Tuesday, December 04, 200714
Medicare and single-payer
I am consistently baffled at why single-payer pundits want to put our health care in the hands of the government. People like Ezra Klein and Paul Krugman simply don't know what they are asking for, and have zero insight into how restrictive Medicare really is for a practicing physician.
Their ridiculous reimbursement decisions, rules and restrictions are far, far worse than any private insurer. Roy Poses agrees:
Update:
So, the liberal dragons have awakened. Thanks for your responses Graham and Ezra.
Graham is particularly inspiring:
In theory, a single-payer system may result in less administrative waste, reimburse and focus on primary care, and provide universal coverage. It may look good on paper. And in a utopia where a government was knowledgeable about health care and had limitless dollars, it may work.
I'm sad to say we don't live in that world. Medicare given countless examples why the government is inept in managing health, ranging from their inane coding rules, misguided emphasis on documentation, to their short-sighted and damaging cuts in physician reimbursement.
Yes, this is indeed America. A country where its government has turned a blind eye to Native Americans and Veterans, by critically underfunding their health care systems to the point of uselessness. I would not have tremendous confidence in that track record.
And yet, people are still willing to give them the keys. Call me a cynic, but be careful what you wish for. Forgive me if I don't think these are the right guys for the job.
Their ridiculous reimbursement decisions, rules and restrictions are far, far worse than any private insurer. Roy Poses agrees:
This is also a reminder that those who put their faith in establishing a single payer health care system to cover all US citizens may be sorely disappointed. If a single payer system continues the irrationality, opacity, and susceptibility to political influence of our current single payer system, having such a system cover everyone might just make things worse.My question to single-payer advocates, for which I have yet to receive an answer. How do you explain the miserable failure of the single-payer funded Indian Health Service? And before you explain that it's underfunded, why do you have such blind faith that the government will appropriately fund a national single-payer system? I would honestly like to know.
Update:
So, the liberal dragons have awakened. Thanks for your responses Graham and Ezra.
Graham is particularly inspiring:
Why do I think we need to do it? Because of the mess. The mess of billions of dollars wasted on duplicated tests and administrative overhead. The mess that millions of people in the richest nation in the world decide between eating and buying their medications (which would often prevent doctor and ED visits in the first place), or that many honestly consider waiting out an appendicitis because they lack insurance and know their financial lives will be ruined by a $50,000 hospital bill. The mess that fragmented care complicates care so greatly. The mess that other countries can apparently do it–and for cheaper–and we apparently can’t. I could go on.There are countless horror stories on both sides, so let's get past the hospital bill anecdotes.
Why do I think we can do it? Because we’re America, god damn it. We’re the land of opportunity. Innovation. Creativity.
In theory, a single-payer system may result in less administrative waste, reimburse and focus on primary care, and provide universal coverage. It may look good on paper. And in a utopia where a government was knowledgeable about health care and had limitless dollars, it may work.
I'm sad to say we don't live in that world. Medicare given countless examples why the government is inept in managing health, ranging from their inane coding rules, misguided emphasis on documentation, to their short-sighted and damaging cuts in physician reimbursement.
Yes, this is indeed America. A country where its government has turned a blind eye to Native Americans and Veterans, by critically underfunding their health care systems to the point of uselessness. I would not have tremendous confidence in that track record.
And yet, people are still willing to give them the keys. Call me a cynic, but be careful what you wish for. Forgive me if I don't think these are the right guys for the job.
Comments
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Evan
Kevin I really have to disagree with you. Obviously experiences in various regions are different, but out here in the West, Medicare is FAR simpler than most private insurances. Even more, in Nevada it is the BEST payer when you combine promptness and claim processing requirements.
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Kevin
Evan,
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Anonymous
Kevin--both Klein and Krugman have been advocating individual mandate style plans that, at most, give people the option to buy into Medicare. I'm not sure about the substance of your argument, but get better strawmen.
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Kevin
Anon - that's true.
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Evan
Kevin, IHS is poorly run because the policy of the US has been to give a fixed pot of money to the IHS and the department it is run out of is the BIA. The BIA was for long stretches of its history charged with genocide. That it is not the ideal department to run a health care service out of seems self-evident.
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Kevin
Evan,
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serial catowner
Kevin, the short answer to your question is that the government will adequately fund and oversee the program because we're white.
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Pei Loo
"because we're white"
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Evan
"It is difficult for me to comprehend why single-payer advocates feel that the government would break this trend with some kind of national system. Why the blind faith Evan?"
