists for elective surgery, which can run to months or occasionally over a year for conditions judged to be non life-threatening.

Acute and emergency care is immediate and of very high quality, and every time I have been to an emergency room (asthma or in one case, a copiously bleeding gash) I've been seen within 5 minutes of reporting to the triage nurse. Most medical clinics bulk-bill, meaning seeing a GP is completely subsidised, and if you are prepared to wait until a doctor can see you, you can usually get an appointment immediately. Seeing a specialist, or seeing the GP of your choice if they do not bulk-bill sometimes requires a copayment.

There are also private medical facilities, used largely by people with private health insurance, and there are tax incentives for taking up private health insurance; an attempt to ease the burden on the public system. If you are careful, private health insurance can pay for itself, particularly if you go in for complimentary medicine, wear more-than-basic glasses or visit a dentist (they are finally going to bring in universal dental care ... sometime before the next election would be my guess).

It's not a perfect setup, but medical care is readily available and will not bankrupt a family, even in an emergency. The Government has just announced a major overhaul of the system, as it's run by the individual states at the moment, and the current feeling among the bureaucrats is that efficiencies and economies might be gained from a national approach. The more cynical among us believe that it'll just add another layer of bureaucracy without much change on the ground. We shall see.

I am somewhat optimistic, because healthcare is such a limiting factor amongst just about everyone I know. Everyone is scared of losing their jobs because that means they lose even mediocre insurance for their family and themselves, and private insurance companies are like sharks.

You often can't afford private coverage that's very good if you've just lost your job---and in this economy, are unlikely to get a new one anytime soon that actually has benefits. Often what you can afford privately is that which doesn't, for instance, cover emergency room visits or hospital stays, and especially doesn't cover over 75% of the costs for having a baby.

On the other hand, I'm pretty sure the rich would just prefer everybody else to die. So on that part I'm less optimistic.

Wyman, #5: This is the tiny nut of semi-truth at the root of the "Medical treatment will be rationed!" argument -- that the wait for non-critical medical treatment in Canada is sometimes longer than "walk in, get treated, walk out". However, the wait for non-critical medical treatment in America is effectively infinite if you don't have either insurance that covers it OR enough money to pay for it out of pocket. As one of those who frequently falls into both of those categories, I have very little patience with this particular argument; I'd be happy to wait a while for a treatment, as opposed to not being able to get it at all.

The Netherlands have pretty sucky dental care. Taiwan has crowded and noisy waiting rooms. So what? We don't have to copy either one: we can look around the world at half a hundred systems and copy the best parts of each. And both countries have standards of medical care that I'd consider more than adequate, after direct experience with both.

I am optimistic because the era of the steady day job with health benefits is drawing to a close. More people are freelancing than ever before. More people have steady day jobs that classify them as freelancers -- albeit freelancers who have to come in on Saturday for no extra pay -- to avoid paying health benefits. More people are being kept on payroll as contractors or part-time staff or... whatever justification corporations can use in order to avoid paying for health insurance.

And people are not going to put up forever with not having insurance, with not having their children and siblings and friends insured.

I've had a ridiculous run of medical bad luck over the past couple years -- none of it truly serious, all of it expensive. This, while my twin sister was a "permalancer" and (as a twenty-something woman in perfect health) being quoted $700 a month for health insurance. What I can't get out of my head, what makes me willing to try anything different, is what if the broken bones and the expensive tests had happened to her?

Oh, fuck.

I just heard from a college friend -- a guy who has helped run an SF convention and an all around great fellow -- that his wife has a malignant melanoma. This, three years after losing their son to leukemia.

I hope to hell they have good coverage.

Emergency room waits --
When my 7-year old recently put his hand through a window he cut his thumb, not really badly (G/d looks after children, fools and drunks).

I, of course, panicked.

I took him directly to the ER, where they triaged his cut, put a temp bandage on it and told us to wait.

Waited about 4 hours, and then, within about 15 minutes, we was formally seen by a doctor, and they put in two stitches.

Would I have preferred that the wait was shorter? of course.

However, when we were waiting, I was looking over the pretty full waiting room, and wondering just how many of these people were there because they could not afford a "regular" doctor's care, and had to rely on the ER for routine care, or had to wait until something that could have been treated early turned acute.

I see rationed health care *now*, based on what procedures an insurer will approve, and on how long it takes for the insurer to make that determination.

I see a lack of choice of doctors now, based on what the insurance company will pay and who they select for acceptance as primary care and specialist providers.

They claim that the government will subsidize health care on their backs? it's already happening, when you have group plans, and those who are not ill pay premiums that pay for care of those who are ill.

Everything the conservatives claim that the government plans would happen happens *now,* under the private insurance system.

John Chu @ 4: "More importantly, why is this argument working?"

I think, if delivered in the proper horrified tone, "Under universal healthcare pills will taste like candy!!!1!" would undercut support as well--as long as no one ever pointed out how ridiculous it sounds. That's the thing: any argument, no matter how stupid, eventually sounds persuasive if you hear it enough times without hearing any opposing view. Single-payer is dying because no one is bothering to fight for it. Everyone centrist enough to get away with advocating single-payer on prime time has already come to the conclusion that single payer is DOA.

Honestly, I'd rather have a good public option and a strong health care exchange than a single-payer system. Trying to put into place a single-payer system for 300 million people from scratch is a difficult enough task that I'm not sure the government could pull it off, even if they got the bill through the Senate (snrk! guffaw! chortle!) If government administered health care is really better (and I'm guessing it is), then it will gradually absorb the private market anyway, once it's available.

(My super secret backdoor single-payer plan is to pass a bill inducting every living American into the military, and then discharging them immediately and popping them into the VA.)

The VA is actually a step beyond single payer: it's real live socialized medicine, where the government owns hospitals and employs doctors.

It's an important distinction. Either system would be better than what we have in the US today, but they're very different systems.

The argument* that you'll have a long wait in a ER in Canada is probably overlooking the fact that you'll have a long wait in an ER in the US, too. Especially since hospitals in the US are closing ERs because they lose too much money. ERs here are overwhelmed by the number of the uninsured, who show up with problems which are only severe because they've been left untreated.

*I have no idea if this is fact-based.

Matt Austern @ 23: "The VA is actually a step beyond single payer: it's real live socialized medicine, where the government owns hospitals and employs doctors."

You're right, of course. It's actually my super-secret plan for backdoor socialized medicine.

I have made decisions based on medical considerations. I stayed in a marriage that I would have left years ago because I have significant health issues that would make getting insurance nigh on to impossible, and my husband has good insurance through his employer.

And I'm lucky. My husband and I have reached equilibrium where we can live together equitably and with mutual respect, and he was never abusive. I often wonder how many people stay in abusive relationships for health care for them or their kids. I know people stay in hellish jobs for that reason.

p1. If you want some stories first-hand about the Canadian health-care system, you could do worse than starting with Sara Robinson's post on the topic at Campaign for America's Future.

p2. That said, the political viability of a Single Payer plan is likely to be tested by H.R. 676 in the House of Representatives after the recess, but there are reasons to be pessimistic. You need a plan for kicking the Blue Dogs in the teeth, and there really isn't a very workable one available. Sadly.

p3. The "public option" phrase is perfectly reasonable. It encapsulates precisely what's in the proposal that makes it the next best thing to Single Payer. It's workable, and as we've seen, the only effective response to it is let the Brooks Brothers Brigade off the leash. If the Democrats would grow a spine, they could counter that easily.

heresiarch @22: "Single-payer is dying because no one is bothering to fight for it." - I'm not sure if this is rebuttal or confirmation, and you do address it in your next sentence, but I think it worth linking Ezra Klein's observation observation that health care panels and events are constantly well attended by single-payer activists asking questions and advocating. Reports just ignore them.

I had my own little Catch-22 go-round with Kaiser recently.

Short version: they raised my co-pay for BP pills from $30 to $60. I griped and was advised to try to get a cheaper plan from Kaiser. I filled out forms and three days later was told I didn't qualify because I'd been taking BP pills within the last five years. On Kaiser's doctor's prescriptions.

Waiting times, my personal experience:

My first doctor's surgery in the UK (where one sees one's general practitioner; it's the first port of call for non-urgent care) was horrifically badly run. It generally took over a week to get an ordinary appointment. I understand it's improved since then.

When we moved to a different area in Edinburgh, we moved surgeries. The second one was in an area of high unemployment, with all its associated social ills, but the surgery was fantastic. They did same-day appointments if you called between 8 and 8:30, and appointments in the next few days thereafter. One did better in timings by being flexible about whom one saw, though they did try to make requests to see "a lady doctor" about the same as requests to see any doctor. There was also a drop-in clinic, but that tended to have one to two hour waits, so anyone who could phone for appointments did.

The only time when I called in the afternoon was when my baby daughter had an eye infection and needed a prescription for drops to stay in nursery, I called at 4:00 and got an appointment for 4:50.

My grandmother in law has had two hip replacements, both because of falls that broke a hip. Surgery was immediate in both cases. The second one was in her 90's, though the hospital knew that she was unlikely to return to mobility afterward.

Dental was not covered in the UK.

I haven't used any medical care but dental in NL. I'm afraid I disagree with Dichroic @18 about the quality of dental care here. Our dentist is really good, though he doesn't always offer pain relief when an American might expect it. You can always ask, of course.

But the rest of the family had had medical care. Doctor's appointments are generally same-day or later in the week. My son waited a few months to get into developmental physiotherapy and speech therapy. My daughter ended up in the emergency room with a broken finger, and waited a couple of hours to be seen. And my husband had to get a chest X-ray, for which he managed a same-day appointment through adroit timing (the alternative was the next day).

Note that my health insurance has not raised a single quibble, whine or murmur at any of our claims for payment. All treatments are coded on all the bills we see*, with codes that match our insurance documentation. This makes it much easier for us to determine what we've had and what's covered.

-----
* Some bills, like dental, we pay ourselves and send on to the insurance company for reimbursement. Some we receive and send on for the insurance company to pay directly. And some we never see; they go straight to the insurance company. But everyone knows the system and can explain for us newbies.

Okay, here's a snapshot of where I'm sitting in Australia. I've grown up with the Australian Medicare system, and I'm used to it as a baseline of what to expect by way of good medical care. So here's my experience.

Context: I'm female, 38, and "overweight" according to most measures. I also have an underactive thyroid gland, as well as chronic depression. I'm currently taking 2 different strengths of both a thyroid medication and an SSRI-type anti-depressant, as well as a second antidepressant which has recently been added to the mix. I'm currently unemployed and receiving Newstart allowance from the Australian social security system.

When I phone up my primary care physician, or general practicioner, I can usually get an appointment within the next day or so - sometimes on the same day. I can speak to this doctor about getting repeat prescriptions for my medications, which means I tend to see her approximately once every six months or so (a standard prescription for the anti-depressants is 1 month's supply and 5 repeats). Approximately once or twice every year I'll have a blood test to monitor how my thyroid levels are doing, which is taken at the pathology collection lab in the same building as the surgery. My pap smears are done by the same doctor, rather than me needing to speak with a specialist gynaecologist in order to have one done. For a standard consultation (about 15 minutes to 30 minutes) I pay approximately $49, of which I receive $33.55 back from Medicare (the scheduled fee amount).

Last year, I needed help with the depression, so I was referred to a psychologist. I was entitled to twelve sessions of psychological counselling on Medicare (cost of sessions $165 each, getting approximately $115 back from Medicare) provided I had a psychological health maintenance plan created by my GP (which she did). This year, I've been referred to a psychiatrist, because the balance of my medications needs to be altered a bit. I've been to two sessions, one long, one short, and in each case I've been refunded the difference between the scheduled fee and the amount I paid.

Currently I have private health insurance (a habit I picked up from my parents) because while the Medicare fees cover the cost of the lenses in a pair of spectacles, they don't cover the cost of the frames (and the frames are the costly bit). Medicare also doesn't cover a very wide range of dental services, nor does it cover ambulance transport. I'll probably drop this fairly soon, since it's using money I don't really have to cover the costs (unemployment benefit is enough to hold body and soul together... just) but for me this won't be a tragedy. Instead, it'll mean I'll have an extra $50 per fortnight to spend on things like food and rent. Of course, before I do so, I'm going to be using up the $1000 "Package Bonus" I've accrued over the past eight years of not needing the silly thing (probably new glasses, and maybe a hearing test).

I read about comparable situations to my own in the US, and the thing which keeps springing to mind is "I am so damn lucky to be living here."

Forgot one aspect of waiting times, and it's a prominent talking point, so I should mention it.

My British doctor's offices all seemed to run 20 - 40 minutes late. A 10:00 am appointment tended to mean seeing the doctor at 10:20; a 3:00 slot implied 3:40 face time.

That's about what I remember from American medical care, but I could be wrong. It's been a while.

Abi, I'm surprised you say "dental was not covered in the UK". I don't know how it is in Scotland, but in England, the NHS used to offer free dental care to all UK citizens until a few years ago. As an immigrant though, you had to apply to be granted cover. Then demand started to outstrip supply, because dentists opted more and more to "go private" and not work with NHS schemes (cause? the usual: unregulated greed), so people were still entitled to free NHS services but wouldn't be able to find a NHS dentist in the area. In the last ten years, various plans have been attempted to fix the state of things (basically, free cover has been restricted to the old, the poor and the pregnant), but the result is that one way or the other, almost anyone born after 1975 has to pay something for dental care. Which is why I have insurance, kindly offered by the US megacorp I work for.

Dental is the NHS black hole, but the rest of the system runs fairly well. Obviously it doesn't make money for the government, but it's the largest employer in the country (I think 40%+ of the active population works for it) and it literally stops the underclass from rioting. There are constant debates on priorities (e.g do we need more experimental drugs to cure cancer, or more psychiatric services?) and costs (Labour will usually spend more for it, Tories will invariably slash budgets with a passion), but all in all I'm not disappointed by how they use my taxes. I recently had my first baby and I have nothing but praise for my local service.

Giacomo @33:

You are correct; dental is covered if you can find an NHS dentist. In Edinburgh, at least, that meant that dental care was effectively not covered, because none of the NHS dentists I tried were taking new patients.

I went private and paid cash.

As you say, dental is the NHS black hole (well, that and glasses; you used to be able to get basic, ugly frames on the NHS, but I think even that option is gone now.) This is unfortunate, because both dentists and opticians frequently find the first symptoms of disease.

The Tories used to want to privatize the NHS. But after what they did to the train system, it wasn't bloody likely that anyone would go along with it. The saying in the UK is that the NHS is the electric third rail in politics. Touch it and you die.

Giacomo @#33: The NHS is excellent and wonderful and employs my sister and has saved my life twice at enormous cost to it and none to me, but 'I think 40%+ of the active population works for it' is certainly untrue: that would make it by far the largest employer on Earth, and while it's close, it's not there. The last figure I heard was somewhat over a million people (Wikipedia says 1.3 million as of 2005). The UK has more than three million people active in the workforce! :)

My Medicare supplement coverage consists of plans to sell my comic book and Magic the Gathering collections.

FWIW, my experience with UK waiting times - I live in central London, and am just old enough to have been looked after by the NHS since birth.

To see my GP, I can either make an appointment for the afternoon/evening, which can take from a couple of days in the summer to over a week in winter, or turn up in the morning and wait until he's free. With an appointment, you actually see the doctor within half-an-hour or so of the acual appointment time, depending on how busy they are, and without one, you can wait for up to an hour, again depending on how many other patients there are - in the winter flu season, they sometimes have a nurse to do triage before you see the doctor. I had a blood test last week (no appointment, drop in to the hospital with note from my GP); that took about ten minutes, and I'm just off now to get the results from my GP now.

Last year I had a hip replacement; it was diagnosed in September 2007, and I was told the operation would be in about five months. I was actually called in within four months, and couldn't make it (my fault, not theirs), so I ended up waiting until June 2008 but, as I say, this was my fault. Treatment and care were exemplary (apart from dubious hospital food). Now I'm wondering about a knee replacement; I've been told I can get my name down for one any time I like, with a wait of about five months again, but I'd like to lose some weight before going through the whole process again.

About dentists - here in central London I haven't had much difficulty finding an NHS one, although there are plenty of private ones as well, and certain newspapers like to make a lot of their alleged scarcity. You have to pay for NHS dental treatment, but it is very much cheaper than going private.

Much of the rest of the world manages to have an equitable health care system. That doesn't mean there's any possibility of meaningful health reform in America.

Equitable health care systems in the rest of the world are a leftover product of an earlier era and cannot be created anew today. If any other country was to try creating an equitable health care system today it would run into exactly the same obstacles to reform as are present in America.

The problem is one of ideology. Health care systems in the rest of the world were enacted when the global Overton window was considerably further left than it is today. Equitable health care is simply not on the table as the post Reagan-Thatcher Overton window defines the only acceptable purposes for government as upward wealth redistribution and authoritarian control over the public.

America is also encumbered by two dysfunctional legislative chambers that operate on the basis of legalized bribery and a sociopathic, sadistic, political elite that values insider self dealing above all else and has no empathy or sympathy for anyone who wasn't born with a silver spoon in their mouth.

Health reform will not happen in America without a repudiation of Reagan and a complete reform of the political elite.

Snowball. Hell.

25: or, as we say in the Federation, "Service Guarantees Healthcare Coverage! Do You Want To Know More?"

jsgbs @38:
Equitable health care systems in the rest of the world are a leftover product of an earlier era and cannot be created anew today.

The Dutch system was substantially changed in 2006. It's still equitable.

Health care systems in the rest of the world were enacted when the global Overton window was considerably further left than it is today. Equitable health care is simply not on the table as the post Reagan-Thatcher Overton window defines the only acceptable purposes for government as upward wealth redistribution and authoritarian control over the public.

Your Overton window is not the global Overton window. Government in much of Europe ranges from a right wing of welfare states to a left wing of open redistribution. Even the wave of right-wing victories in the recent European elections leaves a scope of debate much wider than America has seen since before World War 2.

But the global Overton window is entirely beside the point. America needs this. If we can't do it, the fault lies with us. Don't blame the rest of the world.

Snowball. Hell
Man. Moon.

JFDI.

me @40:
Snowball. Hell
Man. Moon.

Also:
Black man. White House.

Dental care is the only healthcare I've paid for (except for prescriptions; unless you fall into one of various concessions and exemptions, prescriptions all cost a flat free of about £8 to fill). Can any USians tell me how the prices compare? I had three fillings (where my gums had receded) and it cost around £75, including the initial checkup when he told me I'd need them.

The NHS may be one of the top-5 employers on that planet, behind the Chinese People's Liberation Army, Walmart, and the Indian Railways.

The total can be argued about a bit, because there's a fuzziness about who is "employed". A GP practice is technically a separate business providing services under contract.

The NHS isn't immune to political interference, and look what the idiots did to the railways in Britain in the name of value-for-money. But I feel a certain jingoistic pride in knowing that we Brits set up two of the operations on that list.

Kirilaw@8: I was that middle-aged chap with chest pains.

Ring GP at half-eight after sleepless night, mention chest pain. Receptionist goes 'Come in NOW'. I duly beetle to the surgery where they wire me to the ECG kit, squint at the readouts for thirty seconds and say 'There's nothing wrong with you but a seriously raised heartrate. What's up?'

It takes a while to tell the nice GP how b0rked things are, but I eventually leave with a cheery grin and a vast box of beta-blockers (to be taken as and when, as anti-anxiety meds). Cost to me: seven quid.

If you pay attention to the likes of the Daily Mail (and there's no help for you if you do) then you'd be under the impression that the NHS was a terrible communist edifice dedicated to sawing the wrong legs off pensioners and bumping 'asylum seekers' (aka filthy foreign undesirables who push down property prices) to the front of various queues.

My own dealings with the NHS have for the most part been splendid (their adventures in computing less so, but then I did that for a living and came away with the firm opinion that many NHS IT consultants need a good shoeing) and I really can't understand why anyone might think that socialised medicine is a bad idea.

One caveat I would enter about the NHS is that the GP service is patchy, and I personally know a number of people who suffer from conditions their GPs failed to diagnose or failed to diagnose in a timely manner.

However, it's also true that they were all treated successfully in NHS hospitals after they finally got past their GP. This includes the bloke who needed emergency surgery to remove a rare tumour from his colon and intravenous antibiotics to treat the septicaemia that developed as a complication of the cancer, and who is now celebrating passing the 5 year threshold of survival.

GP practices, of course, are private businesses that act as subcontractors to the system (there are now a few NHS-owned practices, but they aren't common); this is the upshot of Nye Bevan's famous remark about stuffing their mouths with gold.

One claim I came across on a libertarian site was that the admittedly-high US spending on health was actually funding some vast percentage of medical research, and that all the rest of the socialised-medicine world was happily and parasitically riding along on the US's coattails. Anyone got a potted refutation to hand?

Adrian Smith @46:
the admittedly-high US spending on health was actually funding some vast percentage of medical research, and that all the rest of the socialised-medicine world was happily and parasitically riding along on the US's coattails.

I don't know if it's true or not, but if it is, it's hardly an argument for the status quo.

If the rest of the developed world is not paying its way, then it's time we start. The US medical system cannot, and should not, be subsidizing European health care at the cost of its own citizens' health.

If the capitalist system for maximizing profits is so very good (and if it's not, roll on another way of providing coverage and care!), then the research companies will find another way to make money. I have great faith in their motivation and ability to do so.

I had three wisdom teeth taken out on the NHS on Thursday, under local anaesthetic (I was offered general but don't have childcare cover for that long!)

I was able to eat potato crisps on Friday. I'm a little achy now but basically fine. It cost me nothing except fare to the hospital. Oh, and the £17 co-pay for the visit to the NHS dentist who referred me for treatment.

Adrian Smith #46: No numbers to hand, but the claim does not sound credible to me.

Yes, there's a lot of expensive gadgetry and drugs such in play, but most of the real expense in our healthcare system is the cost of insurance -- both actual health insurance, and malpractice insurance. Note that the high costs of the latter are aggravated by the excessive workloads for doctors, which are pushed by, again, the health insurers trying to cut costs.

The basic problem with our system is that the insurers, who were supposed to be working as facilitators, have morphed into gatekeepers and "rainmakers" -- that is, extortionists.

Adrian Smith, #46: "US spending on health was actually funding some vast percentage of medical research,"

US medical research funding is a drop in the bucket compared to US spending on care. So what's the point of saying this, except to whip up conflict? The USA could still fund the research, and have better and cheaper medical care.

We corvids like conflict. More food.

The reactions I get when I describe the American system is "That can't be true". For example: "$800 a month? That can't be true. You mean a year."

The reaction I have is: "Why aren't Americans rioting in the street with pitchforks and flaming torches?"

Because that's what would happen here if the Tories were to attempt to privatize the NHS.

BTW, my surgery seriously sucks, but on the other hand my NHS dentist is ten minute's walk away. Then again, I live in London.

For an interesting look at health care systems in countries other than the U.S. I recommend the PBS Frontline documentary "Sick Around the World."

I've been a member of a group-practice HMO (Health Maintanence Organization) for 35 years (first Group Health Association and now Kaiser). What the medical lobby denigrated as "socialized medince" back in the 70s during a prior attempt to reform our health non-system.

Kaiser isn't perfect, of course, and taking an informed role in my own care is important. But I prefer being under their centralized system--I don't want to put my medical care in the hands of a random private practice doctor, who may be overworked and not up on the latest of medical best practice.

At Kaiser I've had the same primary doc for ten years. There's round the clock medical advice availbale. Just this week I stopped by the Kaiser lab Monday for routine blood tests (results viewable on the Web) and Friday I'll return to the health center on for a routine doctor's appointment and then down to the radiology department for my annual mammogram.

There are other viable alternatives to employee-group-based traditional health insurance. I hope the final health reform plan includes a community-based public option or at least something along the lines of a co-op (which is how GHA began).

SeanH @42 asked: Dental care is the only healthcare I've paid for (except for prescriptions; unless you fall into one of various concessions and exemptions, prescriptions all cost a flat free of about £8 to fill). Can any USians tell me how the prices compare? I had three fillings (where my gums had receded) and it cost around £75, including the initial checkup when he told me I'd need them.

I'm lucky; my husband is a civil servant for the state we live in (IL), and therefore has (a) a defined-benefit pension, which NOBODY gets anymore -- he just needs to make sure he's still working there for another 20 years before he retires; and (b) quite decent health insurance, for not much money paid by us.

Because I grew up well under the poverty line using actual real professional medical care for as few things as could be managed (and a lot of homecare for things like wounds, ingrown hairs/toenails, and other things I was baffled in college to find other people thought meant an automatic trip to the doctor), I cannot bring myself to trust that this happy state will continue indefinitely, and so when it came time to find a dentist (because I could see my own dentin through the cavernous hole in the front of one of my teeth: never a good sign, by the way), I went to the dental school of the university he works for.

At dental schools, you trade your time for money. There's a lot of sitting waiting, a longish (1mo+) wait on appointments, and getting almost anything done involves about 4 hours in the office, because everything has to be checked by instructors. Also, they don't 'take' insurance, though they'll print you out a receipt to mail into your private insurer for reimbursement after the fact. But the bonus is that fillings cost less than $80 each tooth (and that's for complicated ones), and crowns about $500; I'm going to be getting an implant this year to replace that extracted tooth, for about $600 total, including the bone work, the post, and the tooth-shaped thing mounted on top.

In the 'real world', implants cost upwards of $2200, depending on where and how you get them done ... and what insurance you have. Yes, that's what you pay AFTER the insurance pays. It's been a really long time since I got a filling out in 'the real world,' so someone else is going to have to provide cost estimates.

I have no idea what we're going to end up paying from the birth of our first child in February; we keep getting bills that talk about discounting and insurer responsibility, with zeroes for what we owe right now, so we'll see. The downside of the insurance we have is that it's 'self-funded' by the state: they pay CIGNA to run the infrastructure, but once a claim is accepted, it takes the state about 8 months to cut a check to the poor health provider, so there's a really long delay before we find out if WE owe anything, since that happens after they get the insurance check and then we owe the balance.

I'm all for developing some sort of rational health coverage that covers all Americans. It's just not going to be easy.

Right now, there's a $2.4 trillion pie that's growing larger at more than twice the rate of inflation, and the people benefiting from that increase don't want it to change. One person's excessive health care cost is another person's well-deserved compensation -- it all depends on your POV.

That's the real kicker. Doctors, hospitals, pharmaceutical companies, insurance providers are all getting a good deal of money, are used to that revenue stream, and want it to continue. And just eliminating insurance companies isn't going to make that much of a difference.

There are interesting Catch-22's in the business model of health care. Conservatives like to say that if consumers had more say in paying health care costs directly, then market forces would come into play and slow the increase.

However, it's just that disconnect from consumers' direct payments that enables things like the development of new procedures, drugs, and therapies. Since those are far too expensive for an individual to pay for, the only rational reason for expending huge amounts of money in developing them is the expectation that they will be covered by insurance programs.

********

It can be done. We can have better health care. We're just not going to get anything perfect.

Anna #51 - the tories privatise health care? As far as I can tell, new labour are dedicated to slowly hiving the entire NHS off to the private sector. They have to do it slowly and quietly, but they've done a good job with the PFI/PPP landing hospital trusts with millstones of debt, and the internal market system doesn't help either, according to some people.

As far as I am concerned, this argument has been over for some time. Other countries seem to know how to do decent health care AND pay for it without bankrupting their countries. We can do it too.

I just heard on NPR that in order to fix the costly universal health care system in Massachusetts, (which insures 97% of the population) the state is eliminating fee for service payments, and establishing a system similar to Kaiser's, where doctors are paid per-patient, not per procedure. Should have done that from the start, but better late than never.

I couldn't get through to Dianne Feinstein's office yesterday. I'll try again today.

Kirilaw @8: How long IS the wait for a hip replacement in Canada?

I'm asking because my Mom had a knee replacement here (Columbus, Ohio) last year, and the demand here is so heavy she had to wait three months to have the surgery. Medicare picked up most of the tab.

For part of my childhood I grew up in England, so I've seen the way that things are done in the US and the UK. (I returned to the US when I was 18.) Obviously I don't have a full picture, because I had parents watching out for me and didn't have to worry as much about the troubles of the world, but I still think it's a good starting point.

A friend of mine in a solidly middle-class family didn't have to worry when he took a shuttlecock to the eye and subsequently had to have cataract surgery. Neither did his parents. It was taken care of and that was that. There wasn't any worrying about claims being denied, being out of pocket a significant amount of money, or anything like that.

My sister still lives in England. She's a hairdresser. She doesn't have to worry about being out of pocket if she needs to see her GP. My mother has occasionally mentioned maybe seeing about having her move back to the US, and I pointed out that she has a whole lot of safety net for the times she's unemployed (and even when she isn't—it's not like hairdressers get health insurance) in the UK that she just wouldn't have here in the US.

Are there issues with the NHS, waiting times, and available hospital beds? Yes, there can be, but it's my experience that they manage to prioritize fairly well and the people who need care get it.

Under the NHS, people who are poor and ill can see their GP. They don't have to use the services of the emergency room just to get basic care, or wait until it's really bad and then be forced to go to the emergency room.

I'm comfortably middle class, and yet, even when economic times were better, I worry about seeing the doctor just because I don't really want to deal with the insurance company. I worry that I won't have insurance if I'm laid off. I like lots of things about the US, but this is most emphatically not one of them.

All of this makes evident one thing: the foes of decent and universal care depend greatly on Americans not knowing anyone who has used another country's health care system.

*Note they are already trying to scare seniors with nightmares of Obamacare just writing them off to save money. As the apocryphal old woman said, keep the government out of my Medicare!

Price point for basic dental care, last three years, Maine/USA, uninsured patient (that is, all out-of-pocket):

Cleaning and X-rays and exam by dentist- $171 (2006)
Two smallish fillings (2006) - $225
Cleaning and exam by hygienist - $115 (2009)
Cleaning and X-rays and exam by hygienist - $162 (2008)

I should add, as a footnote, that I had to call three quarters of the dentists in the local directory before I found a practice that was taking new patients - and this without any insurance hassle.

(I've learned to promote myself as an insurance-hassle-free patient: no paperwork, just let me know cash, check or plastic. Crazy, but sometimes it can get me in the door of a busy practice for a little thing that needs attention.)

We pay a little over $600 a month for health and dental insurance for a family of 4. Employer subsidized. My employer recently switched us from HMO to high deductible plan without reducing the premium.

Child A developed eosinophilic esophagitis. Gastro and allergist visits, testing, medication, and other routine /unexpected medical needs (such as a sprained neck and injured shoulder) at the beginning of the year caused us to spend ~ $1000 out of pocket, much of which did not go toward our deductible (copays and prescription costs apparently don't count).

Husband needed a dental implant. The damage, after insurance paid, was over $800.

I recently had an infected gall bladder. Dr. visit (my primary care dr thought this needed a gastroenterologist, apparently), $30 copay, hospital bill, $11,000+ of which I get to pay $2,300+. I still have the surgery to remove said organ to go later this summer, my share of which will probably run another four figures.

Child A will need braces soon. I shudder.

And just think, I am lucky to have insurance in the good old US *sigh*

Lizzy L #56:
Yes there is a universal health care plan in Massachusetts, and yes, it covers about 97% of the population, but it is a mix of private and public insurance, with the mandate enforced by tax penalties. If your employer offers insurance, that is what you get to use, possibly subsidized by the State if you are below certain income guidelines. For those who don't access to employer-sponsored health insurance, the state has arrangements with various health plans to offer reasonably priced policies. For low-income people there are special plans with various costs/copays. For the lowest tier, there are no monthly fees and the only copay is for prescriptions (2-3 dollars per script). This tier even comes with free dental. The state contracts with health plans for this care, and there are multiple plans available with various features to choose between.

I am currently officially poor, and this is the best healthcare coverage I've ever had. And I need it since I have some major medical issues going on. The state pays the plan about $500/month for me. After I was laid off from a big employer several years ago, they were paying around $600/month for me, and co-pays were in the $20 range. To continue coverage after the grace period, the price went up to $850.

The problem is that it is still costing the Government too much. Too many people still use Emergency Rooms for basic care (partly due to not having access to a primary care doctor, but mostly by habit) so the state isn't getting the savings from that to cover the plan, so change are in the works.

Since many more people now have access to primary care doctors, there can be real problems getting a doctor. I'm in far suburbia, so finding my doctor was relatively easy.

A lot of healthplans pay doctors for basic care by capitation rather than fee-for-service, but care outside of the norm is by fee, and external services are by fee.

A routine appointment gets booked about a month out. Urgent appointments are available within a few hours.

Anticorum @ 59:

I think it's more general than that. There are an awful lot of Americans who have not been outside the US at all, or have only gone briefly on holiday to another country and remained rather insulated from the way things are there. I'm well aware that being able to travel like I have is a marker of privilege, but I still think that having people experience non-US ways of doing things would help the country immensely. If nothing else, it would help to dispel the unquestioning, everything's-better-in-America mentality.

A lot of this plays right along those lines. If you're already convinced your country is the greatest, anything the other countries do is obviously not as good as what you have. I think it's sad and disgusting that the people who would benefit the most by having good healthcare coverage are being manipulated into agitating against it.

Lori Coulson @57:

Wait times vary enormously by location.

In Ontario, according to this site, the average wait for a hip replacement is 162 days. The shortest wait times seem to be 35-40 days, and the longest as much as a year.

(If you're curious about other provinces, Health Canada has a list of provincial initatives to track wait times here.)

Elliott, #53: Either your estimates of the cost of dental care in the "real world" are seriously inflated, or I have the exception to the rule. I'm currently in the process of getting caught up after 5 years of putting off dental visits, meaning some half-dozen fillings including one that's going to require digging out and cleaning underneath an older one, and the total I'm going to be paying is less than $600 -- spread out over several months, as I can afford to have them done. I had a crown a few years ago, and it ran about $400 IIRC; still a painful nip when done all at once, but not completely out of reach. Of course, my dentist's clientele (as far as I can observe from his waiting room) consists largely of lower-income people, so that may have something to do with it.

The coverage rates in the US look even more dramatic when broken down by age and by state.

I have a graph based on data from the Behavioral Risk Factor Surveillance System, a large telephone survey conducted by the Centers for Disease Control.* The data are from the 2007 survey, while the Massuchusetts plan was being introduced, so MA is better than most places but still has a lot of uninsured people.

It's very clear from the graph that Medicare works. Also, HI and MA have noticeably better rates of insurance coverage, because of evil socialist government interference in the free market. Texas as a whole is bad, but it looks even worse because the situation in the areas near the Mexican border is truly abysmal. BRFSS is large enough that none of the apparent differences between states are likely to be sampling error (total sample size about 450,000).

* For detail-oriented people, the question was "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?" and I counted "Don't know" as "No".

Although we now have "good" insurance, we're still paying off $15,000 from my husband's 2005 two-day hospital stay when we were uninsured. Any system that doesn't load its users with crushing debt if they're unlucky enough to a) not have a job with insurance and b) get sick is fine with me.

Echoing vian (#15) and Meg (#31) in approving Australia's Medicare (formerly Medibank) system (with optional private extras). Room for improvement, but pretty good.

2009 marks my 10 years' survival; 1999 was the start of a whole saga of family and medical problems that pretty much took over my life. Without Medicare and associated social supports I would be some combination of:
   dead;
   imprisoned/criminally insane for murder; and
   bankrupt
long before this. My outlay would maybe add up to tens of thousands (I had a job paying the average wage, so not all "free" care. Some was partly covered by my private insurance, now ~$1000pa, over 30 years.), but not hundreds of thousands.

Lee @65, it may vary a lot by geography, too. I was without insurance and too poor to afford any dental care whatsoever for over a decade, and am trying to make up for that now. My first dentist visit cost me $2,000 out of pocket, WITH insurance, for a crown and a few fillings.

I've since changed both dentists and insurance plans, so things aren't as expensive, but nonetheless the impression I got from asking around at the time was that that amount wasn't out of the ordinary.

One issue I'm not seeing a whole lot of discussion about is that standard of care dictated by insurance companies. In trying to catch up on dental care, I've been told repeatedly by Aetna that I can only have amalgam fillings rather than anything better. Since the amalgam fillings I had as a teen* are now having to be replaced, I'm not all that eager to have more short-term fillings. I'd imagine this sort of thing happens in all medical fields.

There's also a strong thread in American debate of blaming the victim. If only those people** wouldn't make the wrong choices and get sick, there wouldn't be all this fuss!

*I have incredibly thin tooth enamel. It's quite possible to take adequate care of one's teeth and still have issues requiring care.

**Generally the poor, the uninsured, and those without access to the "right" organic foods.

I pay just over $600/month for my wife's and my health insurance. This on a program that insures all state employees, a group numbering over 100,000. You'd think the state could get a better deal than that, wouldn't you?

Well, a lot of us have been asking that question; it seems that BCBS (the insurer) has entered into a really nice, lucrative, exclusive contract with the state of NC; they get to administer all the health related costs and issues, and in return the state pays them several million dollars a year, PLUS a cut of the premiums we all pay.

Every year their contract gets renewed, under a no competitive bid agreement. That's right, BCBS gets to set the price and the state accepts it.

And we state employees wonder why our premiums keep going up while our coverage covers less and less...

Adrian @46, on the subject of innovation, that particular assertion has been comprehensively refuted for drugs at least.
See for example
http://www.gooznews.com/archives/00956.html
Briefly stated, "science and public health drive real innovation, while the market innovates products that satisfies a demand that may or may not have anything to do with public health."

The invaluable Ezra Klein makes the same point, as well as observing that innovation is useful only on the margins - we don't need innovation as much as we need to implement what is known to work.
http://www.prospect.org/csnc/blogs/ezraklein_archive?month=08&year=2008&base_name=the_perils_of_innovation

John @44, Alex has written about the infestation of managerialism in NHS IT, well worth reading,
http://yorkshire-ranter.blogspot.com/search/label/NHS

The problem of a healthcare IT system has been solved by Vista (the Veterans Admin system) but it's free which is unacceptable. So, it's being killed by the profit motive.
http://www.healthbeatblog.org/2008/06/sapping-vistas.html
As Ezra (again) has observed, the real healthcare problem is a dysfunctional political system.

My only hope is that the camel's nose of a public good can be inserted into the Republican tent, where they huddle reciting free-market mantras and readings from Ayn Rand. But as Stefan notes, the forces of the stupid arrayed against reform are both wicked and strong. I am so tired of fighting falsity.

Part of what drives me nuts with this whole thing is that the argument against universal healthcare is driven not even by ignorance but by a twisted patriotism. The ameri-centric jingoism behind the argument goes something like "America is THE BEST, therefore all of our systems are THE BEST THERE COULD EVER BE, therefore if you want to change the system YOU HATE AMERICA!!!"

By extension, anyone willing to have a discussion about this is an anti-american flag-burning commie-pinko in disguise. [Why is it that all of the Right's epitaphs have hyphens?]

Which, come to think of it, is pretty much the Right's argument about anything these days. Don't like waterboarding? You're in bed with terrorists. etc.

Wasn't this the country founded on the ideals of progress and consensus, free discussion, and equality between the people? The founding fathers (which the Right loves to trot out time and again) weren't exactly known for picking a position and refusing debate from the opposing viewpoint. Hasn't anyone on "their team" read any of the Jefferson and Adams letters?

It's not like America has never adopted a better way before. If we were THE BEST at everything spontaniously and without precedent, we wouldn't have adopted submarine warfare, mechanized tanks, vaccines, rockets (either military or for space exploration), radio or RADAR.

What's sad is that anyone who has ever had to COBRA their insurance after a layoff knows exactly how bad the system sucks. But if you've never had a job that provided health insurance, or you've never worried about the costs of health care because your trust fund never shows you the bills and the family doctor doesn't have a waiting list or office hours...well then I'm sure you think everything is hunkie-dorie.

When I lived in Reno for a couple of years I worked a crisis line. It was an eye-opening experience, to say the least. I remember turning from a call to ask my supervisor if I could send the caller to one of the different supports I would have offered in Canada and she snapped "Don't talk about your damn system here." I think she was close to crying with frustration. People with suicidal kids were saying, "Don't send Ambulance. No ambulance." No body blamed them.

Since I've moved back to Canada I've had two children at no cost to our family. I was hospitalized for an extra three days with the first one and my second child has Down Syndrome. I had all his testing and care paid for. I'm now on a fabulous program that gives him specialized medical care once a year and sends me communications and play therapists to work with him, again at no charge to me. I could never move back to the States with Sam (my second child). We simply couldn't afford to.

ER, Canada:
Broken arm, expect it to be stabilized (if it isn't already), and pain meds if you need it; and then I hope you have a book. It might be all night.

"generic pains" - same deal. I even slept on the floor that night. (Note: Specific pains - we all know which ones - get preferred treatment. Note2: once we did see the doctor, it led to a referral to a specialist, a real diagnosis, and surgery in about 2 months. The pain was real, and chronic, you see, but not constant or life-threatening).

I was taken to Emergency for my Little Problem. Because the noise and the general "peopleness" of the area was making it worse, I moved as far away from everyone else as possible while still being in the waiting room. After about an hour of that, the triage nurse came over and asked me to go back to the main area, because she was concerned I might be forgotten (likely I had been). I explained the problem, and that it was barely tolerable here; if I had to go back there I would have to leave instead.

That got me into a non-medical room (usually used for "talks with the family") in 15 minutes; I waited there (in the dark and the quiet) for another hour or so, then had the medical discussions. I was in the program I was in waiting for (yes, there was a year-long wait; it's now about 15 months, I think; mostly because people on the list get worse, like me, and...) the next week. It would have been the next day, but "Friday's a half day, probably not that helpful...Can you come in Monday at 0800?"

I was in Ontario for this one. My friend fell down the stairs carrying a glass apple juice container, which shattered and embedded in his hand. That got him in and out of the waiting room in half and hour; he did have to wait 2 hours or so "inside", but that's because the guy who walked in, went to the triage nurse, and said "I've been shot." got his place. *He* was inside and being looked at before the police got there.

Oh, and no question about payment, even for the month-long, 35h/week "program" I mentioned above. Yep, there's waits. Nope, my time is not worth thousands of dollars a day for less wait. My life? Well, yeah, but then again, when it became a life-threatening issue, the wait went away.

Note: we don't have public dental coverage. My company's insurance pays for that, and drugs, and crutches, and the other wonderful things we sick people need.

While I believe our potential access to excellent care in the US is second to none (hence the "greatest health-care system in the world" bullshit), I don't believe we can continue with the system as it is now. And I wonder how much the lack of a system in the US affects the availability of services in Canada, with many specialists relocating south of the border.

Lee @ #65, the prices you're quoting are about what I paid for some catch-up dental work from the Baylor Dental College in Dallas in 1990. In 1999-2000, I caught up again and, for x-rays, cleaning, three fillings and one root-canal-and-crown, I paid nearly $3,000. Actually, that included impressions for a replacement bridge (I chew so vigorously that I dislodge dental work), as well. However, during that process they raised the cost of the bridge from $2,500 to $3,900, so I backed out.

My own experience with the American health-care system: Other than a few dental problems, I had been extremely healthy to age 50, with only a trip to the doctor every couple of years for sinus infections. In my early 40's, I had a job for a couple of years that gave me medical benefits, and I started getting semi-annual check-ups. However, after I went back into business for myself I did not get health insurance, because of the exorbitant cost and encouraged by my ongoing good health. My work involved some hard physical work, I was in good shape, with blood pressure in the high-normal range and total cholesterol of 140+/-. By age 50, I had retirement savings of >$200,000, as well as a healthy business that allowed me to also support my brother, who had suffered a debilitating back injury. He was on full SSI disability, but at that time in Texas, his monthly payment was only $551, which did not cover his living expenses, much less his prescriptions, which Medicare did not cover.

On 04 Oct 01, I had a major heart attack. I was taken by ambulance to the local hospital, stabilized, then transferred to an area hospital with a good reputation as a cardiac care center, and received immediate emergency care. The next morning, after an angiogram revealed blockages, I went into surgery, and received a quadruple bypass. I was in CICU for three days, and then on the cardiac recovery ward for another three. My hospital bill alone was $99,800; additional doctors' and lab bills added $65,000 to that. The charge by my local hospital for my 40-minute stay in the emergency room and a clot-buster shot was $14,000. All my medical expenses, plus the costs of aftercare and living for the two months before I was able to return to work in any meaningful way took up most of my savings.

In January of the following year, I had chest pains again, took myself to the local hospital, and was again immediately admitted. My symptoms only lasted an hour, and lab work indicated just a very minor infarction, but the doc there kept me for a week, because my doc wasn't in town and he didn't "want to take any chances." That $38,000 stay was something I couldn't pay for in a timely fashion, and it pretty well shot my credit.

Since then, I've had several other health problems, and then, in 2008, a new blockage caused five more heart attacks before another angiogram (my third) revealed the problem and an angiogram fixed it. Because of the emergency nature of my problems, I've always had immediate access to great care. My cardiologist's group continues to treat me, with only a small monthly payment. However, other health problems go untreated, because visits to other doctors must be paid at time of service, and I just can't pay. That's exacerbated by the fact that my problems have affected my ability to work, and now I'm basically penniless.

I can't complain about the care I got, at all--it's been excellent. But I'm not sure exactly what all that life-saving work has saved me for.

thomas @ #66 writes: "HI and MA have noticeably better rates of insurance coverage, because of evil socialist government interference in the free market."

What that means in Hawai'i is that back in 1974 the state passed a law called the Hawai'i Prepaid Health Care Act which required employers to offer healthcare insurance to all employees who average 20 hours/week over a four-week period. This has done a pretty good job of getting full-time employees group insurance; it's also affected hiring decisions since it's an additional cost to be considered when adding staff. Some small businesses (restaurants, from what I've seen, are particularly prone to this) developed a strategy to get enough people to do the job required while keeping them at 19 hours/week or less.

Something I didn't know until I looked this up: ERISA (Employee Retirement Income Security Act) was also passed in 1974; one of its mandates was that states couldn't mandate health and retirement benefits. Hawai'i got a Congressional exemption from that rule.

LMB MacAlister, when you had your heart attack in 01, at what point did the ambulance service or hospital require to know your credit-worthiness or insurance status?  If your answer had been “no credit, no money, no insurance”, would the outcome have been different?

LMB, what makes that even more of a royal shafting is that the health insurance companies would have negotiated payments way less than what you paid. The "list price" of hospitalization bears little resemblance to the negotiated price that the insurance companies pay.

Some experiences with the German health care system:

Choosing your doctor is not influenced by your insurer at all, so you can decide where to go. Small catch: In each quarter of the calendar year, you have to pay 10 Euros the first time you see a doctor, so you will usually choose one regular general practitioner as Hausarzt. She or he will provide you with referrals to specialists, free of charge. If you see a specialist directly, it's those 10 Euros again at the first visit.