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serial catowner
Pei Loo of course has a good point. I was simply speaking to the underlying dynamics of why Indian health care has been bad, and what about the situation would be different with universal single-payer.
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Los Anjalis
So your question was this -- How do you explain the miserable failure of the single-payer funded Indian Health Service?
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Anonymous
Actually, the "because we're white" poster has a point.
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Anonymous
In my community....
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Moo-jae
Since no one seems to have actually answered your question as to why the Indian Health Service is in such shameful conditions allow me, Kevin, to venture some of your vitriolic sarcasm and try.
Post a Comment »Are you really saying that Medicare A and B are worse coverage where you practice than Medicare part C HMO plans?
12:19 PM
You have a point regarding regional variation. I work in southern New Hampshire where the private plans I deal with are consistently top-10 in the country and pay 140% of Medicare rates.
Medicare is by far the more restrictive option for physicians, and cover significantly less services than most private plans I deal with.
On another note - as a single-payer supporter Evan, I am curious to hear your take on the single-payer supported Indian Health Service.
Thanks,
Kevin
12:59 PM
1:14 PM
However, if they had their pick in a utopia, single-payer would be it.
I don't have time to find the links to where I read that, but they are supporting the plan that is most politically feasible and palatable to them.
Kevin
1:20 PM
If I agree that the IHS is a poorly run example of single-payer, will you agree that the military medical care system, or failing that, the congressional health benefit plan is a well-run single-payer system?
1:46 PM
I am not familiar with the Congressional plan, so I can't comment on that.
I am familiar with the VA - and it's benefits are its EMR and quasi-"universal" coverage for vets. That's about it.
Again, it's underfunded - which you can say for every government program. There are long waiting lists for appointments because of physician shortages. Their drug formulary is quite restrictive - much more so than a private payer plan.
It's supposed outcome improvements are coming under scrutiny, and there are claims that they are exaggerated:
http://www.kevinmd.com/blog/2007/05/va-exaggerates-its-achievements.html
A single-payer system would be acceptable if it were funded and managed appropriately. I have zero confidence that the government can do either - as the IHS and VA single-payer systems has proven.
It is difficult for me to comprehend why single-payer advocates feel that the government would break this trend with some kind of national system. Why the blind faith Evan?
Kevin
2:13 PM
Strange to say, about 20 years ago I took your side of this argument in a long, and eventually bitter, argument with an old friend. Fortunately, this argument took place on a long drive to an Indian reservation on the Olympic Peninsula, where we drowned our differences in good scotch and better scenery.
Suffice it to say, you don't appear to know anything about Indians or how they've been treated. This is not meant in an unkind way, nobody has to know everything about everything. But when you post, you should know something about something.
Incidentally, your link about Medicare reimbursement regs being more arduous than private insurers not only doesn't actually prove that, but ignores the fact that Medicare and Medicaid pick up the tab for uninsured medically indigent people. Getting some care eventually is certainly a lot less arduous for the patient than getting no care at all.
2:52 PM
Looks like someone isn't uptodate about US demographics. Minorities now make up about 30% of the population and in a few more years, this percent will be at or over 50%.
3:48 PM
Of course it's not blind faith. We have a system for distributing political power that vests ultimate power over EVERYTHING in the United States in the hands of the Federal government or its courts. You trust them with that if you live here. They can shoot you and if they justify it to themselves, they get off scot free. They can take all your property. You trust them with that power.
You also trust them with a monopoly on legally exercised force, police, fire protection, the protection of our borders, tax collection, management of disease epidemics, medical licensing, hospital licensing, regulation of tobacco and alcohol, food safety, drug safety, maritime safety, environmental protection and the oversight of all nuclear power.
Those are all pretty important things -- not to mention the inconvenient fact that over 50% of all health dollars in the US already come from the government. So it's not in any way a blind faith. It's a statement that political power is easier to manage than corporate power.
Corporate boards never get elected by even their shareholders most of the time. CEO's don't have to be responsive to public outcries as long as the profits roll in.
Far be it from me to lionize congress, but every 2 years every congressperson does have the ability to lose his/her job and occasionally (as in 2006) they do.
Thus, ultimate power in the government in theory should come from the consent of the governed, whereas ultimate power in the corporation comes from the collection of money.
There's no system that doesn't require you to believe that one system is better than the other, but I can guarantee you which one is ultimately more responsive to the desires of the population at large -- and it isn't corporations.
Why do you put such blind faith in them when you chronicle their misdeeds in excruciating detail?