Für medicine, there is a co-pay of 10%, but not less than 5 or more than 10 Euros, mostly. Many insurers have a system that gives you a bonus when you pick one "personal" pharmacy. Plus, there is much political arguing over branded and generic drugs; the insurers would prefer if the doctors precribed mostly the latter. It can be a bit of a hassle if you are allergic against lactose and the only cheap genericum is lactose-based, but I had never problems a talk with the doctor could not solve (doctors may note on the prescriptions that no generic replacements are allowed, but that cuts into their money a bit).

By law, you do not have to spend more than 2% of you annual gross income for co-pay; 1% if you are treated for a chronic illness. When you reach the treshold, your insurer issues a small card you show to your doctor and pharmacist to prove you're exempted.

Note: that is not all you pay for your healthcare. Depending on the insurance company you have chosen (you must have one unless you are self-employed or earn ~50000 Euros a year), you pay nearly 15% of your income. Age or current health makes no difference. (So I really did not understand the US stuff concerning "undisclosed medical conditions" at all the first time.)

So basically, the maximum payment you may have to spend is 17% of your income.

Waiting times: In my experience, they depend on the individual doctor. Some are good physicians, some are (or hire) good organizers, some are both, some are neither. The good ones are more sought after, of course, but it is rare that a doctor does not accept new patients.

Usually, you get an appointment for the next day or a day later, often coupled with the offer to come right in and "bring along some time", since you may have to wait two or three hours without an appointment - unless it is an emergency, of course.

Waiting times for specialists are longer, of course, up to weeks or even two months. Usually it helps very much when your doctor phones the specialist. But generally, there are no waiting lists per se, you just ask for an appointment and get one, perhaps quite late. For all I have experienced, being put on a waiting list is for people needing replacement herats, livers odr kidneys. There always to little organ donors, so I have heard.

Hospital stay costs 10 Euros per day, for up to 28 days (unless you have reache co-pay exemption, of course). Some hospitals are communal, some are privately owned, some belong to the state, via an university they are part of. All serve bad food.
Oh, and some belong to a church, but in Germany, that does not mean much. In one Cologne-based hospital owned and run by a female monastic order, lots of flyers informed us proudly that they could now offer regular islamic spiritual guidance (by an imam) for the muslim patients.

I once had an additional insurance (basically inherited, premium ~ 15 Euros per month) that guaranteed "Chefarztbehandlung" (the head person of the whole internal or surgical medicine dep. would look at me, not the deputy chief), a single room and Krankentagegeld (I would receive about 25 Euros per day I had to stay in hospital). So when I had to go to the hospital; I decided that seeing the head guy was not worth it, I could forgo that part of the police for additionaly 15 Euros per day; so the two-months-stay paid quite handsomely, especially as I was able to continue my work on a laptop in that single room with a good locker. But did I mention that the food was really awful?

Mobility devices like wheelchairs, additional motors, walkers and those things must also paid by the insurer. There are some differences between insurers and their willingness to pay the more expensive devices; and it took us almost half a year of arguing to convince our insurer that my wife would fare better with a customized wheelchair and a handbike than an ordinary wheelchair; and you simply must not give up after the first negative reaction.

There a kind of rationing: A public list defines which treatments and procedures the insurers have to cover. E.g. homeopathic and most alternative medicine is not covered. Neither are some routine preventive measures like a scan for melanoma, which is quite bad. That does not mean you cannot get them, but you have to pay your doctor directly (prices are regulated). Consumer advocates are annoyed that in many practices the lists of these "special offers" are quite difficult to understand for a layperson, since useful prophylactics and pure cosmetics are not differentiated enough.

But all these reports about people dropping into bankcrupty due to getting sick, or having no job and therefore no decent healthcare; and very many of their countrypeople just accepting that, sound very ... I cannot find a word to describe it. A bit SFnal, as if it were intended to showcase a truly different, almost alien mindset.

Just a sudden thought: The whole concept of lawsuits is different here, too: Lawyers are not paid by hour, but proportional to the disputed amount, and legal expenses insurance is quite affordable. So while not many would *like* to sue an insurer over a rejected procedure or device, the thought is not as frightening as it seems to be in the US.

Steve C., AAMAF, I've always been listed as self-pay with my GP, and have always gotten a discount that seems to average 35%. Same goes with my cardiologist, for follow-up. But that was definitely not the case with the hospitals, labs, or consulting doctors.

John Stanning, I was good friends with the head of the EMS at the time, as well as the dispatcher who took the call, so I can't say about the ambulance. When I arrived at the (good) regional medical center, I was out of it (good ol' morphine). Someone came in a day or two after my surgery to get my information, or lack of it. During my subsequent stays, they've had my records, and just remind me to fill out the forms I get in the mail so they can be reimbursed by the county fund that takes care of indigent care.

So you chose the right place for your heart attack!  We should all be so lucky as to have our medical emergencies somewhere where we’re good friends with the head of EMS and the ambulance dispatcher...

I might ad that, since moving to another town, I've driven myself to the hospital each time I've needed to go, just so there's no question of which hospital. You can't imagine how long that trip can be when you're having major chest pains.

Steve @54

Conservatives like to say that if consumers had more say in paying health care costs directly, then market forces would come into play and slow the increase.

This was the argument - and I was employed by a company making it in 1985 - for increased deductable amounts, copays and employee share of premiums. Employees would be 'responsible consumers' and help drive down health care costs.

After at least 24 years, I have to ask, How's that working out for you?

Yeah, I thought so. The argument fails, at least in part because we go to doctors because they know more than we do. We want access to specialists because they know more than our doctors do.

To continue the argument for having patients second guess the need to see their doctor, I'll hand the podium over to Mr. Jim Henson.

A few things I have forgotten, which may also be interesting: Among the things insurance has to pay for are contraception and brtns; but also artificial insemination. And also cosmetic surgery if indicated by a pssychological expertise. So it is definitely not just emergency-style care.

Concerning the costs: The employer has to pay the same amount as the employed. Since that is not optional, some employers try to weasel out of this obligation by outsourcing, employing pseudo-freelancers etc. So it is definitely not all good here.

Oh, and perhaps interesting for quite a few here: There is the Künstlersozialkasse ("Artists' Social Security Fund"). Membership is open to all self-employed people who live mainly from their earnings as musicians, composers, writers, journalists, critics, translators or copywriters. It is financed by a general contribution all publishers of the written word and music have to pay. This fund acts as the "employer" of its registered members inasmuch as it pays the employers' half of the insurance premium - the artist may still choose the insurance company he wants. It is seen as a very important institution in granting social security to freelance artists.

For clarity, I should note that the €200-plus per month that I pay in health insurance is the whole amount. My salary includes a contribution to that amount from my employer.

But all Dutch employers are required to pay this, so the contribution doesn't tie me to this job. I don't know if Dutch employers try to dodge their contribution like the German ones that Jörg cites.

And I understand Jörg's comment @80:
...all these reports about people dropping into bankrupty due to getting sick, or having no job and therefore no decent healthcare; and very many of their countrypeople just accepting that, sound very ... I cannot find a word to describe it. A bit SFnal, as if it were intended to showcase a truly different, almost alien mindset.

I live in both mental worlds. It's a stretch, sometimes.

As a healthy 30-year-old I've not had a lot of personal experience with Canada's health care system, but being currently grossly underemployed, I pay zero, nada & zip for provincial medical coverage, which is one minor worry off my mind.

There's a fee (co-pay, of sorts) for ambulance rides and certain other things - when I was 14 and broke my wrist we paid an extra $30 for a fibreglass cast. Plaster would have been 'free'. I gather fibreglass is now standard, but possibly you can pay the extra for cool coloured fibreglass - I saw a young girl with red-and-green alternating stripes of coloured fibreglass last Christmas, I know.

A relative had a major medical episode a few years back - diabetes, alcoholism and such combined with septicemia (sp?) to put her in ICU with liver, kidney & lung function all compromised. Two full weeks in an isolation ICU with a dozen lines and wires connected, and a million or so bucks worth of machinery & computers, then another three weeks in a regular hospital bed and she was recovered enough to go home - total cost to her, $35 or so for the ambulance ride.

ICU admission in her case was instant, the care & facility were top of the line, and neither she nor the rest of the family came out of the whole mess bankrupt. Shocking.

Watching the US debate is quite surreal - it's the dark side of American exceptionalism, I guess: the feeling from a certain percentage of the US population that they already live in the best of all possible systems/worlds and all those foreign types can't possibly have invented a more equitable, higher-quality system.

myrthe @ 28: "I'm not sure if this is rebuttal or confirmation, and you do address it in your next sentence, but I think it worth linking Ezra Klein's observation observation that health care panels and events are constantly well attended by single-payer activists asking questions and advocating. Reports just ignore them."

Yes, it's not so much that single payer is without support as it is that that support is rendered invisible by the media/doesn't extend to anyone with power. I don't know--it's possible that single payer is popular only among a fervent but quite small group and that it really is politically unfeasible. The current situation doesn't actually prove that though. I'd like to see them get the chance to make their arguments to the American public before they're written off.

I'd be more upset if I thought single-payer was the only viable option.

Adrian Smith @ 46: "Anyone got a potted refutation to hand?"

Ezra Klein does. Highlights: the pharmaceutical industry only spends about 15% of their money on research, a large chunk of which is just commercializing the results of basic research done by NIH or creating copy-cat drugs to renew patents. In short, Big Pharma is a terribly inefficient source of innovation at best, and an active distraction from it at worst.

hieresiarch@88: Big Pharma is a terribly inefficient source of innovation at best, and an active distraction from it at worst.

While the 'at worst' is certainly true, the 'at best' is a bit oversimplified.

Big Pharma is very good at molecule twiddling to turn initial lead compounds into better drugs. Sometimes this is a waste of time (eg separating out one isomer of omeprazole (Prilosec) to give esomprazole (Nexium)) but sometimes it is very useful, and often it is moderately useful. Take the HIV protease inhibitors, for example. The new ones are much better than the old ones in terms of toxicity. The new statins (Lipitor, Zocor) are better than lovastatin.

The other thing Big Pharma is very good at is running trials, provided they have the right incentives. That is, if the relevant FDA advisory committee is going force them to define safety and efficacy in a sensible way, the pharmaceutical companies run trials very well. The problem happens when they are allowed to get away with bogus efficacy definitions (Avandia: effectiveness of a drug for Type II diabetes defined solely in terms of blood sugar, not in terms of clinical disease events) or inadequate safety studies (Vioxx: no adequate cardiovascular safety studies for a drug that was a priori likely to mess with clotting). Unfortunately the FDA advisory boards vary quite a bit in quality.

From a game-theory perspective you can argue that the purpose of the FDA is to make it more profitable to market drugs that work than drugs that don't work. They have some real effectiveness at this, as you can see by comparing pharma to the 'nutritonal supplement' industry, where effectiveness doesn't provide any real help in marketing and consequently most things don't work.

I think a better FDA would have more effect on drug innovation than changes in health insurance ever will.

Another UK datum here: this time from Edinburgh, Scotland.

I have a chronic condition (hypertension) such that I go to see a cardiology professor about twice a year, and take six different meds. Total co-pay is currently £38 a year for all the pills I can gobble (in the form of a prescription tax pre-payment certificate) -- but the Scottish government has committed to abolishing the tax by 2011, and consequently the co-pay is going down by about 35% per year.

On seeing a GP: I'm with a fairly good multi-doctor group practice. If I have a minor complaint and phone for an appointment and want to see a specific GP at the practice, I may have to wait 2-3 working days. (Or not, if I luck out.) If it's urgent and I want to see a doctor, stat, my current low-waiting-time record is 20 minutes for the appointment (I barely got there in time.); my worst was four hours. If they say "11am" they mean "11am, plus 5-10 minutes"; if a doctor's running more than 30 minutes late you're supposed to bug the receptionists.

Dental work ... I'm with the rare, lesser-spotted NHS dentist. She's paid piece-work, so she's fast and efficient. A checkup, descaling, and one filling will set me back a co-pay of around £20; new bridgework is in the range £80-250, capped at £400. However, dental implants aren't available on the NHS (yet) -- if you want them, you're paying private fees.

Hospital referrals: if it's an emergency, you go to the front of the queue -- if it's a chronic non-debilitating condition, they've got more important stuff to prioritize, so you get to wait. The time I went in with a referral from my GP for hypertensive crisis (when I was diagnosed) I was on an ECG within five minutes of walking in the door -- then had to wait three hours for the cardiology consultant to get to me, and five hours for a bed in the observation unit to free up. (Apparently I'd picked a busy night.)

On the other hand, when my wife had a persisent (multi-week) migraine, after the GP decided that a brain tumour was unlikely, it took six weeks for her referral to a neurologist to come through, and another two weeks for the MRI scan. (Then the migraine went away of its own accord.) That's the NHS in a nutshell. If you're having a heart attack or cancer, it's as good as any other service, but if you've got a headache, you may have to wait.

(Oh, you want to know about the co-pay for the above services? Zero. None. Nothing.)

On the subject of the hip-joint queue: the scarce resource isn't money, it's surgeons. Osteology professors don't grow on trees -- and their relationship to the NHS hospitals who pay them is that of skilled professional contractors. They have their own private practices, and folks who can afford to pay for their attention do so. Doubtless the NHS could shorten the waiting time for a new hip joint by block-buying all the surgeons' private practice time, but we'd end up with the private patients going through the NHS instead, so the backlog wouldn't shrink much. The real solution is more surgeons, but that's a problem where the lead time on delivering the solution is on the order of a decade.

Charlie Stross @89: Thanks for the info -- I'd figured that the wait for the joint replacement involved not-enough-surgeons-to-go-around, and I'm betting that's the case just about everywhere.

Mom did very well after her knee replacement -- now the OTHER knee is acting up, so she may be back in the bodyshop later this year.

Jan lucked into being referred to the best hand/wrist surgeon in town when she broke her wrist earlier this year. Nice doc -- he came out and showed me the x-rays after he'd put the plate in, and grinned when I told him he did great work.

But all these reports about people dropping into bankcrupty due to getting sick, or having no job and therefore no decent healthcare; and very many of their countrypeople just accepting that, sound very ... I cannot find a word to describe it. A bit SFnal, as if it were intended to showcase a truly different, almost alien mindset.

Dystopian, I think, is the word you are looking for.

"..Conservatives like to say that if consumers had more say in paying health care costs directly, then market forces would come into play and slow the increase.."

What they will deny until the cows come home, but what they believe in their hearts is that the cost will come down because the ill people who need procedures will *die* and the need to pay for those procedures will be bypassed

One of the absurdities of the "system" is that at one point, when I was working for a temp contracting agency (IT services) I had elected to be carried on the agency's books as an employee, working on salary, and working (usually) 60 hrs/wk. That meant I was making about 30% less in salary than if I had elected to be considerd as a true "contractor," but I got benefits such as health insurance.

At one point, the company I was doing the programming and support services for offered me a chance to become one of their employees. there was, however, a catch.

I would have to wait for 6 months before I would be eligible to use any but the emergency services part of the insurance coverage, while still paying for the full monthly premiums.

Second catch -- my wife was then pregnant with our first child, after some reproductive health-related scares. The offered job's insurance coverage would not cover the pregnancy *at all,* even emergency services directly related to the pregnancy, becuase it was a "pre-existing condition." And even refused my offer to pay for the waiver to get the "condition" covered. I had to pass on getting that job.

So, yes, I am indeed in the position of knowing *just* what it is like to not be able to move up in one's profession because of fear of what may happen in the medical arena.

And I am at wit's end with these morons who are *approving* of the Brooks Brothers' Brigade doing astroturfing (amd it just happened here in Worcester (MA) when our local congresscritter tried to have a meaningful discussion with people).

One of those a******s had the gall to compare this disruption as something akin to what the "Sons of Liberty" did prior to the start of the American Revolution.

There are times I am very glad that I don't own a gun.

craig @ 92: I think that the fact that pregnancy and birth and related health care needs are not covered automatically (whether privately or publicly or in some way) for everyone is the single thing about the US health care system that I have the most difficulty in wrapping my head around. Even more so than an American family member who has spent significant parts of his life without any treatment at all for Type II diabetes due to not having insurance.

Because I have to get to Family Supper, this is partly a straight-up cut-and-paste from Terry Karney's lj; apologies to those who already saw it there.

My husband Ian had his right kidney removed in 2004. He'd been having troubles since about 2001, of a hard-to-pin-down sort.

We'd been to a neurologist, a rheumatologist, and had countless GP visits (fully covered) when he went into his GP with suspected food poisoning (when the abdominal pain finally made itself known).

They took a look at him, suspected appendicitis, and shipped him off to the hospital by cabs (not covered; had he been in BAD shape an aumbulance woudl have been, but he was mostly just unhappy at that point) for [note: I was not in town for the next bit, the order of the incidents may be off but all of it happened] an MRI (done within an hour), looked at the results, said 'oh dear', drew some blood, and sent him up for a CT scan (within 45 minutes). Whereupon they noticed that his left kidney appeared to be more like an eggcup than like a kidney, scheduled an ultrasound for the next day, looked at his blood results and general condition, and slapped him into ICU with a load of fluids and Cipro and painkiller running into his arm.

After the ultrasound, they realised they couldn't give him an internal stent [boring details skipped over] so they opened him up enough to fit him with an external nephrostomy setup, got him stable and on a pain control regimen, and - after some discussion - sent him home to wait for surgery.

He could have had surgery immediately if we'd wanted to do it the old-fashioned way and crack his abdomen, but as this is far more major an traumatic surgery than a laproscopic removal entails, we [Ian, me, the doctors, all together] decided to wait it out.

This was February, and at this point we have spent no actual money. The province covered all proceedures, all nephrotomy supplies, and all meds given in hospital, Ian's work plan covered all other meds.

Ian was off work from the beginning of February to the end of August. 66 percent of his wages after the first two weeks were paid by the Canadian Government via Employment Insurance; it was made up to 80 percent by his workplace's Long Term Disability coverage, who also paid out Employment Insurance's aforementioned 66 percent to us direct and recovered it from the government rather than leaving us to deal with the two-week delay and the weekly paperwork.

We had a longer wait than planned: yes, there was a 'waiting list'. Everyone ahead of us in Ottawa had active cancer. One of those people was a friend of mine. Had Ian's condition begun to deteriorate, they would have moved him up if possible or else we would have gone ahead with the conventional abdominal surgery.

While waiting we had five rounds of IV antibiotics, numerous nephrotomy equipment replace/repair visits, a weekly visiting nurse, and six or eight rounds of oral Cipro.

So, eight months of fairly constant medical attention with a hospital admission an minor surgery at the front end and another one - with major surgery - at the end.

Oh, and a year and a bit later he developed an incisional hernia, which required an emergency room visit (covered) and more surgery (covered). No Long Term Disability this time, but the lost wages were about two weeks in total.

So because we had good workplace insurance, we were out of pocket 20 percent of his salary and some cabfares.

Had we had NO insurance we would have been out of pocket 44 percent of his salary plus meds plus some cabfares.

We ran into debt, but were out again by November. With no workplace insurance, we still would have been out of debt within a year at worst.

Without Provincial and Federal coverage, we'd have been bankrupt, at best. At worst, I'd be a bankrupt widow, because we wouldn't have been able to find the money to do the tests to find the problem in time.

Quality of care: stellar throughout. They did partially dislocate his shoulder moving him after surgery, but my husband is 6'8" tall and weighed 260 at that time. The doctor assured me very apologetically that they had as many hands on the transfer as would fit. They thoughtfully put it back in while he was still good and out.

We also learned a valuable lesson about "waiting times in Emergency Rooms". You can walk into any emergency room in Canada and go straight to the front of the queue, under certain circumstances. Having lived said circumstances, yself and with Ian, I can testify to this: You never, ever ever want to be that person. You'd FAR rather have time to read a medium-size novel than walk in and say 'my neck just went 'spung' or "I have this pain in my chest that stops me breathing properly' or 'my ear is sort of bleeding, only it's a funny colour' or 'I don't think fluid is MEANT to be coming out of my husband's stoma, is it?" or any of the other things that have gotten me/us immediate service. But if those things happen to you, you will get immediate and efficient and usually kindly treatment, for free. Otherwise you will only get efficient and kindly treatment for free.

Joint replacements: those waiting times are average and include both people who get done immediately because they cannot walk and people like my father whose doctors put them on the list at the 'you're going to need it in the next five years, how is next winter for you?' stage.

Wirelizard @87 said: Watching the US debate is quite surreal - it's the dark side of American exceptionalism, I guess: the feeling from a certain percentage of the US population that they already live in the best of all possible systems/worlds and all those foreign types can't possibly have invented a more equitable, higher-quality system.

I think some of it is that a lot of the decision-making classes in the US have had good care their whole lives, and literally cannot imagine (a) what happens if you get sick without same, or (b) how very many people in the US, through no moral failings of their own, do not HAVE the same quality of care that the decision-making classes take for granted.

It's a matter of privilege, and invisible people.

Which is why I was so severely croggled by the whole hoopla around Sonia Sotomayor's statement that her background affects what facts she sees in a case ... because her background means she sees MORE FACTS than many white male Yale graduates might, not fewer as they all seemed to assume!

I'm a Canadian in Montreal. I've been looked after by our provincial health care system (MediCare) all of my life. This included well-baby checkups with a pediatrician, vaccinations, and the like. Total cost: $0*

My sister had two miscarriages and two normally completed pregnancies, with regular pre-natal care and hospital deliveries; both of her children have seen a pediatrician regularly all of their lives. Total cost: $0*

More recently, my mother was diagnosed with Atrial Fibrillation, and prescribed Coumadin. This required a blood test every second day for the first month, every week for a few months thereafter, and now, every month. For those, she goes to our local clinic, the CLSC. Depending on the day, she might be seen within 5 minutes or 1 hour. She pays a $2 co-pay for the meds; for the care, $0 (Quebec has a provincial drug-insurance program - if you're not covered at work, as I am, you enroll in the provincial one on your tax return).

Last November, my aunt fell and broke her shoulder. She was taken by ambulance, where along with treatment for the break, she was diagnosed with Alzheimer's**. She stayed in the hospital for 6 weeks, until we could place her in a Residence. Total cost: $0.*

Last December, my other aunt had a heart attack. She was taken by ambulance to the hospital, stabilised, taken by ambulance to another hospital where she had angioplasty, taken by ambulance back to our local hospital, and released a week later. Total cost: $0.*

Last year, my friend was diagnosed with a recurrence of her cancer. She had an immediate surgery to remove her lymph nodes, then radiation, then chemotherapy. Then another surgery to replace her hip, because her bones had been infiltrated, and several weeks in the palliative care ward, before she died. While the cost to us who loved her was huge, it wasn't measured in money. The total dollar cost for all of that was $0. I can't imagine her family going through all of that, and then being asked to pay for it.

Gee, I had a crappy winter last year. I shall hope this one is better.

When I worry about getting sick, I just worry about the being sick part. I don't worry that I'll have to sell my car, or my mum will mortgage her house, or I won't get treatment I need because I can't pay and my insurance won't cover. It'll just really suck being sick.

The waiting times that people talk about are real, but in my experience, they pretty much apply to non-emergency care. I had to wait 6 months to see a dermatologist, and two months after that to have a plastic surgeon remove a benign cyst on my hand. But, it was benign, and they knew it (and, for unrelated reasons, two of the original three derms in that practice quit during that 6 month period, requiring the 3rd to pick up the slack until they could be replaced).

*Yes, I know, it isn't really free. It's paid for out of taxes. I see the difference between gross and net on my paycheque every two weeks. But that's the only place I see it - I've never seen a hospital bill in my life.

**We'd been aware that something was wrong and begun to take steps, but the unexpected hospital stay accelerated the process by at least half a year.

One of my medical experiences here in Australia:

I had to have four months of fortnightly chemotherapy in 2006. At the very first appointment, one of the admin staff sat down and went through cost of treatment with me - apparently I had to pay for the chemo drugs. She apologised for the fees being so high, and explained that if I had problems paying they could work something out. Full cost? $360. Not per drug, but for all my chemo.

I had to have 5 weeks of radiation treatment in 2007. Full cost? $0. Medicare covered it all.

My husband (a US citizen) is talking about us moving back to the US in the next couple of years, but the high cost of health care over there kind of puts me off.

@92 and 93: When I bought my own insurance, during my first job out of college, it cost about $250/month. It also did not cover any maternity costs. If I had wanted to get pregnant, I would have had to pay for a maternity rider, another $250/month. If I tested pregnant before buying the maternity rider, I couldn't buy it at all and nothing would be covered. What if I had had an unplanned pregnancy that I wanted to continue? I guess I would have just been SOL.

That insurance company sells the maternity rider as "prepaying your maternity costs," since if you're trying to get pregnant, you may end up paying the extra money for a long time before you actually need the maternity care.

Money worries are just a reality of American health care. I'm still beating myself up for needing to go to the ER with flu-related dehydration, because even with halfway decent insurance it was a poor financial decision. I feel guilty about it, as though I'd run up a credit card bill on clothes. I wasn't dying right there and then; I should have sucked it up.

I understand why people don't go to the ER immediately with chest pain or stroke symptoms. It's a gamble; you have to weigh the possibility that you could die against the certainty that your bank account will be damaged pretty severely. That's just reality in America, even if you have insurance.

vian @ 15: here are tax incentives for taking up private health insurance; an attempt to ease the burden on the public system.

Does that work? I would expect that the well-off and healthy would opt out of the public system, while peope who are poor or sick or have children would stay, which would cause the system to earn less per member and pay more.

I'm in Germany and you need to be either self-employed or earn well to be allowed to opt out of public insurance. It's a good deal for healthy single men under 40. Of course, the public insurance does not have to take them back at previous conditions if they decide to start a family, or happen to become less healthy.

(Also, complaining about health insurance seems to be a national hobby here. Some people I know who went to the States with a "100% coverage, one sheet of paperwork" health insurance paid in full by their employer vastly prefer the US system to the German one, because "the doctors are much nicer".)

Joerg @ 80: Depending on the insurance company you have chosen (you must have one unless you are self-employed or earn ~50000 Euros a year), you pay nearly 15% of your income.

There's an upper limit around 7200 Euro, though. And if you are working more than 21 hours a week for the same employer, they pay half. On the low end, it's assumed that you make (IIRC) at least 800 Euro a month, so you never pay less than ca. 1500 Euro a year. Which is not so good if you make 600 on a nineteen-hour week.

Hugh @ 84: Employees would be 'responsible consumers' and help drive down health care costs.

"No, don't think I'll break my leg this year... the car has to go to the garage, and it's Aunt Martha's 75th birthday, she'll expect a present... So, maybe next year. But I might be able to squeeze in some influenza around the holidays, so I won't have to go without any illness or injury this year..."

One of the right-wing nut groups has helpfully put together a list of Town Hall meetings this month.

If there's one near you, please make a point of going.

inge @#100:

Other way round, in the past: For a while, the rich and healthy were choosing not to take out private health insurance, as they had to pay the Medicare levy anyhow (it's part of our tax system), and figured that since they were paying for it, they might as well rely on the public system. Waiting lists ballooned.

To encourage people who have the means to go back to the private system, we now get a tax benefit which pays for about 2/3 of a private health insurance premium. Also, if you earn over a certain amount and don't have private cover, you have to pay an increased Medicare levy which usually works out at aroundabout the amount you'd have to pay for basic private cover anyhow.

Lastly, people who are over 30 who don't have private cover have to pay slightly higher premiums when they do finally take it up (say, when their salary goes over the Medicare threshold), which is meant to encourage people to pay for private health insurance before they become a drain on the system. So, if you rely on the public system while you are young and healthy and then take out insurance when you reach the age where you are more likely to make frequent claims, you pay more. Mind you, having done the math, I'm still way ahead and I didn't take out private insurance until well into my 30s.

heresiarch, #22, one of my pills does taste like candy. Well, sugar, which is close enough. Smells like it, too. And another smells and tastes like, well, farts. The rest come in between.

I grew up with Navy healthcare and then worked for doctors, so when I worked for defense contractors, I was pleased to have an HMO. Kaiser seemed to incorporate the best of each. I now have Kaiser's Medicare HMO and pay $89 per month. My meds are $7 each per month when generic and too much when brand name. My doctor's visits have a $10 co-pay, but most procedures, like today's mammogram, are free.

I had another stroke in March that wasn't diagnosed as soon as I would have liked and therefore required more ER visits, so of the almost $100K bills for the full 31 days, I'm going to pay about $2K.

When I went to the ER via ambulances (and then the ER of a better hospital via helicopter ambulances), I was taken in immediately, assessed, stuck into CT machines, etc. If I didn't need the ER, I could drive to (checking the time) a Kaiser Urgent Care Center at the other end of the county (after midnight, one in the next county in) and get care, although I might need to wait. I much prefer to be able to wait to the next day because not only will I see a doctor with an appointment then, it's likely to be a doctor I know.

My teeth, however, are not in good shape. There aren't many practices that take the Kaiser Medicare plan and of those, the prices for things other than cleanings and fillings are beyond what I can manage.

And finally for this post, a very interesting WashPost article on how we already ration. People actually expect this kind of treatment:

...he begins his story. "This family of an 80-year-old gentleman came to me a few days after he was admitted into the ICU. He had end-stage emphysema. 'We had a family conference last night,' they told me, 'and we have decided that we want our father to have a lung transplant.' " The doctor shakes his head again. "They were dead serious," he says. "I took them aside and tried to explain the situation: He is 80 years old and a smoker. He can't get a lung transplant."

I really wish we'd stop using the term Insurance about this. You can't insure against certainties and, except for an extremely small number of people there is a 1:1 chance you'll need medical care of varying types in your life.

Having moved to the US from the UK it's weird to be dealing with this concept of "insurance", especially when you change/lose jobs and have to deal with suddenly not having insurance. Even Cobra, with the hefty stimulus discount, doesn't kick in sensibly, hence my wife being stuck without a LOT of medication because they're waiting for Cobra to confirm cover or she'll have to pay a significant chunk of change for the drugs.

It's broken, the problem is I don't understand the mindset of the people who don't see it's broken because the best I can figure is they've either never been ill, or they've never actually had to deal with the system.

Daveon @ #105, but it's the Insurance companies inserted between doctors and patients that are the problem. I'm glad to see the Dems finally using them as whipping boys in this debate.

I keep hearing Republican talking points about government bureaucrats denying patients proper care, and I keep thinking "Oh, so you prefer that insurance company bureaucrats who work for profit-seeking companies do the denying, as we have now. Okay."

Remember, the insurance company bureaucrats are the ones right now who are in charge of allowing you to get treatment, or not.

And their job isn't to ensure public health. Their job is to maximize profits for their employers and increase the value of their employers' stock.

They do this in two ways: They increase income by raising rates, and they lower expenses by denying claims.

I'd far rather have the people who administer truck scales pay the bills, while the medical decisions are made by doctors and patients.

Sure, standing in line at the DMV is a pain, but at least the people at the DMV don't get bonuses for refusing to issue you a driver's license or register your car.

#89
You might want to run down a copy of the current Consumer Reports, in which they discuss the best medications for various conditions, and compare prices. It's definitely educational.

#70
I have some amalgam fillings that are more than 40 years old. I know that at some point they'll have to be replaced, but it hasn't come to that yet.

#105
The people who like the current system have insurance paid for mostly by others, or have never had major or chronic medical problems, and also apparently don't know any people who have. What they're seeing is the insurance you have when you're healthy and have money; what the rest of us see is what happens to that insurance, and the household budget, when medical treatment is needed.

thomas @ 89: "While the 'at worst' is certainly true, the 'at best' is a bit oversimplified."

I think you misunderstand my "at best." Even when they are molecule twiddling like nobody's business, they're still only spending 15% of their budget on it. An engine of innovation that burns up 85% of the cash on marketing and sales isn't a very efficient engine.

Marilee @ 104: "one of my pills does taste like candy. Well, sugar, which is close enough. Smells like it, too. And another smells and tastes like, well, farts."

=) I know which one I would take first, and which one last.

Linkmeister @ 106: "but it's the Insurance companies inserted between doctors and patients that are the problem. I'm glad to see the Dems finally using them as whipping boys in this debate."

Insurance companies are a problem, but they're not the only one. Truth is, medical device manufacturers and pharmaceutical companies are also raking in substantial, unwarranted profits--and as depressing as it is to think about it, there are plenty of doctors who are in it for the money as well. Medical care is a market where the consumer is nearly powerless: we have no bargaining power when death or injury is on the line, nor any knowledge by which to judge the risks and benefits of any given procedure. There's nothing to stop companies from simply charging more and more, creating more waste--and more profit for themselves.

Abi, thanks for this. I've been living in the Netherlands for 12 years now. I have Crohn's Disease, so have experienced more than I care to of both the US and the Dutch systems. The misinformation that is flying around the US about European systems is mind-boggling. There can be longer wait times for a specialist if you are not an emergency and need a scarce specialty, but every time I've needed care here it has been there amazingly quickly. Sometimes I get the feeling that a lot of the resistance in the US comes from folks who have never had a major or chronic illness-- the idea that they don't want to pay for someone else's mistakes.

Steve C. @ 54: It can be done. We can have better health care. We're just not going to get anything perfect.

Indeed! "The best is the enemy of the good." Currently, we've got the nonsensical propaganda that all systems of universal health care are ghastly failures. I sincerely hope that facts will batter that down to manageable levels, and we'll move on to more discussion of how to this. At that point, we need to be reasonable. There's no perfect system for anything, but practically anything will be better than what we've got now.

I've been fortunate (so far) in managing to always have medical insurance through my job, or my spouse's. My sister was on COBRA* after her husband left a regular job to work as a consultant. As the time limit on the COBRA expired, she began shopping for insurance for the family. Did I mention that she was pregnant? It was absolutely impossible for her to buy insurance. She was very, very lucky in having a simple delivery.

*COBRA: For those of you watching in bafflement from outside the States, there's a law that entitles an employee to continue (at their own expense) on their former employer's medical insurance for some months after leaving. This is intended to prevent someone from losing medical coverage the day they are laid off. You really, really, really don't want to have a lapse of even a month or two in your coverage, and not just because you might get sick during that time. If your coverage is continuous, the new medical insurance usually has to be effective immediately. If there's been a gap, then you pay the full price of the new insurance immediately, but they don't give you any coverage for pre-existing conditions for 6 months. Yes, these are the insurance companies that do such a great job of taking care of us!

Janetl, this is a topic that is near and dear to my heart. When I got laid off, they offered me the "option: of COBRA. That option cost $980 a month, which was more than 1/2 of my severance pay and rather more than I was going to get from unemployment.

Right now we're relying on our family physician's goodwill, he's provided me with almost two years of blood pressure meds (the one thing I take every day). And he's asking me to come in for a physical and told us he'll work it in 'under the radar.'

Jim has lost a good deal of weight and is feeling just fine (he gave up soda, for those who want to know and while he likes Monster, he has one a day at most,) Since his family trends toward long lives unless they get hit by a car, He's not necessarily being underserved.

I have hypertension, and a small bit of asthma, which seems to have resolved recently. But right now we're living a bit scared,hoping nothing bad happens.

Janetl, this is a topic that is near and dear to my heart. When I got laid off, they offered me the "option: of COBRA. That option cost $980 a month, which was more than 1/2 of my severance pay and rather more than I was going to get from unemployment.

Right now we're relying on our family physician's goodwill, he's provided me with almost two years of blood pressure meds (the one thing I take every day). And he's asking me to come in for a physical and told us he'll work it in 'under the radar.'

Jim has lost a good deal of weight and is feeling just fine (he gave up soda, for those who want to know and while he likes Monster, he has one a day at most,) Since his family trends toward long lives unless they get hit by a car, He's not necessarily being underserved.

I have no examples because I am adopted, in a state that refuses beyond reason to provide any info about anything at all to do with one's birth parents. Even if one is dying.

I have hypertension, and a small bit of asthma, which seems to have resolved recently. But right now we're living a bit scared,hoping nothing bad happens.

Daveon, #105: In addition to what P.J. says @108, there's also a strong cultural meme of "the only people who don't have insurance are the poor," which then brings in all the resistance-memes to any other proposed measures for assisting the poor: they're lazy, they want something for nothing, they just need to get off their asses and find a job -- most of which contain a healthy, though rarely overtly-expressed, dollop of "they're black / Meskin / [insert racial slur of choice]" as well.

This may be on the verge of changing, as more and more white middle-class people lose their jobs and their easy medical coverage. If the current proposal doesn't go thru, by this time next year there might actually be mobs with pitchforks and torches outside insurance-company headquarters... and they won't be made up of progressives, but of the selfsame people those companies are currently throwing against reform.

Sure, standing in line at the DMV is a pain, but at least the people at the DMV don't get bonuses for refusing to issue you a driver's license or register your car.

Or, in soundbite form, "How often has the DMV withdrawn your driving licence because of a pre-existing condition?"

I live in the UK. I turned down a good job in the US in 1999, for family reasons. This was the best decision I ever made: four months later my son was diagnosed with leukaemia.

Emergency treatment (admitted that day as an in-patient to a specialist paediatric oncology ward) then three years of chemotherapy. Various kinds of surgery (a central line, bone marrow aspirations). Many kinds of diagnostic procedures (blood samples - daily then weekly, genetic assays, cardiac ultrasound to measure chemotherapy side-effects). Various kinds of ameliorative care, under which heading probably comes a number of blood transfusions, a few hospitalizations for neutropenia, and a number of drug treatments including vancomycin. Even now, long-term follow-up appointments every six months. All care delivered promptly by highly-qualified experts, who would frequently take extra time at the end of a shift to talk with us about the illness, the treatment, and our general well-being.

Total financial cost to us of all this care: zero.

He's fine, thanks.

Having been through this and an assortment of less major family medical crises in the last ten years, I would never, ever consider working in the US again. Why would anyone?

I was under the impression that the high cost of American health care mainly subsidizes grotesque levels of executive compensation and marketing for vanity medicine, with "research" trailing way after. That may just be my anti-executive prejudice speaking, though.

One quick comment on early childhood intervention services in the US, since I noticed that people seem to be assuming those aren't provided in the US: although they aren't covered under a national medical plan, they may be provided as part of your state's educational system. The services provided include speech, OT, screenings, etc.

I'm only familiar with one state's program, but I do know the funding for it is Federal (I believe under the Individuals with Disabilities Education Act). The appropriate place to start looking is probably the local school district -- if they don't administer early childhood intervention services, they should know who does.

117: it's only prejudice if it's not based on fact, Earl.

hieresiarch@109 I think you misunderstand my "at best."

Fair point.

I'm generally in favor of attacking drug companies -- I have a close colleague and friend who is one of their Least Favorite People. I do still think it's important to remember that there are things they do better than anyone else.

As far as I understand the Repubs’ arguments, the principal one seems to be that state health care is ”socialist”;  that health care and rationing thereof should be left to the market (in other words – unstated – if you can pay, you get it, and if you can’t, nobody said life is fair, bubele).

Do they also think that regulation is socialist – that the FDA shouldn’t exist, for example, not just because it’s federal and therefore contrary to states’ rights, but because it interferes with the operation of the market?

It's such nonsense to think there's a "market" in health care. There are all sorts of constraints around what the insurance companies must cover, and what hospitals, physicians and drug companies can do. If you collapse, bleeding, into the emergency room, they cannot turn you away, therefore there's no free market. As a medical consumer, you're rarely able to comparison shop. Even if the information was available, if the first diagnosis is bad, your comparison-shopping brain completely shuts down (I speak from experience. It turned out not to be so bad, for me, fortunately.)

#121
I don't know if they think regulation is socialist, but they're certainly against it if it will keep companies from making big profits. (They seem to forget that utility companies are, many of them, regulated, at least in how much they can charge, and still manage to make money.)

P J Evans @108: I'm 29 now, and started having amalgam fillings put in when I was 12 or 13 (like I said, extremely thin enamel). My current dentist is already having to start to replace those fillings.* Like dental care costs, this seems to be one of those areas in which YMMV. I also clench and grind my teeth, which might be affecting the fillings' longevity.

*The one older filling he's replaced so far had broken and a cavity had started in that area, so he just replaced the old filling while he was at it. Unlike some other dentists I've had, this guy is kind and hasn't tried to talk me into unnecessary procedures, so I trust him when he says they're all going to need to be replaced in the next five years.

janetl @122: It's such nonsense to think there's a "market" in health care. ... As a medical consumer, you're rarely able to comparison shop.

Especially since there's no way to find out what anything costs at your different potential service-providers (hospitals, especially) without first incurring the service. I actually called up the hospital we were going to be delivering at and asked how much, say, having a birthing tub * would cost out-of-pocket, and was greeted with something between bafflement and derision: they do not give out that information. Period. She started to tell me that it depends on my insurance; I interrupted and said that my insurance doesn't cover anything 'not medically necessary' under the strictest possible interpretation, so we'd be ala-carte-ing the tub, IF we could afford it, so I wanted to know how much it would cost. Ha. No birthing tub for me, because I'm not in the habit of writing blank checks ...

caffeine @124 said: P J Evans @108: I'm 29 now, and started having amalgam fillings put in when I was 12 or 13 (like I said, extremely thin enamel). My current dentist is already having to start to replace those fillings. ... they're all going to need to be replaced in the next five years.

Thing is, though, on the statistics, amalgam fillings last a lot better than composite ('tooth-colored') fillings, which is why some insurances cover the former and not the latter. Composite cracks faster, especially in really big fillings or where there's composite on the chewing surface itself.

* Birthing tubs are like a hot tub, sort of, only the temperature is controlled to be low enough to be safe for neonates. They're used to help manage labor pain (and sometimes for giving birth in).

Lee @ 114:

I've never really quite thought about it in terms of there being people who believe that it's only the poor who don't have insurance. Perhaps it's partly a denial of the fact that a middle-class existence isn't as stable now as it once was, and that if things go wrong for just a moment that maybe they'll wind up being poor too.

As I said before, though, I find it absolutely disgusting that poorer people who do not have any kind of health coverage beyond an overtaxed emergency room are being fed all this bullshit about state-funded healthcare, and I find it sad that some truly believe it. To see people working against their own interests like that is depressing.

John Stanning @ 121:

I don't think that they think that regulation is socialist (I don't think that the people at the top really think that public healthcare is socialist either, but it's such a convenient buzzword), but I know there are plenty of people who don't like the FDA because it tries to make sure that food and drugs are safe and actually work. It's a lot easier to make a profit if you can sell food with added rat, or drugs that only have a 25% chance of not actually causing your liver to spontaneously combust.

As to your other point, yes, one of the main arguments is that the free market is the best for healthcare. This falls out of the standard, the-free-market-is-the-best-for-everything argument.

I'll chime in here with my experiences in Hong Kong.

If you turn up at the ER with a problem, you get triaged; and dealt with as appropriate. My daughter had some sort of gastro-bug: we had to wait a few hours. My son had a broken arm: instantly stabilised, wait a bit for an x-ray, then a transfer to a hospital with paediatric facilities where they could pin it and sort it out.

Both children were born in public hospitals in HK at the princely cost of $68 per night of hospital stay. For both of them, this was three days, so $204 each. But that's HK dollars, so divide by 7.8: US$26.15 for three nights.

Hospital food was awful, but the Chinese way is that your family will bring you buckets of nourishing broth when you're sick, so the hospital food (rice or macaroni and vegetables) is really only for those with no families and probably better than they'd have in that case anyway.

(There was a canteen in the hospital where you'd frequently see the Doctors eating. Not the best, but not too bad. Pretty typical local lunchtime food: not Macdonalds, but your local sandwich shop, would be a good analogy. There was never a problem with bringing food up from there or bringing ambulatory patients down there.)

You can of course go private here, where you pay lots of money for the same care with better food, and maybe better access to the doctors.

(For what it's worth, and and as an expat point, almost everyone we've ever encounted in the HK public hospitals has spoken more than enough English to do their jobs perfectly. Doctors and nurses, of course, but even orderlies and cleaners have had good communication skills.)

I think one of the bottom lines here is that medical bankruptcy is a risk of living in the USA. The advocacy of this system is of a piece with the rest of right-wing economic policies: basically, there's the wealthy, who get to have lives free of the risk of random financial disaster, and there's the rest of you, for whom random financial disaster is just part of the landscape.

odaiwai #127: Both children were born in public hospitals in HK at the princely cost of $68 per night of hospital stay. For both of them, this was three days, so $204 each. But that's HK dollars, so divide by 7.8: US$26.15 for three nights.

Were hospital prices notably different before the transfer of sovereignty?

earl@129

There was a change a few years after the Handover (still a capital letter Event here), which led to a charge for turning up to the ER. It used to be free, but it went to HKD 100 (about USD 12). This was mainly to discourage people using it for trivial diagnoses which their local doctors (usual visit about HKD 100) could do.

There was no significant change in the hospital rate for Hong Kong ID card holders.

As far as I recall, this was not connected to the handover, and more to do with discouraging peeople from using the ER as their GP.

Hospitals in China are notoriously money-seeky and you get spiels like: you can have this procedure for CNY X, or this procedure plus anaesthetic for CNY 2.X. Usually just after they're prepped you for the procedure and given you an approximation of the levels of pain involved.

John, #121: As you state it here, that's a Libertarian argument. The Republican argument boils down to, "the FDA shouldn't exist because it interferes with Big Food's ability to rake in money." It sometimes comes dressed up in a fancy free-market tutu, but what they want is the ability to have a complete, unregulated monopoly.

PJ@108: I've encountered some strong philosophical opposition to more (or as much as we have now, for that matter) government involvement in the health care system from people who (say they) have their own chronic conditions, and that a single-payer system would be to their personal benefit. Some examples in this thread on a friend's LJ for example.

When I don't know the people, it always sounds very much as though they just have no idea. But the times I've been in a position to raise the question, that doesn't seem to be as true as I had expected.

David Dyer-Bennett, #132: I wonder how much that opposition would last in the face of government-funded care vs. actual illness. There are probably a few people who would be willing to die or suffer prolonged disability for their philosophy, but to judge by the success of Medicare, probably not all that many. This conflict of claimed vs. revealed preference is probably what leads to the bizarre position (apparently surprisingly common) that Medicare isn't government health care.

#35: "The NHS is excellent and wonderful and employs my sister"

Same here. I mean, including the sister. I'm assuming it's not the same sister.

Meanwhile, I've spent 10 years in the US, 5 on a PPO plan and 5 years with Kaiser Permanente. KP is proof positive that a low-cost single-payer system can work just fine in the US, even when it has to compete for doctors with private practices that might be more lucrative. It's not perfect but it's well-organized, integrated, and there's never any uncertainty about whether a test or procedure is going to be covered.

Americans have so much anxiety over healthcare that could be so easily dissipated. I am at a loss for why people would oppose this unless they have a personal financial interest in the current system.

Cheryl @97: Yes, I know, it isn't really free. It's paid for out of taxes. I see the difference between gross and net on my paycheque every two weeks. But that's the only place I see it - I've never seen a hospital bill in my life.