3:59 PM
4:36 PM
VERY simple answer ANY MD should be able to deduce before yelling at single-payer advocates:
1. The IHS is underfunded.
2. The Fire Department is not.
That really SHOULD be the end of the argument.
I'd like to see what a privately funded IHS would look like, if given the same amount of money per capita. Actually, I fear for the health of the people were that to happen, so no I don't want to see that.
With the caveat that I support a few different solutions to our mess, strictly speaking a Single-payer system would include ALL of us. ALL of us together have a damn lot more political power and say than some indians on a reservation who were screwed from the day we invaded their land and destroyed their culture.
And in regards to the Medicare issue (since we're bringing up anecdotes too) -- as an MD, I can count on being paid by Medicare in a timely fashion without having to call them up and argue with them about whether or not the care I provided was needed. And my patients who have Medicare are VERY satisfied.
The private market is superb at adding middlemen left and right -- at every opportunity to suck some more money away from "cosumers" -- hence the creation of things like the VISA Highmark Gift Card. There's innovation for ya. Only in the US...
8:42 PM
Government healthcare does not iron out the healthcare access differences between socioeconomic groups. They may, in fact, make them worse, by taking away your money in taxes while forcing you to non-responsive providers.
The British call their unequal outcome "the postal code lottery". Where you live determines the quality of medical service you will receive, even in the supposedly "equal" National Health Service.
When healthcare is a political entity, it responds to political pressure. The better-off know how to apply the pressure. They get better healthcare.
This may not necessarily translate to "white"....see the NHS....but it does translate to the "better-off".
Speaking of unequal, Medicare does pay differently in different parts of the country, and even within the same state, from one county to another. To some degree, this may reflect what some observe, that Medicare is a good payer in one area, when a doc elsewhere says it's terrible.
Part of the "postal code lottery" you will see in the USA if we get single-payer.
9:48 PM
1. The Indian health center is heavily funded.
2. The fire department is volunteer.
So, sorry. The Indian facilities are badly run because they can be like Central African Republics. Fiefdoms within the tribe, family feuds, factions, and not accountable in anything like a standard government facility, let alone a private charity.
The Fire Department, on the other hand, has two full-time professional firefighters, and everyone else is volunteer. They hold raffles and bake sales and sell T-shirts to raise money, and they do.
10:11 PM
First of all-- don't even try to take things out of context. The current neglectful relationship between the Federal Government and the Tribal Nations isn't a new development. The United States government has consistently and systematically dispossessed of the property, dignity and representation of Native Americans through forceful mediatization. Native American tribes aren't just any immigrant minority. They are a separate quasi-independent political entity, exempt from various local and state laws and benefits. One of the reasons why proper health care has yet to reach Indian Reservations is because of the ambiguity and common misconceptions regarding the political status of Indian Reservations. Native Americans have consistently been treated as second-class citizens, and the pitiful state of federal health coverage towards Native Americans is not, as you seem to imply, the exception but the norm in Federal-Native American relations.
Yes Kevin, "every government program" is "underfunded". But even amongst such "underfunded programs" there are those that get more scrutiny, attention, and help from the Federal Government and those that are simply left in the margin counting pennies. And between being "underfunded", and being underfunded by more than "$1.7 billion short of parity with the benchmark mainstream health plan" is a big difference, don't you think?
According to the Indian Health Service website (http://www.ihs.gov) and the Federal Disparity Index (FDI), "tribal health care delivery sites are funded at less than 60% of the benchmark cost."
In fact, some of the main reasons why the IHS is having so much trouble catching up to par are listed as "rising medical prices" (at a rate of "approximately 5% per year") and "adequacy of funding."
Furthermore, under the 1975 Tribal Self-Determination law, Native American Nations can choose whether to allow the IHS to provide its services directly or to opt for self-determination and receive services on a compact/contract basis. As of 2007, only 42.6% of Tribal Nations were receiving direct services from the Federal Government. 42.6%, that is, of the Nations that HAVE coverage, since IHS currently only provides services (direct or contractual) to "1.9 million of the nation's estimated 3.3 million American Indians and Alaska Natives."
I'll say it again. Don't take things out of context. Native Americans and Alaska Natives have had to suffer from disproportionately high disease rates and lower life expectancy due to "inadecuate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences", not to mention that the Native American/Alaska Native population is generally "younger, because of higher mortality" and "predominantly rural."
I think the real question here isn't why are we putting so much "blind faith" (as you so kindly pointed out) in universal health coverage, but why you are being so insistent on salvaging a system that is iniquitous and lucrative?
12:29 AM