Cheryl, I'm curious: in percentage terms, what exactly is the difference between your gross and your net? I've got a fiver here that says that difference compares favorably to my difference, which is taxes, plus insurance premium, plus my healthcare out-of-pocket. (That last is quite low, because I just don't have the discretionary income to do much in the way of healthcare.)

And then there's the story of one of my coworkers. Last year it came about that her husband's doctor had gotten medical test results switched with another patient with the net result that aggressive cancer was allowed to progress untreated for six months (while the other guy had unnecessary surgery).

Husband is still around, but they've had to sell their house to cover medical expenses. And they're on one of the better employee health insurances available.

Three guess which country I live in.

Randolph, I can't remember if I saw it in this thread, but my current hero is Rep. Anthony Weiner of New York, who offered an amendment to the healthcare reform bill to eliminate Medicare, so Republicans could finally go on record as opposing all government healthcare.

As far as data points on waiting times --- I collapsed with some neurological symptoms in a Florida parking lot in late December. I spent three days in hospital being evaluated -- and the diagnosis was that they thought I might have had a TIA, and that I needed to see my regular neurologist as soon as I could when I returned to California.

My neurologist's practice? Couldn't see me before February 25th. Would not work me in. Would not refer me to an outside neurologist. I saw the first neurologist I could, but still waited two months.

Adrian Smith@46: "One claim I came across on a libertarian site was that the admittedly-high US spending on health was actually funding some vast percentage of medical research [...] Anyone got a potted refutation to hand?"

Can't refute it because it its true. About half of all the really good biological science funding in the world is US. And you make most of it freely available online to anyone with a web-browser. Check out the wonderful NCBI website.

Its true but its an argument on the side of truth, freedom, and universal healthcare for all. Its the US taxpayer who pays for most of the real science, not the drug companies. Their stuff is vastly expensive, mostly directed towards extending the patent life of old drugs by minor variations, and they keep it secret. Secret science is by definition a dead end. It is unproductive. It leads nowhere. The future of biological science - and the future of medicine - is in what is being done in universities and public laboratories. And they are largely taxpayer-funded. With a big dose from charity - though the largest charitable funders for basic medical research have traditionally been British, not American - about a quarter of the Human Genome Project was paid for by British private funding, about half by the US government - in this field we are the capitalists and you the socialists. And US big business sponges off free science provided by US taxpayers. Its the socialised, public, part of the system that works best.

What surprises me in this argument is that so many Americans - even ones who support public health - don't seem to realise how much money they are paying out of their taxes for healthcare already. Medicare, Medicaid, VA, the CDC, public hospitals and so on together cost each of you more than most people in other countries pay for public health service because the broken private insurance system with all its inflated bureaucracy, unnecessary procedures, and bloated legal bills has forced up the price of medical care and of medicines And then you pay all your private insurance on top of that! It is as if your left hand and your right hand were bidding against each other in an auction, boosting the prices that you will have to pay one way or another.

You pay more tax than the Brits do for healthcare, both as an absolute figure and as a proportion of income. But the outcomes, objectively measured by life expectancy, are not significantly different from British ones. In fact on average we live a little longer than you do. Even though we are on average less well off, and we smoke and drink more. So you all are paying twice over for inferior quality of service. You are being ripped off. (In some Scandinavian countries and in France they do pay more tax than you do or we do towards healthcare - but they get even better service for it. Again. as objectively measured by death rates.)

You spend more than any other country in the world on healthcare but your life expectancy is fiftieth in the world! (According to your own CIA) UK is 36th, Netherlands 30th. You guys are slightly behind Bosnia, Cyprus, Ireland, and Portugal; slightly ahead of Albania, Costa Rica, Cuba and Libya. And you are dropping in the rankings - three years you were 48th. In what other field of human enterprise is the USA almost certain to be overtaken soon by Albania, Costa Rica, Cuba and Libya?

You are paying Swedish or French luxury prices for Albanian or Cuban quality of service.

The American people are being ripped off. They are being conned. They are being taken, advantage of, for a ride, in, and to the cleaners. They are being bilked, bunked, cheated, chicaned, chiselled, clipped, cozened, deceived, defrauded, deluded, diddled, done, double-crossd, duped, fiddled, fleeced, flim-flammed, fooled, gouged, gulled, gypped, hoaxed, hoodwinked, hornswoggled, hustled, jived, misled, mulcted, overcharged, pick-pocketed, put-on, rooked, run-around, scagged, scammed, screwed, shafted, shaken down, shammed, shortchanged, shorted, snow-jobbed, sold a bridge, spoofed, strung a line, stung, suckered, swindled, swizzed, tricked, trimmed, two-timed, whitewashed, and just plain robbed.

137: also bamboozled.

A lot of the more conservative sites and fora are touting this collection of stats against health care systems in other countries.

http://www.hoover.org/publications/digest/49525427.html

Hoover digest

I know a lot of games can be played with cancer stats, so I'd like to find some link to expose this as the chicanery I'm sure it is.

My personal take is this:

We are on Kaiser. As a number of people have mentioned, it's a pretty good HMO; you may get treated by different doctors (I had three OBs during my pregnancy and a fourth at the hospital) but they're all well trained and no doubt grateful that they don't have to deal with the obscene amounts of paperwork as the private practice docs do.

I'd like to see a healthcare system built along those lines.

BUT...

I do not believe that Congress will build a healthcare plan that runs along those lines. These are, after all, the people who brought us the TSA, who didn't see the crashing of the housing bubble coming despite the classic bubble signs, and who have, in some cases, flat-out stated that they don't 'have time' to read what they're passing.

(Better than 90% of Congress has been the same folk for the last decade. And I think the majority has been there for the last twenty years.)

I would like to see healthcare re-vamped. I would especially like people to be able to continue coverage at the same levels if they have to switch jobs, because COBRA is brutal. I would like to see pre-existing conditions exempted if they were treated under a prior insurer (which they now are by law IF the coverage is continuous— but a grace period ought to go in there as well.)

I would, most of all, love to see some form of "gap" coverage that works for those income levels just above Medicare, so that those people who make too much for Medicare but not enough for private care can still get the healthcare they need.

And really, while co-pays make sense so that the system is not abused (mine go from $5 to $20, depending on the visit), I think that one physical a year should be absolutely free... AND your co-pays for other things go down if you take that physical. Let's encourage people to keep up on their health.

So really, my problem is not the idea of fixing healthcare, it's that the people doing the fixing have a knack for doing it more slowly, more expensively, and with more unintended consequences that anyone else. Heck, the Mayo Clinic has pulled support for the current version of the bill. That should tell you something.

B. Durbin, #140, another thing I really like about Kaiser is the amount of health info we can access online. I had a phone call with a hospital anesthesiology nurse yesterday as prep for surgery on the 17th and I was able to give her test results from online. I can refill meds from there, make standard appointments with my primary doctor, look up what's on my formulary, email with my doctors, lots of things that are really beneficial to patients.

Another one of the talking points the shills are pushing is that expenses at physicians offices relating to covered services will be subject to audit.

For some reason some people have an issue with the requirement that your service provider not be committing billing fraud.

The comeback someone at work gave me was that it was all a plot to keep doctors salaries down.

I looked at him and said, really? and it's supposed to be a *bad* thing that costs are kept down?

He then claimed that it was against the "free market way."

I then asked him if he and his family shopped at WalMart, and why? He said, yes, because he saves money. I then pointed out that that is exactly what Walmart does to its supplier -- if you want to be a vendor to that monster chain you have to open up your books to them, so you can prove that your operation is lean enough for their taste.

If you want the "market" to rule, you have to prove that both cases are not equivalent. Either you believe in the "market" or you don't.

And if you are going to claim that it's "different" for health care, you have to be willing to prove to me why health care is different, or admit that your argument is not really based on market" at all, but on manufactured-out-of-whole-cloth talking points and fear of "socialists."

Another argument I would have used, but I have to co-exist in the same workplace, would have been to get him to admit that he would stand there, and do nothing, if someone were to be having a heart attack in front of him, if they happened to be an "illegal alien."

For all the talk about the "poor make bad decisions" and "why should I pay for some illegal?" it comes down to their willingness to let people die, because, in the last analysis, "I got mine, f**k you."

As a practicing pediatric ICU doc I'm up to my neck in all of this. I have to say our current system absolutely stinks. I'm salaried myself, but the very worstest aspect of our current, mostly fee-for-service system is the more you do, the more you get paid. And, since most estimates peg about a third of what we do as useless at best, there is every incentive to do more useless stuff. It's insane.

My 23-YO roommmate moved in here never once having been to a dentist because his family could not afford it. His mouth was a painful lunar landscape and I insisted that he had to get it fixed. I was just sorting out that paperwork, so I have some good recent data on the cost of dental care for uninsured ppls here. This is from a dentist who gave us a pity price package:

$80 for exam and cleaning
$77/tooth for 1-surface fillings
$85/tooth for 2-surface fillings
$101/tooth for 3-surface fillings
$700 for a porcelain crown.

We managed to hit $1850 there. The periodontist who did the root canal charged $2200.

This was all out of my pocket, because he has no insurance at all.

How long before Doctors Without Borders (Médécins sans Frontières) starts operating in the U.S? I am American and very ashamed. We must look like a Third World country to you Europeans. Some Third World countries even do better than the U.S. in providing health care.

Craig R @142, also called “I'm all right, Jack” or “Bugger you, Jack. I'm all right.” Is that US/UK/elsewhere dialect too?

[*] “single payer” =/= “public option”?
Is there a fast crib on different ideas around for USA which doesn't assume knowledge of current situation?

sara @ #145, I give you Remote Area Medical, next providing medical services in Los Angeles Aug. 11- Aug. 18. 2,700 people showed up for their services in Wise, Virginia two weeks ago.

Craig @ 142: Cool analogy. I've got to keep that in mind.

My brother -- my younger brother, my only brother -- has a failing heart, and no health insurance. He is using his savings to pay his cardiologist, pay for tests, and buy the drugs which are keeping him alive.

At least he has some money saved -- and it looks like he isn't going to need it for retirement...

I better not meet any of these anti health reform folks. Right now, the way I'm feeling, anyone pushing the Republican line in my vicinity had better be wearing track shoes.

Craig 2142:

I suspect that the reason the "audit of doctor's offices" meme has some fear in it is not the worry that they're being overpaid.

I hear a lot of stories of people getting treatment under the table: doctors keeping them on after they've run out of money, doing what's needed but only charging what can be reimbursed, things like that. People who are reliant on these backdoor deals are only going to hear that their lifeline is being cut.

There's a similar unease about cleaning up medical practitioners' relationships with drug companies. A lot of the free samples that doctors get are funneled to people who can't afford their prescriptions.

(Not saying this was your colleague's take on the matter, but it's worth considering when the topic comes up.)

I'm really tempted to write (at least a blog post) in which a French LPD (perhaps Mistral; a really handsome ship) pulls into Long Beach to offer a free clinic on the tankdeck as part of a political/military influence operation, rather like what the US Marines do in West Africa. (They already delivered a load of schoolbooks for La Nouvelle-Orléans that way.)

Or would the shock/sensawunda delta be higher if it was the redcoats, or rather, Jack Tar and one of the Bays or Bulwark?

Alex, if you do write that, please make it plain that you mean the Long Beach in California. Unless you do mean the one in Mississippi that was almost wiped out in Katrina. Or the one in New York (on Long Island). Or Long Beach Island in New Jersey.

Alex,this class of ship might be going a little too far.

Craig R. @142: Many doctors are already having their books examined and have been since the 1960s. If they provide services to Medicare or Medicaid patients HHS-OIG auditors do come in from time to time to check them.

If there is fraud it is prosecuted. I have helped prepare files to go to the US Attorney's office for such prosecutions many times.

OIG returns millions of dollars to the HHS coffers every year as a result of these audits and investigations.

#151, #153 : Perhaps one of these?

Lori @154: As much as they get back, its a drop in the bucket compared to the stuff that seems to be going on.

If healthcare reform includes sufficient auditors and investigators to clean up the mess we have in terms of graft and fraud, I'm all for it.

This is spoken as someone who works as a CMS contractor.

The view from Belgium:

At around the same time as the government crisis mentioned by Abi, my mother-in-law had a mild stroke. An ambulance fetched her at home, and she was confined to the hospital for two weeks until her neurologist deemed her well enough to go home.
Total co-pay: under 100 EUR. It would have been a bit higher, but she had complementary insurance to cover any hospitalizations, for which she paid about 20 EUR a month.

My husband had a hernia operation which could have been done as an outpatient procedure, but he preferred to pay extra and stay overnight in the hospital in case of complications. Total cost: under 50 EUR.

My husband and I pay 16 EUR/month for mandatory insurance, which covers most lab and professional fees. Coverage for eyeglasses and dental work is rather poor, but even at full price, fillings cost around 30 to 40 EUR/tooth.

For regular consultations with health service-affiliated doctors, co-pay is about 2 EUR (We pay in full - 21 - EUR and are reimbursed within a couple of weeks.) It's fairly easy to find doctors who hold early (before 9) or late (after 5) clinic hours, so there's no need to take a day off from work. Many GPs will also do home visits in their neighborhood but charge around 50% more for it.

I signed up for one of the pricier complementary hospital insurance schemes and pay 33 EUR/month; if I ever need hospitalization, I can go to the hospital of my choice and they will pay for all expenses not covered by mandatory insurance.

It isn't really free, of course - most of it comes from employer contributions and taxes (income tax rates start at 27%; the self-employed see half of their revenue go to taxes and social contributions) - but I am more than happy to pay it because it means I won't ever have to worry about crippling medical bills. The same contributions also cover unemployment benefits.

I was a French government scholar in France, so I paid nothing for mandatory insurance. The scholarship also covered complementary insurance (for lab work and procedures), which cost 120 EUR/year in the early noughties. Co-pay for ordinary consultations was around 5 EUR, and I didn't have to pay the full fee in advance.

Living in the Philippines meant that the very idea of social security and health insurance was absurd. Top-notch care can be had, at steep prices, from a handful of (mostly US-trained) doctors and thoroughly modern hospitals, all found in Manila; a second tier of wholly competent locally-trained doctors work in less prestigious clinics and hospitals at more affordable prices. (Local HMOs work with these physicians.) Most people are in the can't-afford-to-be-sick category, assuming they even have access to medical care where they are. Then again, growing up in a Third World country where 45% of the population lived under $2 a day meant that the lack of adequate medical care for the vast majority of Filipinos was the norm.

Now that I've lived in Western Europe for 8 years, I'm somewhere between Jörg @80 and Abi @86 when I think of the US: bewildered at the Third World nature of the healthcare system in this supposedly First World country.

Trey @156: I know it's a drop in the bucket, but we are trying -- the DME and drug companies' skullduggery doesn't surprise me, but the physicians that commit fraud...

For example, the opthalmologist performing fake laser surgery (since his patients didn't know anything about lasers they were easy to fool); the podiatrist charging for procedures on diabetic patients that were never actually done; I could go on and on, sigh.

I'm inclined to think that the fragility of health insurance in the US is part of the reason why so many people are scared of change.

It's not simply "I got mine; I don't care about people with serious medical problems." It's also "The current system works for me, just barely, and any change might be for the worse."

If it's true that the system fails to work for a majority of people -- well, then it needs to be changed and eventually it will be. Or else we'll become a country where poor people just lay down and die.

BTW, I assume that most people here are familiar with the story of the woman who survived leukemia and will never be able to get health insurance again. Is there anyone in the world who thinks that's acceptable?

Laurence @ 159:

Thank you for posting that link; I hadn't seen that.

Of course there are people in the world who think that's acceptable: the people who make the insurance companies work that way. It's stories like that that make me think that death is too good for them.

Any time the US would care to join the rest of the civilized world is fine by me.

Lori @ 158: Tell me about it. I work with one former nurse manager who tried to keep an employer out of the pokey by telling him to do the right thing.

I think we can all guess how well that worked...

She did hand over the documents when the auditor showed up, along with her letters to the MD about what he was doing wrong and how to fix it. Long story short: it took years but he lost his practice.

Then there is the fact the freaking mob has gotten involved with this since its more lucrative and less risky than the rackets.

Maybe we ought to be asking the people against audits is why are you against rule of law, and for crime?

US healthcare is not good, is too expensive and all the other complaints about it. I have few illusions on that score and know that many other countries provide adequate and reasonably priced care. I think a lot of the pushback on the current proposals isn't so much about the details (of which very few have been supplied) but about our complete lack of trust in the government to run it efficiently or fairly. We have very few examples of ANY government program being efficiently or fairly run. I can just see the special interest groups lining up to see that their senator/rep gets their special 'medical' item covered. And so I expect the costs of any program passed by the Congress to go up, up, up, up and up and, generally speaking, the quality of care to go down. I especially would like to see medical insurance dis-connected from employment. I'm retired but the employment-insurance connection is one of the biggest problems, IMO.

We have very few examples of ANY government program being efficiently or fairly run.

I'd say it's more that the ones that are, are the ones that the conservatives want to cut or shut down, and that don't get much publicity: Social Security does very well, and so does Medicare (at least when the politicians and the lobbyists aren't trying to cut deals to guarantee profits for the drug companies). And there's the SBA and its loan and business-training programs - even if the definition of 'small' is off in some places, they help a lot of genuinely small businesses.

Nan @ #162, "We have very few examples of ANY government program being efficiently or fairly run."

Okay, you cleverly put the "very few" there in case someone cited a government program which does run well.

Exhibit A: The Postal Service. It's always slammed as a horrible agency, yet I can count on two hands the time a piece of mail I've dropped off or expected hasn't arrived in a reasonable time period in forty years of using it. If neither you nor the sender puts the correct postage on it, that's not the agency's fault. Yes, there are occasionally lines. There are lines at restaurants and retail outlets all over this country. I've waited half-an-hour to get a table at a steak house.

Exhibit B: Social Security (this may be really pertinent to you, since you say you're retired). Have you ever not gotten your check, or had it deposited into your bank account late? Has your check not been automatically increased almost every year due to COLA provisions?

I fully agree health care should not be employer-based; that's why I would like the government to run it as a single-payer system.

Laurence, #159: I'd like to highlight one particular bit from that article:

Your ex comes by to pick up your son and tells you that the municipality he works for’s administrator told him in absolute shock that the insurance company slapped a million dollar surcharge on the municipality’s insurance policy, and said it would go on yearly until you are off, but since you had exercised your right to COBRA it would "do no good" if your ex was gone. The administrator said he was so shocked and offended that he went to ALL the other carriers possible, and one by one they all gave him back a "no bid" with the proviso that they would welcome the opportunity to bid...just as soon as that leukemia patient’s COBRA rights expire.

This is exactly the sort of thing that free-market worshippers say would never happen; surely somebody would recognize that there's a market for insurance that won't bankrupt a company with a cancer survivor on the payroll, and start providing it. But it's also an outstanding illustration of why the free market FAILS when you have a bunch of large companies all running with the same set of rules -- nobody else can get started against them, and why should any of them change a mode of operation that's so profitable for them?

Re "government programs" and the running thereof: I submit for consideration the point that the entire US military is a government-run operation. Not just their healthcare, but training, supply, logistics, transportation, and personnel -- and the research, the development, administration and support structures..the list goes on. My government (non-military) paycheck is administered by DFAS, the military payroll folks.

The government is made of people. We work hard for everyone.

ginger,

you're like soylent green that way?

Abi (# 150)

I could see that interpretation for some people, but I'm pretty sure that's not the case here.

The fact of the matter is, if we have universal access to health care there will be *no need* for treating people "off the books."

Same for the free samples of drugs.

I will happily admit that the practice of doctors getting free samples was the way that I got my meds for a while because I couldn't afford insurance (or the full price of the Rx) when I was unemployed.

Now, however, if I were become unemployed,under Massachusetts law, I simply have to provide some minimum of financial data and certify that the cost of COBRA is too onerous and I can get very subsidized insurance until I would be working again.

Again, under a universal coverage plan there would be no need for that strategy of using up the free samples.

The real worry about the coziness of the drug companies and the physicians is the other gifts -- trips, recreational tickets, etc.

From here:

Go to townhall meeting with petition against socialized medicine; get as many people as possible to sign. At the bottom of the form, in small type, will be the text "Signatories of this petition agree to voluntarily give up their Medicare benefits, now and for the remainder of their lives. This petition will be delivered to Medicare administrators so that signatories may be stricken from the rolls." Turn the damn thing in.

Go to a townhall meeting. Tell people you're selling Hitler insurance, and for a hundred bucks each you can assure them that Hitler will not come into their home that night to give them an anal probe. Trust me, these people aren't too bright -- you'll make a fortune. If Hitler does return and starts probing people, declare yourself an investment bank and ask for a ten trillion dollar bailout.

Go to a townhall meeting with tray of jello squares. Tell people you're from the Obama administration and you're giving away samples of a new product. When people ask, tell them the name of the product is "Soylent Grandma".

Go to a townhall meeting. In loud, outraged voice tell the audience that you've read the Obama healthcare plan, and on page six hundred forty seven it requires euthanizing stupid people. Try to gauge which audience members seem most concerned by your revelation.

Go to townhall meeting with "I hate healthcare!" sign. When people take picture of you, shout "YOU'RE STEALING MY SOUL" and chase them from the building.

Stefan Jones #169: From here: [Go to a townhall meeting with tray of jello squares. Tell people you're from the Obama administration and you're giving away samples of a new product. When people ask, tell them the name of the product is "Soylent Grandma".]

If done as jello shots, that could be a big hit at Tupperware-styled Health Reform parties. Or, for a more classic vibe, you could go with raw organic green crackers.

It's been a long, long time since I've commented, but having seen this, I've gotta...

I'm a former military brat (my father was in the U.S. Air Force for 23 years before he retired, and I like to joke that I was "Made in England," but "Born in the U.S.A." because my mum, who's from London, was pregant with me when my parents left the U.K. back in 1959).

The U.K. was my father's last assignment before he retired. We lived in a couple of different places, including a village called Shenington, about 6 miles outside of Stratford, and then in Bloxham, not too far from Banbury. I spent the bulk of my high school years (grades 9-11) in the U.K., attending Upper Heyford High School, one of many schools in England for military dependents. (Unfortunately, the school no longer exists, as RAF Upper Heyford has since been turned into a car park, and they've also built housing on the land, too.)

When we lived in England, they had a law that if U.S. military lived more than 20 miles from the nearest U.S. military installation, then they could use the NHS. Well, we did,... and we did, and even back in 1974-1977 the NHS functioned well enough that neither I, nor my brother, nor my parents had any complaints.

I've a friend, who's from Texas, who has lived in England for several years, having married and now divorced a man from there, and she has no intentions whatsoever of returning to the U.S., for a variety of reasons. From her I've learned that the NHS isn't quite as bad as many make it out to be. A few years back, when I had hernia surgery, I explained to her how long I had to wait to have the surgery done here, and asked how I would've had to wait if I'd had the surgery in England. Her answer was that the wait wouldn't've been much different at all.

Several of my schoolmates from UHHS stayed in England, too, and they use the healthcare system there with little or no complaint.

My girlfriend is Portuguese and lives in Porto, in northern Portugal. They don't have the best of healthcare systems in Europe, but neither does it equate to the nightmare that rightwingers like to say that nationalized healthcare amounts to. During my annual visits to Portugal, I've never had to make use of their system, but I have made use of their pharmacies on a couple of occasions, and the cost, even of ibuprofen, is significantly lower than it is here in the U.S.

I'm always telling co-workers (most of whom have rarely, if ever, set foot outside of the U.S.) that much of what's said about healthcare outside of the U.S. is complete crap. I think what I hate the most is the whole "your taxes are going to go up" bull, because the one thing I never hear mentioned is that while taxes might go up, you also won't be paying those insane insurance premiums, and it's highly likely that a person's take-home pay wouldn't even be affected (and that's what would concern most reasonable people). But, as usual, the Right wants to use scare tactics by conveniently leaving things like that unsaid.

miriam beetle @167: Tasty and good for you!

Gary, #171: Would your friend's name happen to be Joyce? If so, I may have met her, when she was in Dallas for a visit a few years back! My partner and I drove up from Houston and we had lunch.

All right. Have a look at this piece of incredible nonsense: Palin: Obama's Health Plan Evil.

Right now, I'm not sure whether I should just curse stupidity in general, or pray for my country. Maybe both.

I'm sorry to add fuel to the fire, but I just had to say this to someone: Arrgggh!

Mary Frances @174:
Sigh.

It's because the Republicans want all of the Death Panels to continue to be privately run, for profit.

Mary Frances @ 174... Speaking of Obama and Evil, there's a comic-book out called "President Evil". The cover spoofs Bruce Campbell's "Army of Darkness" movie poster and, in spite of the title, Obama appears not to be evil but to be an exterminator of zombies.

Abi @175: Yeah. I know--or some Republicans do, at least. I suppose I was venting because if I didn't I was going to choke on the bile, and I figured ML would understand.

Serge @ 176: Thank you. I needed that.

One of my Facebook friends was out at a Farmer's Market in Durham, NC this morning, collecting signatures on a petition to encourage NC Congresscritters to support a public option. She just posted:

That was the easiest political work I've ever done. Just say "health care petition?" and they're all "where do I sign? give me a pen!"

She says a few people refused to sign because they won't accept anything less than a single-payer plan, but I think that's dead in the water for this cycle.

Lee @173: No. Her name is Melinda.

Nan @162 “I expect the costs … to go up, up, up, up and up and … the quality of care to go down.”

But this is what's been happening over decades of US “free market” privately-based system.\(Potential high-end care quality may get higher, but fewer get it; great majority have actual access & quality reduced.)

Sarah Palin was the Republican Party's vice presidential candidate.

And she's a fooking nutter.

Whatever misgivings I have about a few specifics, I'm glad I voted for Obama. I'm glad I sent his campaign $500.00.

Because Sarah Palin is a fooking nutter.

Pendrift @ 157: Doctors still make house calls in Belgium! I recall that from when my family lived there in the 1970s, and had wondered if it was still an option.

Gary Townsend @ 171: I was in England at exactly the same time for exactly the same reason. We lived near the base (Feltwell, but my dad worked at Mildenhall), so never used the NHS. Instead we used the American military's government-run health service, which was just fine, thanks.

janetl: doctors still make house calls in the UK -- my parents are over 80, and apparently over-80s are entitled to a regular monthly house visit, plus house visits when they need one and can't get to the surgery. (Not so sure about under-80s but I think they're still available for patients who can't walk; in terms of a health organization, it's a logical triage step before calling an ambulance for somebody with, say, suspected meningitis.)

While not house calls per se, my father is getting in-home physical therapy sessions and nurse visits during his much-longer-than-expected post-cardiac-surgery rehab.

When he asked me to guess how much his bypass, valve replacement, and month in a convalescent home cost him out of pocket, I figured a few thousand.

More like $20! Medicare is fairly astonishing in its comprehensiveness.

One of the many things that get me riled is the common assumption that "the government can't do anything right." I drove on paved roads today, with clearly painted lanes, well-placed stop signs, and working stop lights. I'm glad to know that the other drivers had (mostly) taken driving tests to be licensed. I had confidence that the food at the grocery store was handled in accordance with safety regulations*. The water that came out of my tap was tasty and safe. I have a toilet that flushes to a sewer, and not an outhouse. I don't need bars on my windows or a tall fence to protect me and my property from criminals. I have a great local library. This internet that I love so dearly started with government funded research into TC/IP and then a grant to some grad students who had a wild idea about a "browser" to put a graphical user interface on that network people were using for newsgroups. The public schools that I attended were much better than the private parochial ones that I also did. And so on.

No, the government doesn't get anything right. And neither does private industry. I've signed Non-Disclosure Agreements, so I can't tell you some of the howlers that happened at companies where I worked, but I can assure you that millions of dollars have been wasted by nimble, capitalistic entrepreneurs.

Given the choice of medical insurance companies** making decisions for me, and some government oversight, I'll take the oversight every time.

*I'm not that confident about the ground meat, or beef in general, and I avoid that. But the problems there are due to the meat industry successfully resisting government regulation.

**And if you don't like the decision your insurance company makes, it will be adjudicated by an arbitrator hired by the insurance company. And you can't appeal. Can't be any more fair than that!

Argh! I don't get everything right either! The 2nd paragraph in #186 is supposed to read:

"No, the government doesn't get everything right. And neither does private industry."

"The government can't do anything right" is an article of faith for some of these folks.

Suggest shutting down the V.A. hospitals and putting Halliburton in charge of running medical facilities overseas.

The claim: "The government doesn't do anything right." The truth that is loosely related to the claim: The failure modes of government are different from those of big business.

It seems to me that a lot of the time, when people say, "The government can't do anything right," what they really mean is, "The government can't do everything perfectly all the time."

But if they said it that way, everybody would realize what a stupid assumption it is. So instead, they trot out a bunch of anecdotes and then make a sweeping generalization -- a tactic that traces back directly to Reagan and his "welfare queens".

Tim Walters @ 183 Where did you go to school while in England? London Central? The former students of UHHS recently had an all class reunion in Myrtle Beach. We hold them every three years. Always so good to see old classmates from England.

Prior to moving to England, my family lived in Bangkok, Thailand. We used American military hospitals there, and I was hospitalized there for a couple of days due to blood poisoning when I was 12 years old. So, I agree. I, too, have/had no problem with the healthcare provided by the military either. I continued to use it after my father retired, and two years after I graduated from high school, as I went on to join the Air Force myself. I was in from '80-'84, and served in Greece and at Andrews AFB. The only problem I ever had with a military doctor was with the 'bedside manner' of a certain dentist in Greece, but that's hardly a pitfall exclusive to military medicine alone.

Lee @ 190: Ah, yes, Reagan's anecdotes of welfare queens driving up in Cadillacs to collect their checks. I think he only mentioned a "big buck" using food stamps to buy liquor once. Even he had limits.

Steve C @139:

I keep intending to take the time to take apart the Hoover thing, but I'm not going to have it any time soon. Here are two thoughts:

1. It's cherry picking. The WHO uses many, many statistics to describe the health care systems of the world. See here for core health indicator query and display system.

2. It's missing some statistics that aren't gathered anywhere, because they're not relevant or prevalent anywhere else in the developed world. Off the top of my head:
* personal bankruptcies caused by medical care costs (excluding simple inability to work because of a medical condition)
* marriages made to extend health care coverage†
* divorces not undertaken because of health care coverage†
* job offers turned down because of lack of health care coverage
* new business starts abandoned or failed because of health insurance costs

Most or all of these phenomena are all but unknown everywhere else, but I've found references to them in the US all over the web. I'm sure there are more patterns to highlight.

-----
† Is health care another piece of "defense of marriage?"

The government doesn't do anything right

...while the corporate world never does anything incompetent, imbecilic, incompetent or idiotic. That makes me wonder what made those Dilbert cartoons so popular.

abi @ 193... I keep intending to take the time to take apart the Hoover thing

Just make sure you can put it back together. I've got dust bunnies piling up in the corners.

#193
Businesses that cut back on health care coverage, or lay people off, because of the cost of that coverage.
(I've seen that one, too. Most recently from a woman whose husband's company is looking at shutting down (and laying off a hundred people) because they can't afford to pay for health insurance any more.)

Janetl, #186: "One of the many things that get me riled is the common assumption that 'the government can't do anything right.' I drove on paved roads today, with clearly painted lanes, well-placed stop signs, and working stop lights."

You don't live in Seattle, clearly. (Except for the stop lights.) California is in even deeper trouble. "The Government," unless hopelessly corrupt or authoritarian, is the people. And if the people don't get it right, the government doesn't get it right.

Abi @ 193 -

Thanks -- the cherry picking is certainly going on, which is why it's concentrating on cancer stats. The 5-year survival rate for cancers is heavily skewed by slow-growing types of cancer, and touting that exclusively as a measure of quality of health care is disingenuous at best.

Abi@193, Steve C @139:

The cancer stats are particularly misleading because of the effects of cancer screening on 'survival'.

Suppose you have tiny, but untreatable, tumor that is going to kill you in 2016. If you get screened and diagnosed today, you will have seven years survival after diagnosis. If you get diagnosed in 2014, when it starts causing symptoms, you will have only two years survival after diagnosis. So, cancer screening will improve your survival after diagnosis by five years. Or, to put it another way, screening will mean you have cancer for five more years of your life.

The bias is even greater for cancers that mostly occur in old people (such as prostate cancer). If you have a cancer diagnosis and then die, it is quite likely that your cause of death (or a cause of death) will be listed as cancer.

The first problem means that it's extraordinarily difficult to get an honest comparison of anything other than mortality figures either over time or between countries. The second problem means that even mortality figures need to be considered carefully. Dying with cancer (rather than of cancer) is probably one explanation of why Australia hasn't reduced melanoma mortality as much as would be expected.

It's not impossible to do these comparisons properly, but anyone who claims that the data speak for themselves is either ignorant or trying to trick you.

To some extent this is true of other cause-specific mortality, but much less so: figures for heart attack vs cardiac arrest vs heart failure aren't wonderful, but figures for 'all cardiovascular causes' should be pretty good.

I think I know what's going on with the 'statin' claim, but I'm less certain. Statins (at least in people under 75 or so) are effective at reducing heart disease risk and are extremely safe. This means that the risk-benefit tradeoffs would favor giving them to a very large number of people. Cost-benefit tradeoffs, on the other hand, mean that it isn't really worth spending much to reduce someone's annual heart attack risk from 1/5000 to 1/10000. This means that the threshold for prescribing statins is higher in Britain or Australia (at least, it used to be) than in the US.

So, this is a semi-genuine point: cost-effectiveness considerations mean that a lot of people who would benefit very slightly from statins are not prescribed them in other countries but are prescribed them in the US. If the Hoover stats are accurate, this is larger than the number of people in the US who would benefit a lot from statins but can't afford them. Also note that a lot of statin users in the US are under Medicare.

The situation is likely to change now that simvastatin is available as a generic, and change even more in a couple of years when the atorvastatin patent expires.

The Raven@197 -- I live in Seattle, and the roads are a hell of a lot better paved than in many areas (they're generally paved, and not made up of cobblestones or bricks except in Scenic Areas), stop lights work, and while a few stop signs are hard to see because of trees -- they're mostly in a standardized place. Complaining about the roads in Seattle is similar to complaining about the UK's health care system -- it's not perfect, but it beats the hell out of most of the alternatives.

Tom Whitmore, #200: The road-building was in the past & there hasn't been adequate maintenance for years. What are the streets going to be like in another generation? What is the city going to be like in another generation, with hopelessly inadequate policing? But there will be stop lights!

Watch California. California is the bellweather, and California is tearing itself apart.

Raven, California isn't tearing itself apart, it's going into legislative gridlock. Not at all the same thing.

Raven* @201 So it's not that Government can't do these things**. It used to. Now it has problems. Immediate questions are:

What changed?
How to get it working (supporting its citizens, society & country***) again?

Sail on, sail on
O mighty Ship of State!
To the Shores of Need
Past the Reefs of Greed
Through the Squalls of Hate
Sail on, sail on, sail on, sail on.

BTW, a "wether" is a type of sheep. Shepherds belled one which led the flock so they'd find both, hence "bellwether".

* I hope dropping the "The" is OK.
** Many which I see as the function or purpose of government, the (good) reason for setting it up and keeping it going.
*** In the Australian sense, i.e., the land.
There's another thing, maybe "infrastructure" — if "society" means the human institutions that support families and individuals; "country/land/(environment?)" the organic and inorganic ecosystems; this is all the added constructed physical stuff: communications (incl internet), water, waste, energy, transport, shelter, shops, etc. I'd like a better word, with fewer syllables (preferably starting with c or s). "Society" might include both, but I don't think most people immediately envision phone and rail lines or water mains when you say it, though they may think schools, courts or hospitals.

201: The point is, the state government is responsible for maintaining the state roads, the local municipalities are responsible for maintaining the local roads, and the federal government is responsible for the federal roads. When the economy suffers, everyone hurts, so no one has an easy time maintaining the roads -- but the government still built the roads in the first place.

Second, California is in legislative gridlock, as PJ pointed out. They created their own monster starting in the 1980s, when they began putting legislative questions to the general population. As anyone who has ever sat on any general committee -- PTSA, neighborhood association, anything -- would know, the vast majority of people are not qualified for positions of power and authority. Mob rule translates to gridlock, particularly when you have the opportunity for small but loud and well-financed groups to make life difficult for others. As has happened, time and again in California. Recent years have emphasized their legislative error, and I believe they are trying to correct that now, a bit late, but still wiser. In the meantime, they struggle with their demands and needs, but they still meet those needs to the best of their abilities. That's what a state government does.

The Federal government has a different set of priorities, and rightly so. As a famous character once said, "The needs of the many outweigh the needs of the few.."; that is the mandate for the Federal government: what is best for the majority of the people.

So, while you may not like the condition of the roads in Seattle, at least you have roads, and stop lights, and electricity that is reliable even in bad weather, and good quality water with no parasites floating in there, and food that meets a certain Federal standard in order to be sold, and reliable communications devices, and cosmetics that won't kill you or blind you, and medicines that are safe to take or at least safe enough with care, and support for community policing initiatives, and standardized exams that high school students take, and a whole lot more. That's the point.

People who claim that they don't want government interference in their lives should stop and think about all the things the government does. that they never think about and take for granted, and then decide whether they need less government.

Finally, it's easy enough to demonize the government for all our ills, but it's not right. A citizen has a duty to pay attention to the little things that seem so unimportant on those ballots in those unimportant off-year elections; a duty to contribute towards society by volunteering and helping out; and a duty to do more than just complain about things they don't like but can't be bothered to fix.

PJ Evans, #202: I think you are quibbling over terminology. The California legislature has set the stage for human misery, destroying long-standing institutions in the process. The real tearing will start when Californians realize just what the legislature has committed them to.

Mez, #203: "the people" need to reweave the social contract. Isn't that what Obama campaigned on, after all? But the opposition is astonishing.

BTW, "Raven" is fine. I looked up bellweather in the OED; both spellings are given.

Circling around a bit to the original topic -- I don't think government (city, county, state, federal) does anything perfectly, but they do quite a few things just fine. I think our current way of insuring access to health care is astonishingly bad. In 2007, about 46 million Americans, or 18 percent of the population under the age of 65, didn't have coverage. When they get really sick, they end up in ERs getting incredibly expensive care. I'm confident that any plan that makes it through the legislative process will be better than that.

I had Kaiserdocs visiting me at home a few times after both renal failures, plus IV nurses and caregivers. Didn't cost me anything, but that was 1987 & 1990.

And on Friday, I got a lot of help when a fire started in the building where I was on the second floor waiting for my pulmonology appointment.

Bellwether is the leader; bell weather has an entirely different etymology.

Raven, #205: I'm with Mez re "bellwether"; the other spelling just looks odd and wrong, as if it were a back-formation of the "Wallah!" sort.

Marilee @ 207: Fire an 2nd floor, oh my!

Raven, I am entirely too familiar with California government: I had the good sense to vote against Prop13, and against the recall (and against nearly every GOP politician in the last 40 years - the one exception when there was an adequate Democratic candidate was Pete McCloskey in 1972).

One of my suggestions for fixing things is to raise the number of signatures required to put initiatives on the ballot to something like 5 or 10 percent of the registered voters, so we won't have to deal with the stuff that a competent legislature should be handling.
Then we can maybe get the state constitution re-written to a more reasonable document.

P J Evans @ 211: Me, too, but for Oregon. That is, substitute "Measure 5" for "Prop 13" on the property tax limitation. I have the impression that ours is less draconian. Ballot initiative are easy in Oregon, and create nonsense here, too.

I can't take statin drugs, as I have the dreaded musculature deterioration side effect. Instead, I am prescribed another drug that is very effective (much more so than statins were), without the crippling side effect. Because cholesterol metabolism is the biggest part of my heart problem, this is a big help. However, the drug (Zetia) is pretty expensive, and my cardiologist gives me samples because I couldn't afford it otherwise.

abi @ #150: I happened to need to visit my cardiologist's office Friday, to pick up more samples of the cholesterol med I use, so I asked about the policy on free drug samples. The clinician who came out to talk told me they're not required to account for whom the samples are prescribed, only that the samples are given rather than sold. In some cases, a brief course of a drug is given to a patient to determine its effectiveness, and the doctor doesn't feel the patient should have to pay for an experiment. In other cases, the patient just can't afford the needed medication. The only cases where non-controlled medications are tracked by patient is if there's an inquiry by a payer or a lawsuit.

I told her the reason for my asking, that a posting on a blog about health care coverage had stated that required government accountability might consider free samples as fraud. She told me that she was aware of the call for more accountability, and strongly agreed with it. She said the two main areas of concern are gifts and perks for high prescription rates (basically, bribes) and issues surrounding the prescription of narcotics. She did say certain types of universal coverage would probably end the need for free samples, but that currently "discounts and samples" are at the discretion of any practice, and that will probably continue, as "there will always be a few people who fall through the cracks of the system, just, hopefully, not so many."

Ironically, when I got home, local sheriff's officers and the DEA were conducting a raid on the medical clinic across the alley. They walked two of the doctors out in handcuffs. I'd heard rumors that there were "scrip doctors" there and noticed what seemed like a large percentage of young, healthy-looking but druggy-looking people there, considering it's a radiation oncology practice. Apparently the docs continued to prescribe oxycodone and hydrocodone even after their licenses to do so were yanked.

Governance by ballot initiative and referendum works, methinks, better on the inverse of the size of the governed body. The idea that Mr. or Ms. Everyperson can run an enterprise larger than most corporations and, indeed, most countries (i.e. California) is beyond insane. The fact that so many Californians are just shocked and angered that things are in gridlock only goes to prove the point.

Substitute Referendum 69 for Prop 13 and Measure 5 and you have Washington; the west coast state governments have been impoverished by the toxic interaction between Progressive-era constitutions and Reaganite->neocon anti-tax activism.

Re: "bellwether"--actually, the OED does give "bellweather" as an alternate spelling for "bellwether," but only from the 16th to the 18th centuries, I believe. Approximately during that period, the word "weather" is also listed as an alternate spelling for a "wether," aka a male castrated sheep--but only as an alternate.

The modern spellings are "bellwether" and "wether," invariably.

Sorry to interrupt. I just couldn't resist an excuse to go play with the OED.

Janetl @ 206: I'm confident that any plan that makes it through the legislative process will be better than that.

I wish I had your confidence. My big fear is that if anything makes it through the legislative sausage-grinder, it will have so many complex loopholes and giveaways to vested interests that it won't actually be an improvement.

If it’s permitted to continue off-topic:  the OED I'm looking at gives bell-wether with a hyphen.  As Mary Frances says, wether is the invariable modern spelling, and preferable IMHO because the derivation has nothing to do with meteorology.  Similarly with the hard grey sandstone boulders that occur on the chalk downland in Wiltshire county, England, brought there by glaciers in the last Ice Age;  Stonehenge is partly built of them.  They are called sarsen stones, or locally “grey wethers” because from a distance they can look like sheep in the valley.

I don’t know when English spellings became consistent.  My impression is that up to the 18th or early 19th century, spelling was pretty variable.

You can find pretty much any combination of letters at all attested somewhere in the OED.

A great deal of the current dysfunction of our government is the direct result of several decade's worth of Republican sabotage.

Bluntly, they have been purposefully backstabbing our government, in large part so they can point to it and say, "look, government doesn't work!"

Their sabotage includes not only direct starvation of federal and local agencies, but structural attacks, such as eliminating oversight over critical areas. (Those themes overlap, for example in the muzzling or outright suborning of the SEC and other regulatory agencies.)

John Stanning @ 217: So does the one I'm using, as the main entry.

Jim Macdonald @ 218: I think that's one of the reasons I have so much fun playing with it.

Sorry. I'll stop interrupting now.

@218

Usually as a disease of sheep.

Not really enough of a sample on YouTube

And a belle wether is going through gender reassignment surgery.

When there's a $2.4 trillion pot on the table, look for the players with the biggest pockets to win.

P J Evans, janetl, JESR:

Prop 13 was one of the primary reasons we left California in the late '70s: our oldest child was almost old enough to enter public school, and we were seriously concerned about the quality of education post tax revolt.

Of course, we moved to Oregon, found really good schools in the Portland area, and then had to face Measure 5 a few years later. Result: our older son squeaked through high school before the rot really set in; our 4 years younger son, fell into the pit; he was not motivated enough to make up the difference himself, and is only just now finishing up a bachelor's degree, after years of catch-up.

Despite decades of watching bozos vote for the destruction of their state's educational and regulatory systems, I still can't believe they've never heard the expression "eating the seed corn".

In either funnier or more depressing news from the world of health care misinformation, look what one of the folks at Rumproast has found!

Raphael @225:

As PNH once said, now I have stupid all over me.

If I hit my head on my desk a few times, do you think I can forget that someone said that?

Raphael @ 225: I'm not sure what's got me laughing or crying the most--the essential idiocy/fact-free nature of the comment, or the underlying assumption that of course Hawking must be a U.S. citizen. He's a brilliant scientist, isn't he?

Well, in context, it's the ridiculous attack on the NHS, of course, but--ouch. Just, ouch.

I'm thinking of writing up a list of totally transparent BS "REAL FACTS ABOUT OBAMA'S HEALTH PLAN!", like . . .

"A hidden clause in the Health Plan requires white males in southern states to be castrated at age 13, supposedly to prevent prostate cancer but really because HILLARY CLINTON HATES NASCAR!"

"Language inserted by Nancy Pilosi will allows illegal immigrants to approach American citizens on the street and demand they give up a kidney for transplant. They don't even have to have a need for a new kidney!"

"When the health care plan is signed Obama will reveal himself as an arab and demand all government doctors to covert to muslim! They'll have to wear unhygenic turbans and you could die on the operating table when they interrupt surgery to pray to Mecca!"

. . . . and sending it a certain family member, but I'm afraid it would end up getting picked up as fact by these chowderheads.

* * *

Something occurred to me this morning.

You know the joke about the hikers fleeing the angry bear?

The one with the punch line "Hey, I don't have to outrun the bear, I just need to outrun you!"

The misinformation about the health care plan is like that. They don't have to fool us, they have to fool . . . well, people who are just a bit slower.

Stefan@228

Or faux-Republican bumper stickers.
The authenticity of "Keep government out of Medicare" beats my previous favorite "Support economic diversity", though there's something to be said for the relative subtlety of "Mission accomplished"

Raphael @ 225:

The stupid, it burns!

(Also what abi and Mary Frances said.)

Stefan Jones @ 228:

If you do send off that email, at least we'll know where it originated instead of having to track it down.

Stefan, don't forget the one about mandatory sex-change surgery. (Yes, someone actually was saying that. Don't know who, but the stupid is strong in that one!)

The depths of stupid is really, really bumming me out.

I could probably take time off to go to one of David Wu's town halls to show my support, but for the sake of preserving my remaining tissue of respect for my fellow citizens I don't think I will. I don't want to witness stupid in person.

#232: Oh, my. Of course.

I'm not sure if my spoof would measure up to the reality of the . . . non-reality.

Because of NAFTA, Obama's health care plan will be used to pay for Canadians' sex-reassignment surgery.

Oh, for cripe's sake:

Conservative crank scare fiction about grandma attending a euthanasia counseling session.

The letter I just sent to my senators. Admittedly, the part about being an Ursuline alumna was only in the letter to Mary Landrieu. Presumably David Vitter didn't actually attend an all-girls Catholic school. His had something about being intimidated by the melee that is Louisiana politics.

Having recently moved back to Louisiana, I'm excited to be represented by a fellow Ursuline Alumna. That said, I have to urge you, most fervently, to support a public option in the health care debate now before Congress. Mandating that everyone buy coverage from insurance companies will do little to stop the excesses of that industry. It is important that we maintain a public option to push down management costs, provide a force in negotiating lower prices from drug companies, and provide an example of ethical coverage. Although I am young, healthy and well-insured, I know that one serious health crisis would leave us mired in debt and unable to recover. In the past year, we've paid over $4,500 in co-pays due to the birth of my son and his subsequent ear problems. This, although there was nothing life-threatening, was our percentage of the bill. I will admit, there were months I depended on my father to buy us food because we had nothing spare after paying the hospital. I spent my tax refund on the deductible for mental health care after struggling for 8 months with post-partum depression and paid my OB/GYN with a credit card that I've yet to pay off. And I'm LUCKY.

I've also lived in the UK, and despite all the horror stories, I've seen my grandfather-in-law cared for in his own home through strokes, Alzheimer's, and various other ailments. He was comfortable and close to family throughout his illnesses. While I was visiting family last fall, my son developed a fever, and I was panicked. We called the local health center, and they saw him that afternoon, at no cost, just to reassure me. While I don't doubt that not all of those served by the UK health system are able to receive the cutting edge treatment available in the US, I also have no doubt that were I to get sick there, I would be cared for. That's not something that I can say with any confidence here.

People are drowning in debt related to medical bills, and finding themselves un-insurable if they have the temerity to recover from a serious illness. People are dying because they are not able to pay for life-sustaining medicine and by the time their illnesses force them to the ER, it's too late. We lose countless productive members of society, because they can't work if they have Medicare (the only health care available to them), and they can't live without that health care.

We cannot call ourselves the greatest country in the world as long as we continue to disregard all our citizens the way New Orleans was disregarded after Katrina. This is your chance to make a change, and do something that could be truly great for the United States of America. On the other hand, you could always vote to further enrich people who earn bonuses based on how much they are able to lower payouts by denying treatment and cutting people from the rolls of the insured. Listen to your conscience, because it's clear to me that the free market stands in opposition to basic humanity on this issue.

Stefan Jones @ 235: I read it. I think I'll go be sick now.

Did you look at the comments? I did. One person suggests that the author actually go read the bill, and she answers that she'd love to--"is it available online?"

Everyone else thinks it's a wonderful cautionary tale.

Words fail me.

I know I haven't posted much here lately, but...two things.

#1. Medicaid is saving my life. Less than two months ago, I got a referral from a friend to a local counseling service, since I've known for some time I wanted to get some advice on long-standing matters messing up my mood and general motivation. They in turn referred me to a local medical office, and there I got an array of basic tests and examinations. One of the first things the doctor said to me was "I'm genuinely surprised you haven't had a stroke yet."

It turns out that in the last few years I've developed life-threateningly-high hypertension, and also type 2 diabetes. Now I've got medication for both and training in dealing with the diabetes, and counseling is underway. And Medicaid covers all this except a few of the medication refills, and those I get at $4 for a month's supply thanks to a generics program that Fred Meyer pharmacies participate in.

Now keep in mind, this isn't Medicare. This is the low-end stuff for people on SSI. It's the butt end of medical care for those in serious need. But it's good enough to get me first-class help from people I really respect and trust, and help with the expenses of getting from here out of crisis to as good health as may be.

My view is simple: I think every American is entitled to at least the quality of care I'm getting right now. Rich, poor, smart, stupid, wise, foolish, whatever. All my fellow Americans should have as few worries about their health as I do right now, or fewer.

#2. I have to say I'm not optimistic about the prospects for legislation. Medicare and Medicaid work partly by proceeding (where allowed) in blithe disregard for private practice. Mandates strike me as a terrible idea, because I know what everyone in "low-income" brackets does: you pay the fee up front in full, and help comes (if at all), late and often less than you were promised. Likewise, I notice that all the talk of the public option begins with people not being allowed to choose it, only having it as an option once everything else has collapsed, and even then after jumping through hoops. That doesn't make me feel happy or safe about the setup at all.

It's very, very possible - and maybe even likely at this point - that health care legislation that can make it through a Congressional vote will end up being a net loss to the country's well-being. Precisely because I hope for so much better, I think it's critical to pay very close attention to what actually passes, if anything does.

One little bit of info on the health debate: pharmaceutical manufacture is regulated, for quality-control reasons. For a generic to get on the market, there's a barrier in the proof needed that the plant produces the right chemical.

Was it last year that Charlie Stross was facing a problem with the supply of one of his hypertension medications, because a plant refurbishment was taking longer to complete, and re-certify, than had been expected?

Now, this could be abused. If a large pharm company could nobble the certification process they could stifle competing supplies when their products come out of patent protection.

Even without that, they will have a working plant, certified and producing. It's a big advantage.

But eventually it will need refurbishment. and that's when a generic can appear.

EClaire at 236: Excellent!

Re the VA: It's a bastard. Some of it is "single payer", some of it isn't. How it does things is arcane beyond belief, and the rules change from budget year to budget year.

I have 100 percent covereage for "service related conditions", except that some of them aren't seen as such, and I have to fight to not pay for them.

If it's not service related, it's means tested, and there is a sliding scale of co-pays. Depending on when one was discharged, and where one served, one has different credits against being charged.

That said, if you are a vet, you get treated (this didn't happen to be the case in years past, when one needed to get a "blue card" and folks who had one made sure to use it at least once a year to keep it; but I digress, that was under Reagan, when things were different; much like Bush II he "supported" the troops).

I gashed my knee a week ago. I went to the Palo Alto VA. Walked in, told them I was a vet, gave them my name/last 4 and they handed me to a triage nurse.

Fifteen minutes later I was being x-rayed. Three hours after that I was stitched up and sent home. I got a vicodin in the meanwhile.

If I am going to be billed, I will find out in a coupl of weeks. If I can't afford it, I get to explain why. Then they decide what to do. In the meanwhile, my service related treatments will continue, no muss-no fuss.

Steve C: From what I was told when I negotiated the cost of my kidney stone (from 9,000 to 1,100) the cost for the uninsured is directly related to the negotiated price. The insurers get a "discounted" rate. The only way to make the rate a discount is to jack the price up for the uninsured. So the insurers are paying about what it really costs, and the poor saps who have none are paying a big fat surcharge.

re Cobra: The other thing Cobra does (and why some people HAVE to take it), is prevent an insurer from excluding, "pre-existing conditions". A friend just got laid off. I don't think the need to get PT for tendonitis had anything to do with it, but if they don't take COBRA, they will have to pay to get it treated out of pocket.

The Raven: Actually, the legislature hasn't done much of anything. The people (in 1976) passed Prop 13, which effectively (over time) ate the budget, by making it almost impossible to fine tune the tax code. Since the lie that "no tax ever goes away" was married to the pernicious idea you are trotting out here (about gov't not being able to do/maintain anything) any politician who tried to adjust taxes failed (because to fix one thing, a minor problem with property taxes, everything was dicked up), and then, as often as not, was turned out of office, bonds became the vehicle of choice to do things like maintain schools and roads and other infrastructure.

But bonds cost more than taxes, and they get paid from the general fund. So we ended up robbing peter to pay paul's usurious interest.

And Paul is allowed to convince us that more of the same is still a good idea.

Amazed to find that the page at the Investor's Business Daily is still up, the one with the gaff about Stephen Hawking inserted into a heap of nonsense about the British NHS.

I was half thinking they would have taken it down in shame. Is it that they really don't understand how stupid they look? Or is it the Big Lie? Do they know perfectly well that what they are saying is in fact evidence against their side of the argument, but assume that if they say it loudly enough and often enough, and if they assert against the facts that the evidence is on their side, people will be conned into believing them?

"People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless."

One wonders what sort of healthcare Hawking would have got in the USA when his illness first become obvious. He was a 21-year-old student at the time, not as far as I know in any kind of employment. His disease is one with a typical prognosis of gradual decline into complete immobility and then death in about ten years. Would he have got any insurance in the USA? Would Cambridge University even have been allowed to offer him a job?

[Fixed link to Investor's Business Daily. Please, everyone, look at the Preview when you're posting. If a link is greyed out, the post won't appear but rather be held for moderation, which is not instantaneous.--JDM]

Repeating my query @146, spurred by Bruce's par 2 @238.

[*] “single payer” =/= “public option”?
Is there a fast crib on different ideas around for USA which doesn't assume knowledge of current situation? Or even simple explanation of current situation?

(e.g. What's difference between (USA) Medicare & Medicaid? What's single payer & public option? Is there a mandated "gap" (possibly = co-pay) size, or standardized prices for services? Can you get "gap insurance"? Are chronic diseases (HBP, diabetes, &c) covered automatically as you change jobs (COBRA is something in there)? Can you choose doctors? And so on…)

Epacris, not that I know of or can find. If I have time, I'll try to write one up, because it seems like that'd be a useful thing for lots of people.

This PDF [link goes directly to PDF document] makes a start (particularly in explaining Medicare and Medicaid), but doesn't explain nearly all of those terms.

Here is A Primer on the Details of Health Care Reform (New York Times). It's a starting point.

Epacris: A quick primer on the brtn that is the USian system.

Medicare: Government single-payor program open to seniors (age 65+) only with a handful of exceptions. The government pays medical service providers directly. There is a 'gap' of 20% on most services, and there is private "medi-gap" insurance available.

Medicaid: Run by the states on grant money from the federal government, this is health coverage for the indigent. Government pays the bill, mostly without gap/co-pay. The threshold income above which one is disqualified from this is very low, far lower than any income that makes private cover affordable.

Under Medicare and Medicaid you can choose your doctors within limits - there are some doctors who do not take patients from these programs.

There are two broad categories of private cover, employer based (group) and individual.

Group coverage through work puts everyone working for a given employer in a pool. Insurers are limited in their ability to screen for health conditions. Premiums are split between employer and employee depending on the generosity and competitiveness of the employer, but it's the same ratio for all employees. There is typically a deductible, one must spend x amount out of pocket before insurance picks up anything, and co-pays that vary by the type of service. When you leave a job, you leave the employer's group and lose your cover as well, but COBRA allows you to continue your benefits out of your own pocket. Starting a new job and being added to the employer's cover, the insurer is only required to cover pre-existing conditions such as the chronic diseases you mentioned if you have had continuous cover with no gap prior to joining the new group, which is why people are willing to pay the exorbitant premiums charged under COBRA.

Individual insurance is a whole different other. With no group to share risk, the insurer spends a great deal of time and resources screening out bad health risks in individual applicants. If you have a chronic illness and you're forced into the individual cover market, you are essentially fscked - if you can find an insurer that will take you on at all, the premiums will be back-breaking, and the pre-existing condition will likely be specifically excluded from coverage. To top that off, if you do get individual cover and you do end up needing it for a serious illness, the industry's latest trick is to microscopically examine the application going back however many years looking for errors and omissions, however unintentional, to retroactively void your cover. Nice, innit?

Under private cover, you can choose your doctors within some limits - most private plans have lists of approved physicians and facilities, and there's an extra charge if you go to a doc who isn't on the list (if they'll pay at all).

Fees for services: Vary wildly, by provider and location. There are prevailing rates regionally, but those are guidelines. Medicare and Medicaid have mandated fee schedules that are all they'll pay for a given service in a given region, which is why not all doctors accept those programs. Private plans negotiate with providers, driving fairly hard bargains - demanding a deep discount in exchange for a certain reliable number of referrals. In order for the discounted rate to meet expenses in many cases, providers have to jack up the non-discounted rate through the stratosphere.

And finally, single payor vs. public option:

Single payor is like the NHS, Australian Medicare, etc. - government pays the bill, no private insurance necessary. The key players in Congress have pretty much taken this off the table despite a majority of the population thinking it's a good idea.

Public option would make a government-run program like Medicare available for anyone to pay premiums and participate in, as an alternative to private insurance, which would still exist. The idea here is that the government program would apply competitive pressure to an otherwise collusive private insurance market and drive costs down for everyone - keep the private insurers honest is the popular phrase. This would come along with a prohibition on pre-existing condition exclusions, creation of risk pool groups not tied to employment and other reforms designed to protect patients from the abuses of the current system.

Aaaand Caroline and Macdonald's Google-fu trump my mad typing skills. Bad me for not refreshing before posting. :-P

Mark @ 246/247:

No worries. Your summary and Caroline's link combined are incredibly helpful. James's less so for defining terms, but a little more for a snapshot of what some people think.

Mark, no apologies needed, that was useful.

Though, I'd contest that the single payor is different from the NHS, Single payor is more like Canada, where the government pays the bills but the drs are independent. The NHS is more like the VA system, where the government both pays the bills and employs the doctors.

Paul Krugman talked about this at the worldcon. If I remember correctly, he compared the proposals to Rube Goldberg contraptions. BUT. He also suggested that anything that gets implemented would be a foot in the door, giving the example of Massachusetts's system: it had problems, but it made people realize that something like it wasn't such a bad idea so, instead of throwing the whole thing away, they decided to try and fix it.

Private for-profit Death Panels

I have to thank all of you for your links -- a college friend of mine has been very worried about the possibility of denial of coverage for the disabled (she has a son with Down's), and I've used the posted links in my replies to her. I hope she reads them. She's a smart woman and I hate to see her fall for the propaganda being sent around.

I used to half-seriously be happy that my kids have Euro passports, just in case America goes (more) insane. Now that my son has kidney problems and my daughter Crohn's? I'm no longer half-serious; having that Euro citizenship may literally be a matter of life or death.

As you all know by now, I bought a cheap house in Indiana, and that brought me back from Puerto Rico. In Puerto Rico, there is universal healthcare. It's not as good as it used to be (it's been seriously weakened by the rich lately) but coverage for the four of us is $300 monthly, and yeah, they covered my son's biopsy no questions asked.

In Indiana ... well, we haven't actually made a decision yet. To be honest, we're coasting on our Puerto Rican insurance, because we know that our choice is either to lie about the kids' preexisting conditions or to just not insure them. Last time we were in Indiana, we lied. It's not like they've been diagnosed in the United States, after all. But this time, so-called "insurance" that we all know ensures nothing at all is even more expensive than it was then.

And the kids are already insured ... in Hungary.

The current whammo - braces. Here, $5450. Hungary, about $500 if you go state, but still only $2500 if you go private. That, my friends, pays for the airfare for the four of us, so braces will have to wait until next summer.

But the big question then is: do we come *back*? And I just don't know. If America had health care, the answer would be, yes. As it is ... maybe The House should be a summer project for a few years.

This anonymous comment comes from some one known to the moderators, and from an occasional commenter. It’s intended to add a data point on non-US health care, particularly in the area of mental health. Hence, the anonymity. (Thank you for your understanding.)

My background: I’m from the United States, born there, but have lived abroad for something approaching half my life.

My age is the latter 40’s; my sex female; marital status - married; resident in Belgium. While I am otherwise physically in good shape, I have been a life-long sufferer of depression; this is my primary reason why I cannot return to the US with the current health “care system”.

(To be a bit fair to my home country, when my depression first manifested, back at age 5 or so, there was not a lot of treatment available to something so “low-grade”, as it was then considered. Besides, how could a child be depressed? Childhood was supposed to be the best time of life? As time progressed, however, treatment options have also multiplied. And so should have the possibilities for conveying them to sufferers.)

My current mental health situation is that I’m stabilized, reasonably happy, semi-productive as a returning-student at a university. It was through the university system that I made my entry into the mental health care system - a bad depressive event combined with the stresses of exams, and I just lost it.

However I knew from some earlier interventions in previous countries that I could find help by talking to a psychiatrist. The diary/date-book that the university hands out to all students contained all the needed contact numbers. On the last week of classes (roughly a month before exams), I phoned on a Friday at 3 PM.

I was talking to a psychiatrist at student services by 5:30. (I did get the distinct impression that this particular doctor had agreed to stay late, to meet with a student in crisis.) The issues quickly sorted themselves into two catagories: short-term “what to do about exams” while preserving my confidentiality (yes, they have such safeguards in place, so that you are not made to explain to your examining professor that you’ve been knocked out by depression), and long-term. This is where stuff like drug treatments and repeat consultations come in.

Cost of seeing a psychiatrist: 67 Euro (rounding up to whole Euro) for an hour’s therapy, with the insurance returning all but 16 of that to us. I haven’t had to enquire about an upper limit to the number of consultations yet, so I’m afraid I can’t say with any certainty if there even is a limit.

Cost of a 56 tablet box of Escitalopram (in the US marketed as Lexapro, in Belgium as Sipralexa): if I show my health insurance card, it costs 11 Euro (For those on social welfare or pensions, I believe they get the even lower price of 7.) If I did not (for some reason), it would cost 43. (Prices for the more commonly available 28 tablets: my price 8 Euro, the others 5 and 31.)

I could continue this prescription with my GP, once consultations were no longer needed. I see a GP at a shared practice within walking distance of our house in a mid-sized city. I've never waited more than an hour during the open hours of the practice. Getting an appointment, if I wanted to deal with something longer, might have been a bit tricky - 2 weeks, if I really needed a specific and popular time slot for a non-urgent consultation.

Price of the consultation? 21 Euro. Price of a house call? 50. But we get back 19 Euro of the in-office consultation, and 40 Euro if we have needed a house call.

Our insurance is actually more like an enrollment fee, as the 120 Euro per year we pay for 2 healthy adults of middle age would no where near cover even the modest costs of a visit to the emergency room (for a nasty fall - and we were seen within the hour, and had X-rays giving the all-clear before 2 hours were up.)

Heck, the health insurance will even kick-back 10 (some places will do 25!) Euro for their policy holders who have paid a membership in any assortment of sports/martial arts/health/gym clubs. There is, in addition, a “hospitalization” insurance, which would cost 300 Euro off the peg (for 50+ that will go up to 375), but if negotiated through the particular employer of our household costs... 24 Euro per year.

So, it’s pretty clear to us that our taxes are paying for the health care here. The larger question of taxes is a bit complicated. We reckon as a household we’re paying about 30%, if only the tax on income is counted, and 50% if one puts in everything like sales’ taxes, municipal fees, property taxes.... (7.35% of gross salary goes from taxes to health care. For everyone. Half of that is deducted from the employee’s salary, the other half is paid by the employer.)

We know we took a net cut in the household income when we moved here. However, we feel more than compensated by a hugely increased quality of life, which includes the responsiveness and accessibility of the mental health care. (I won’t go into the other services from which we benefit, but I can say, they are mighty.) It would take even more than we were earning before to have the same kind of quality of life where we lived before.

Meanwhile, I have been keeping track of mental health and related issues in the country of my birth. I have a couple of friends who due to depression issues are not doing well at all, and are both certainly employed beneath their capacities as human beings. I know that one friend doesn’t so much get treatment for depression, but rather exists from charity sample to charity sample from the GP...

And certainly, I have experienced nothing like what I read at the Real Preacher (http://www.reallivepreacher.com/node/1262), when he and his came within a hair’s breadth of becoming uninsured due to mental health issues of his and elsewhere in his family.

That and the stark difference between my life here, and those of my friends with their patchy treatment has made me realize that with the way things are now, there is also no going home for me.

Thanks for the detailed run-down Anonymous.

One geeky followup to 246:

COBRA premiums aren't actually exhorbitant: by law, they are 102% of the actual premium for the group policy.

The current proposed solution is for everyone to pay COBRA rates; this isn't a solution that appeals to large numbers of people. (That's what Obama's 8 conditions net out to--all insurance works like COBRA.)

Well, when one loses one's job, COBRA is not even remotely payable. My partner went uninsured for a year because we could not afford the COBRA payments. We are far from poor, and yet we had to gamble with our coverage.

Jacob Davies, 134: It's [Kaiser Permanente] not perfect but it's well-organized, integrated, and there's never any uncertainty about whether a test or procedure is going to be covered.

News to me. I once worked for them, and my job involved denial of claims for what often appeared to be routine procedures.

That said, true universal single-payer healthcare cannot come soon enough to this nation for my liking.

Mark, #285, Medicare is available to seniors and disabled folk who have worked enough quarters.

SamChevre #256: COBRA premiums aren't actually exhorbitant

Only if you're rich enough to pay USD$800 a month for it and not quite rich enough to afford boutique health care.

ibid.: That's what Obama's 8 conditions net out to--all insurance works like COBRA

I don't know you well enough to tell whether your just pulling my chain about that. COBRA and Risk Pool insurance rates are too expensive for real people to afford. Eliminating 85% of health care executive jobs would go a long way towards making health care affordable; let the executives choose between digging ditches or contributing their valuable biomass for recycling.

Caroline @244, James @245, Mark @246 (& others thru' thread adding their 2c) – Thank you all. Will have a look around those. Just found computer access spotty this week, tho'.

Special thanx, Mark, for your trouble writing that out.

Also vian, Meg & Katie, who saved me from hurting brain by attempting elucidating Australia's

#135 Jacque

Cheryl, I'm curious: in percentage terms, what exactly is the difference between your gross and your net? I've got a fiver here that says that difference compares favorably to my difference, which is taxes, plus insurance premium, plus my healthcare out-of-pocket. (That last is quite low, because I just don't have the discretionary income to do much in the way of healthcare.)

Sorry, I've not had an opportunity to keep up with the thread and respond.

Is it a sign of how accustomed I am to the taxes that I don't know the answer to your question? It may be as much a third, I think. Of course, this isn't all MediCare; it's various provincial and federal programs.

Summer Storms @ 258: AFAIK, if a Kaiser member gets treatment at a Kaiser facility, there may be a copay required, but there are no claims involved. (And thus nothing to be denied.) Treatment somewhere other than a Kaiser facility would involve post-treatment claims to get the payment taken care of — but since Kaiser members get routine procedures done at Kaiser facilities, that shouldn't apply. (I don't know how referrals to non-Kaiser docs for procedures not available at Kaiser work, but those wouldn't fall under "routine procedures".)

Emergency room treatment is a different matter, as the ambulance may well take the patient to the nearest hospital, not the nearest Kaiser hospital. It's a good idea, if possible, for a patient to say at least once, as loudly and clearly as possible, "I'm a Kaiser member; take me to a Kaiser hospital." The ambulance driver may ignore that instruction, but that should be sufficient to protect the patient from being asked to pay for having "voluntarily" received treatment from a non-Kaiser doctor. (This is based on when I worked for Kaiser about 15 years ago, on a project specifically related to how claims for treatment at non-Kaiser EDs are handled. I'm also a current Kaiser member and reasonably satisfied with my care. Other than that, I have no particular affiliation with or loyalty to Kaiser.)

On the topic of pushing back, my grandfather's a non-ironic Sara Palin supporter known in the last few years for misapplication of the terms "muslim," "socialist," etc. Rambling story short: I got the very first of the euthanasia emails form him weeks ago and have been arguing with him since then. He's been astonishingly rational and agreed to call his congresscritters if I can show him dollar figures that support my case and point him to the relevant bits of the bill. If he's willing to be this rational about it, there are a ton of people out there in the same boat.

I work on the fringes of the industry, so the facts of how it works now and exactly which bits suck about it and why I have covered. I've got tons of research about the bill itself to hand. I've got people helping me put it all together in an accessible format. What I need to know is what the crazies are saying.

If you guys could forward chain emails and links to websites and forum threads where people are being wrong about the bill, that'd be hugely helpful. Sending them to thinkers.party at gmail dot come will be best, but of you're leery of sending things to strange email addresses, anaeatheblue at gmail dot com is the address I normally post here with.

When we've got a finished product I'll link it here so you can see what we did. Massive thanks in the meantime.

Keith Olbermann just addressed the Stephen Hawking thing, in his typical dryly humorous fashion. I LOL'd.

Lexica, 262: First off, Kaiser doesn't have facilities everywhere, so if a Kaiser patient happens to become injured or ill while traveling, for example, he or she doesn't really have much choice but to be treated outside the Kaiser system. I saw more than a few situations like that where claims for said treatment were denied. Secondly, I did indeed see treatments even within the KP system denied on a regular basis. I also saw a LOT of things misidentified by the very doctors and nurses whose job it was to decide whether or not to deny claims.

Anaea @263: I'll be happy to forward the email my friend sent.

FWIW, my wife and I paid COBRA for about six months, since the alternative was to go uninsured. (The preexisting conditions would have kept us from getting insurance on the normal market at any kind of payable rate.) It was ruinously expensive, presumbably because healthcare costs in the US are really high. It was also stunningly unhelpful, in ways that I'm convinced (but can't prove) were intended to drive us away. We were paying about the same amount for health insurance and rent, and we lived in a pretty nice place.

As an aside, I think one of the most important points to bring up in this debate is the loss of job mobility (and thus decrease in entrepreneurship) that comes with the current system. I have three children, one with asthma, one with a peanut allergy, and I also have asthma and high cholesterol. Suppose I wanted to start a consulting business--my wife would have to go back to work somewhere with insurance, because we couldn't possibly pay the rates we'd be quoted (if anyone would sell to us at all), and we wouldn't dare be without it. So I won't be starting that consultancy, which is maybe good for my employer, but not so great for me or perhaps for the economy as a whole. I know a couple who own their own business. But the wife also works an office job with benefits, because they have a sick kid, and this way he can see a doctor now and again. Ignore the humanitarian side of this, and just look at the economic side--it's a disaster, dumping wealth down a sewer by having people do stuff that makes no sense (like work in a job you don't need to work in) to get health insurance.

Earl Cooley III @ 260:

Only if you're rich enough to pay USD$800 a month for it and not quite rich enough to afford boutique health care.

I was on COBRA for more than a year after I was laid off in the summer of 2001, and the premium then was just over US $800 per month. I've been on COBRA for almost 8 months this year, and the premium (before the stimulus bill was passed) was almost $1800 (I admit the coverage is very good). I paid it (by burning my retirement savings) because I knew I was going to have some really big medical expenses this year (so far, the sticker price, before insurance discounts and such, is over US $100,000). The stimulus package helped; with its subsidy I only have to pay a little over $600 a month. This will go back up to the full amount in December, because of course we can't have open-ended subsidies.

In other words, I can't afford not to pay the exorbitant amount. Funny, I'm not best pleased by all this. I'm hoping I have enough money left for retirement; right now it looks really dicey. But this is one of those times when the short-term trumps the long-term.

COBRA right now is much less onerous than usual - I'm paying 35% of the normal cost, which (I think) is on par with what was coming out of my paycheck when I was employed. Neither here nor there as regards health insurance reform, but useful to know for people currently eligible for COBRA and not even considering it because of the normal cost.

I've recounted this before, so I won't again. Suffice to say that Kaiser just turned down an application from me for a cheaper plan with lower copays for drugs because I'd been getting blood pressure medication from Kaiser for the past five years.

Maybe every Kaiser location is different, but the one in Hawai'i is not, in this patient's view, particularly praiseworthy. I've watched individual plan premiums go from $140 to $344 in ten years and my copays go from $7 for a visit to the doctor to $25.

Obviously that individual plan premium is for a single payer; I haven't a clue what a family plan premium might be, except more.

I have a question: I'm writing a post, and I can't recall the name of the girl in Texas who was allowed to die because she didn't have lots of money.

It was only a little while after the Schiavo mess.

As I recall reading some months back, lack of job mobiity was built into the program. The various autoworkers' unions wanted to have a small surcharge/copay on salaries, and everyone would be insured.

The manufacturers balked; because they would all of a sudden be looking at people who could leave, and go to better jobs, in the same industry.

So the big players got together and offered insurance, which was job-tied. The idea spread.

Jacque @135: Cheryl, I'm curious: in percentage terms, what exactly is the difference between your gross and your net? I've got a fiver here that says that difference compares favorably to my difference, which is taxes, plus insurance premium, plus my healthcare out-of-pocket. (That last is quite low, because I just don't have the discretionary income to do much in the way of healthcare.)

Cheryl @262: Is it a sign of how accustomed I am to the taxes that I don't know the answer to your question? It may be as much a third, I think. Of course, this isn't all MediCare; it's various provincial and federal programs.

Yar har. I "win" my bet. If I'm doing the arithmetic right, mine comes in at just under 30%. And I'm in a low tax bracket. This is without out-of-pocket medical expenses. So we are at about the same rates...as long as I don't require anything more than two monthly generic prescriptions.

I can't quite work out what the best way is for me to cheer from the sidelines. I am UK born, bred and living, but have a married with 2 children cousin living in Montana, and friends in CA, at least one of whom has no insurance and will possibly be left to die if there is an accident.
Therefore I have some interest in seeing you guys get the health service people deserve, rather than the one you have now, and wish you all the luck and energy that you can use.
*Insert cheering noises here*

Terry Karney @275 - I recall the case, but not the name, sorry.

I did see (via Jezebel) a reference to the Deamonte Brown case, where a twelve-year old died of a brain infection because of the paperwork, delay, and hassle involved in Medicare dentistry. A lack of an $80 tooth pulling caused a $270,000 emergency room stay that ended in his death.

I'm not sure why dental care isn't a larger part of this debate - dental insurance is arguably worse than basic health insurance. It's expensive and maxes out pretty quickly.

Deamonte Driver, of course. Gah. Brain skip, multiple windows.

Fungi: That's a nice example, but sadly worse than not useful. I am writing a post using the IBD Hawking quotation, so a medicare error plays into the, "Gov't care would just let him die," meme.

I know there are examples of failures in the system, but they are just that, not systemic problems (re Medicare, as opposed to for profit industry denials).

Hm; I don't see that as an error, I see that as the current system working as intended - trying to keep from paying for health care. It's true in private industry and with Medicare, and less frequently in other facets like TRICARE. This does tie into what I see as a major Republican argument against government health care: "You don't want it, because we'll shit in it." I don't see it as an argument against government health care, but instead an argument against trying to keep the undeserving from getting health care. I do see your point, though.

On the subject of Stephen Hawking, I don't know if you saw that the TPM folks sent him email and he responded "I wouldn't be alive today if it weren't for the NHS. I have received a large amount of high quality treatment without which I would not have survived."

Or, there's always the "Which pandemic would you want to be in: the one where everyone has sick leave and health care, or the one where a large chunk of the population has neither?"

Terry: Are you thinking of the Sun Hudson case, by any chance?

I'm probably an outlier here, but I'm looking at the percentages take home vs everything else, and it's messed up.

Including employer and my contribution, my health insurance is 20% of my gross income, not including dental. Federal income taxes are on the order of 3%. (Yes, 3%. Roughly a month and a half of my health insurance). If you include the payroll side, the SS tax is 15%. (If not, 7.2). I include the employer side because it's it's a direct cost of my employment, and if I were doing freelance, it would be my responsibility.

(This is all US, decent family coverage, but nothing like what I had a few years ago, and I'll not detail how little it pays for things, but rather just disallows it.)

The sick thing with the Federal tax percentage is the marginal rate if I were to start a business (like photography or occasional computer stuff.) If you add in the SS, marginal federal tax, and what I'd pay in state tax, you're looking at a marginal rate of above than 40%, and then there's the reporting hassle. So instead of diversifying and having a few part time things on the side, I'm locked into something that can pay healthcare. I'm dependent on it.

(as an aside, what happens to COBRA if the company isn't a going concern? In this economy, that's a significant question assuming that one can actually fund it in the first place)

Bastards:

Leaked Email: CNBC Went To Tea Partiers Looking for Angry Protests
By Zachary Roth - August 12, 2009, 12:21PM

CNBC approached Tea Party activists, looking for angry protest events that would make good television, according to a leaked email from a Tea Party discussion group. And one Tea Bagger responded by flagging an upcoming event that, he said, "should be a riot ... literally."

Yesterday, Tea Party Patriots national coordinator Jenny Beth Martin sent an email, obtained by TPMmuckraker, to a Tea Party google group. Martin told the group: "We have a media request for an event this week that will have lots of energy and lots of anger. This is for CNBC."

She then asked: "So, where are the big events this week and where can TPP best be represented on the news?"

Later that day, a Tea Bagger named Pat Wayman responded with a suggestion, also obtained by TPMmuckraker: "This one should be a riot! literally...." he wrote.

Wayman then posted information for an upcoming town hall meeting hosted by Rep. David Scott (D-GA).

Earl,

OK, relative to ability to pay, COBRA premiums are exhorbitant.

But relative to average medical costs, or average large-group premiums, they are perfectly reasonable. That's what medical care costs, for the average person. (Problem #1: that average person is over the 75th percentile of costs. Medical care costs have an extremely skewed distribution. Or in non-geek terms, if you have 100 people, in one year, 50 will have no medical bills; 25 will have less than $6,000 in medical bills; 24 will have $6-$25,000 in medical bills; and 1 will have $60,000+ in medical bills.)

Currently, insurance companies charge large groups about $6000/person/year. That's the average cost in the example above. They try very hard to figure out which individuals will be in the "more than $6000 in medical bills group", and to charge them more (or not cover them, if they aren't allowed to charge enough to make a profit on average). But this means that for the people in the "not likely to be expensive" group--which is about 2/3 of people--coverage costs less than $6000/person/year--often a lot less.

If you get rid of underwriting for pre-existing conditions, and require coverage, you've got insurance like COBRA is today--and it will cost about as much.

And most of that money goes to medical care. Getting rid of every dollar going to insurers/lawyers and it might go down as much as 20%; I'm not thinking that for most of us, $1450/month is easy to come up with. (Using Bruce Cohen's $1800 as a month is a base.) It's a cost problem.

Terry, 274: You're not thinking of Nataline Sarkisyan, are you?

eric @ 283:

(as an aside, what happens to COBRA if the company isn't a going concern? In this economy, that's a significant question assuming that one can actually fund it in the first place)

This happened to me in 2001; the company that laid me off ceased to exist the next day (it was sold by its parent company to the executives running it for less than the outstanding accounts receivable). The company's coverage for COBRA lasted 4 months after that because the layoff invoked the Warn Act, which required that the company maintain the coverage for a minimum time. When that expired, I was allowed to switch coverage to the Oregon Health Plan, a government-regulated safety net program. This was treated as a an extension of the COBRA coverage, with no check on pre-existing conditions, and approximately the same premiums (premiums are determined by ability to pay, I guess they figured I was already paying that much, so I could). So I think the outcome is dependent on where you live and how much you've been paying into CORBA.

Incidentally, the Oregon Health Plan triages procedures: there's a list of all types of procedure prioritized by probable success, urgency of need, and cost, and, based on the amount of money in the pot, every year the plan board draws a line on that list. Above the line all procedures are covered, below the line, none are. I may end up on it again; my COBRA coverage expires about a year before I'm eligible for Medicare, and the job market doesn't look much like reducing the suck here in Oregon any time soon.

Neither of those. It was in Texas, the child was about 11-14 (as I recall). Had a problem with her lungs (massive fluid buildups) which required constant drainage. The insurance ran out, and the insurer pulled the plug.

This was in the same time frame as Schiavo, except the victim wasn't a vegetable. She was aware, conscious and knew that when the pug was pulled she was going to drown.

The really misanthropic side of me says her being a dark skinned child of an immigrant had something to do with it, but I don't like thinking that way.

Terry @ #288

No, that isn't a misanthropic thought. You just don't like the barbarians and Nazis and their sort.

Well, I did some pushback just now. I had to make a run out to our T-shirt supplier to get some blanks, and I talked to one of the owners about health care. Amazingly, she's against reform even though their coverage has just been canceled! I pointed out that access to a public option would help them, mentioned insurance-company death panels, made it clear that one of the people who will just have to die if they have a major medical trauma is ME (aka "putting a face on it"), made the "Medicare is a government plan" point, and told her that the "government medical guy" she saw on Fox News was not the HHS Secretary, since that's Katherine Sibelius.

What I wish I'd thought to do was point out that the insurance company considered their profits to me more important than her and her husband's health, and that insurance companies are beholden to their stockholders, not their customers. But it was better than doing nothing.

Lee @290:

Sounds like you made plenty of good points. Thanks.

Iowa Senator Chuck Grassley and GOP chair Michael Steele are onboard with the Grandma Must Die meme.

Shameless. Utterly shameless.

The GOP are a bunch of cynical political hacks. Screw them all.

Dave @239: the problem I had last year was this: one of my antihypertensives was so old it was queuing up for its pension, never mind voting. Lotsa generics on the market, you betcha. Trouble is, it's a med that isn't really used outside the UK. In 2008 we had flooding, and the city of Sheffield was pretty badly inundated. A few weeks later I went for my repeat prescription ... only to discover that this medicine wasn't available for love nor money form any of the usual generics manufacturers. Turns out that Sheffield was home to the only chemicals plant in the UK that was turning out hydrochlorthiazide, and when it flooded that shut down all the generics manufacturers simultaneously.

A big oops, but that's a problem for industry in general, not the NHS: what do you do when a critical element in your supply chain is flooded out by a once-per-century natural disaster?

Eric @249: Single payor is more like Canada, where the government pays the bills but the drs are independent. The NHS is more like the VA system, where the government both pays the bills and employs the doctors.

Er, no, that's not how the NHS works. Doctors are either independent professional[*] practitioners, or members of group practices, or hospital employees or contractors. There's a broad spectrum of status there, but in general they're not government employees; rather, the local health authority has a contract with the hospital trust or GP practice and pays them to provide a service.

How the doctors work for their employers varies, but many/most of the high end hospital consultants (and some GPs) have private practices on the side; if you wave money under their nose, you will get treated as a private patient.

The NHS is a single-payer system, but it's not the only way to get healthcare in the UK.

(Yes, there's private health insurance in the UK; my parents have it. It amounts to about 5% of the total healthcare market, because most people are happy enough with the NHS.)

[*] "Professional" as in "a member of a trade/occupation regulated and policed by a body established by statute and recognized by parliament", not "professional" in contemporary marketing weaselspeak for someone with a sharp suit and an attitude problem.

Charlie, 293: I'm not sure how uncommon hydrochlorothiazide is outside the UK, but it's one of the blood pressure pills I take. I think it's a fairly frequently-used diuretic in the US.

Chris: brain fart on my part -- I wasn't on hydrochlorthiazide, I was on cyclopenthiazide. Way rarer.

(So many thiazide diuretics, so little time to get up close and personal with their weird and whacky side-effects!)

You know those 'death panels' in 'Obama's' health plan? Republican senator Johnny Isakson doesn't understand why people are misunderstanding the end-of-life counceling part of the plan that he's firmly for.

Also, Lee, very well handled. I think that, unfortunately, a lot of people who pick up crazy ideas need a known, human face before they can realize quite what they're really advocating.

Latest Big Insurance lie: "Oh, but the insurance companies are hardly making ANY money!"

Fortunately, there's a good counter for this. Most people do have some idea of how the stock market works (or is supposed to work), so you ask them where stock earnings and dividends come from. The answer is, "from company profits". So then you point out that the insurance companies have been paying HUGE dividends and earnings to their stockholders for years -- but that part of profits doesn't get reported as part of the company's earnings.

This is also a good place to note that the insurance company's primary responsibility is not to its clients, but to its stockholders... and that every claim approved cuts into the money they can distribute to stockholders. Ask if they know anybody who's had to deal with a denial of claim that was just wacko; they probably have. Point out that this was an example of an insurance company looking for ways to deny service. That their stockholders' profits are more important than your friend's/relative's health, and that this is not going to change until we have a public-option plan.

(Yes, I know, it won't really change until we have a single-payer plan, but one step at a time.)

KeithS, #297: Wow. Now watch this interview be completely buried. I can't believe he actually called Palin and her supporters "nuts" -- that's the most honest thing I've heard a Republican say in years!

New conservative blogger rumor: The people who are hold up Obama-as-Hitler posters are Democratic operatives trying to make Tea Baggers look crazy.

Hey, conservative bloggers? Your party's chairman, senators, and revered pundits are doing a fine job of that on their own.

I wonder how many of the birthers are also deathers? If I were in America, I'd be terribly tempted to turn up to a town-hall meeting with a sign saying "Kenyans will kill your grandma."

Sorry Charlie -- You would be the expert on the NHS thing. I just visit the inlaws over there.

Oops, Isakson recants; looks like Limbaugh somebody must have made a phone call. I wonder if he muttered "eppur, si muove" as he left the mike?

Maybe I'm wrong on Texas, but it wasn't an infant.

Very annoying to have this tickling my mind, as I am sure I wrote about it at the time, but I can't find it, and my google-fu is failing me.

Terry, you're right -- it was Texas, concurrent with Schiavo, and a young woman of color. I can't think of her name either, but perhaps googling for Schiavo will give us articles which compare her to the Texas case.

Terry, do you mean Tirhas Habtegiris?  If so, I’m not sure that it’s a clear enough case, since the hospital disputed* the facts (as it would, of course, but the opposition would point to that).

* The pages cited in the Wikipedia article are no longer on the hospital site that I can find.

Then there was Andrea Clarke, whom St Luke’s hospital, Houston, wanted to unplug in 2006.  But I think she was in her 50s, and I haven’t found an MSM story about her, nor anything that says what happened to her in the end.

John, that was it. And I managed to find my piece on it.

Yay!

Well, for once, a bit of good news to report:

Congressman Jared Polis has moved the location of his next constituents meeting to a bigger parking lot after concerns about health care reform drew hundreds to a similar event last week.

[...]

Unlike the town halls that have drawn national media attention for the aggressive tactics of opponents of health care reform, supporters of a public option and more government involvement in ensuring health care access made a strong showing at Polis' last event.

Polis supports a public option in which people can buy their health insurance from the government instead of from a private insurance company, and Cottingham said Polis has heard from plenty of constituents who don't want him to back off from that support.

Well, this is the People's Republic of Boulder after all, but still...

The Stephen Hawking thing was just too funny to let go, so I didn't.

I am deeply ashamed of my country.

Really, it's one thing for scared, stupid proles* to believe this Death Panel crap.

It's another for people in public office who are fully aware that it is false to spread it.

There's no use arguing with them about this, finding examples of where living wills helped, or pointing out hypocrisies or inconsistencies. The GOP has found a weapon that works and they're going to keep using it.

My old manager found a relevant quote:

To argue with a man who has renounced the use and authority of reason is like administering medicine to the dead.

I see no way around this. Does anyone know any FAQs on how to take up drinking?

* I was going to write "gullible ignorant meme fodder," but that wasn't contemptuous enough. I have no sympathy for these tools. I have no desire to change their angry primate minds. If they're literate enough to follow the directions to a town hall let them read a goddamn newspaper.

Stefan @ #310, "Does anyone know any FAQs on how to take up drinking?"

Check your wallet first. It may not be as expensive as smoking is these days, but it's getting there (and why isn't alcohol a principal target of new taxes like cigarettes are? Booze is nearly as deadly, particularly when combined with driving.)

Stefan @ 310: You could look here for some "useful" guidance . . .

Remember to train in both right and left-handed drinking, to help reduce the incidence of repetitive stress injuries such as drinking elbow.

Stefan Jones @ 310:

This is something that I have a hard time with. On the one hand, I believe that people aren't stupid, just miseducated. On the other, you have people who believe in things like the idea that all taxes are bad, government is bad, creationism, anti-vaccination nuttery, and so on, and who believe it so firmly that they continue to hould onto it even though reality itself contradicts their position. It's hard to see people as people, which I think is the right thing, when I also constantly think of myself as better than. And yet, but for certain experiences in my life, I would believe some of these things too.

That said, I have nothing but contempt for the powerful who deliberately lie and cheat. I think that Sen. Isakson is amoral scum for speaking the truth one day, then going back to the party line the next. I was going to say that he has no principles, but obviously his principles are money and power.

What I think would help would be if the media would do their fucking job and actually investigate and report, not just be an amplifier for anyone with power and money (and the right views). Then again, my idea of what their job should be has probably never actually been what it is; it's about making money. The more I look at the way that the news has been over my life, as well as some things in history classes, the more I think that any truth that was reported was incidental to making money. Someone please tell me I'm wrong.

Yeah, we could have guessed this was coming:

A leaked memo sent by an oil industry group reveals a plan to create astroturf rallies at which industry employees posing as "citizens" will urge Congress to oppose climate change legislation.

The memo -- sent by the American Petroleum Institute and obtained by Greenpeace, which sent it to reporters -- urges oil companies to recruit their employees for events that will "put a human face on the impacts of unsound energy policy," and will urge senators to "avoid the mistakes embodied in the House climate bill."

Stefan Jones @ 315

As you know, Bob, the internet will be the cause of a great upsurge in democracy, because it allows individual citizens access to the information they need to make decisions on public issues, and it allows them to easily spread the knowledge they gather to others.

*chokes on his own sarcasm*

#316: Yeah, we pretty much went from Bedford Falls to Potterville in twenty years.

...with the wingnuts living in the suburb of Otisville.

314: I was going to say that [Sen. Isakson] has no principles, but obviously his principles are money and power.

Nah, he just got taken aside yesterday and told "Recant, or we fire you. Then you'll have to go on COBRA." And he couldn't afford it.

(yes, I know that's not how it would have worked)

On Free Prescription Samples: That's not necessarily an argument in favour - I may still be alive as a result of them. Canada's medical coverage doesn't cover prescriptions (without other coverage or indigence). There was a year or so when I just couldn't afford the C$75/month (that would be, it looks like, about USD250/month if I lived in the States, so while prescriptions aren't covered, they aren't as expensive here), so the option was not taking them.

We eventually found out that my problem doesn't respond well to pills, dealt with the real issue that the pills weren't fixing, just making livable, and here I am. But still.

#320 Mycroft W

Canada's medical coverage doesn't cover prescriptions (without other coverage or indigence).

"Canada's" may not. That's because there isn't really one system across Canada; it's a collection of provincial plans. My province, Quebec, does provide prescription coverage for those not otherwise covered (which I mentioned else-blog). Info on the provincial plan is here.

Your Province May Vary.

Posted by Pam Spaulding, over at Pandagon:

Barney Frank tells it like it is.

Q: Why do you continue to support a Nazi policy, as Obama has expressly supported this policy, why are you supporting it?

A: When you ask me that question, I am gonna revert to my ethnic heritage, and answer your question with a question. On what planet do you spend most of your time?...You want me to answer the question? As you stand there with a picture of the president defaced to look like Hitler, and compare the effort to increase health care to the Nazis, my answer to you is as I said before, it is a tribute to the 1st Amendment that this kind of vile, contemptible nonsense is so freely propagated. Ma’am, trying to have a conversation with you would be like trying to argue with a dining room table - I have no interest in doing it.