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Health Reform: The Public Plan Option

Yesterday's Wall Street Journal has an interesting piece comparing government-run and private health insurance plans. The piece is by Kerry Weems, who was, until recently, the acting administrator of the Center for Medicare and Medicaid Services (CMS) and Benjamin Sasse, a professor at the LBJ School at the University of Texas, who served as the assistant secretary for planning and evaluation in the Department of Health & Human Services. The context of the article is the proposal to create a "government-run health-insurance option, or 'public plan,' to compete with private health insurance."

The Obama Administration's case for a public plan was concisely stated by Governor (and HHS Secretary-nominee) Kathleen Sebelius in her responses to question 5 from the Senate Finance Committee.

The President wants to make health care affordable for families and businesses. We want to give Americans a choice of which health insurance option works for them. While the President discussed proposals to ensure that Americans had benefits as good as Members of Congress, his campaign plan also proposed a public option alongside private insurance options in a National Health Insurance Exchange. He recognizes the importance of giving the American people this choice, which will also challenge private insurers to compete on cost and quality, not cream-skimming and risk selection. At the same time, he recognizes the importance of a level playing field between plans and ensuring that private insurance plans are not disadvantaged.

You can get a feel for the politics of the proposal, and the competing arguments here.

Weems/Sasse sketch out the basic dispute as follows:

Some lawmakers support or oppose a government-run health-insurance option for purely ideological reasons. Others are open to it because they are pragmatic and -- laudably -- want to be persuaded by data and facts. These moderates have been much influenced by the supposed fact that a public plan such as Medicare is more efficient than commercial insurance. Advocates of the public option routinely ask, "Aren't Medicare's administrative costs a fraction of those of private insurers?"

But the comparison between public and private plans is a false comparison. Private insurance and public benefits are not the same business. For all its warts, private insurance tries to manage care. Medicare is mostly about paying the bills presented to it.

Weems/Sasse offer four reasons why the the higher administrative costs associated with private plans is "money well spent."

First, private insurers must build provider networks. These networks can include high-value providers and exclude low-quality providers. Except for certain circumstances, including criminal acts, Medicare is forbidden from excluding poor quality providers. It lets in everyone who signs up. So one question to ask is, will the public plan have Medicare's indifference to quality -- or invest in the cost of a network?

Second, private insurers must negotiate rates. Medicare just fixes prices using a statutory and regulatory scheme. And anyone who imagines a public plan would be less costly than private plans must keep the following issue front and center: In the many procedure categories where Medicare's statutory price does not cover full provider costs, shortfalls are shifted to private payers who end up subsidizing the public program. So, will a public plan negotiate rates or simply use fiat as a means of gaining subsidies from private insurance?

Third, private insurers must combat fraud -- or go out of business. Indeed, these payers have every incentive to invest in antifraud personnel and strategies down to the point where return and investment are equal. But anyone who thinks that a public plan could serve as a "yardstick" for the private sector needs to consider Medicare's dismal record with regard to fraud, waste and other abuse.

Fourth, private insurers must incur the administrative cost of marketing. Medicare, of course, does not need to market. A public plan competing with other alternatives would have to market itself to the public, and this means tax dollars used to advertise against private plans. Or the public plan could "compete" by using heavily subsidized marketing channels not available to private insurers, such as Social Security mailings, welfare offices, unemployment check stuffers, and the constellation of government-funded "advocacy organizations."

In the next few posts, I will address each of these claims, and the broader issues raised by the proposal. To summarize, the issue is whether a public plan will be a maverick, a monopsonist, or much ado about nothing.

Houston Lawyer:
There are also many physicians who will not accept Medicare patients. Would they be allowed to opt out of the government plan?

Will the government plan charge the same rates to everyone? Will you be able to enroll in the govt plan only after you learn that you have an expensive illness? Will you be able to switch to the government plan after you have exhausted the benefits under your private plan or after your private plan has denied coverage of your preferred treatment option? Will the government plan pay for itself with premiums, or will it be massively subsidized?
4.15.2009 2:15pm
Bruce Hayden (mail):
Second, private insurers must negotiate rates. Medicare just fixes prices using a statutory and regulatory scheme. And anyone who imagines a public plan would be less costly than private plans must keep the following issue front and center: In the many procedure categories where Medicare's statutory price does not cover full provider costs, shortfalls are shifted to private payers who end up subsidizing the public program. So, will a public plan negotiate rates or simply use fiat as a means of gaining subsidies from private insurance?
I think that this has to be kept in mind. Medicare keeps its costs down by forcing the rest of the health care industry to massively cross-subsidize it.
4.15.2009 2:17pm
Sagar:
Govt. run healthcare is inevitable and probably also a solution to the coming crisis of medicare/social security funding.

it is just not possible to tell the average person that 'healthcare' is not a 'right'. so politicians will not do that. govt healthcare with govt officials rationing healthcare based on needs, cost/benefit analysis, etc. is probably the only "acceptable" way of denying care to sick old people so they can die quicker instead of receiving expensive treatments and collecting retirement benefits for too long.

hopefully the US will not ban private healthcare system, so the people who can afford to have private insurance will continue to do so.
4.15.2009 2:21pm
einhverfr (mail) (www):
I would completely favor such a proposal provided that it simply reduced cost rather than providing government competition to private services.

For example, I would like to see "preventative/routine-only" insurance offered by the government only to people with no other insurance.

However, such programs really ought to be kept minimal.
4.15.2009 2:26pm
Andrew J. Lazarus (mail):
My wife and I have spent maybe fifteen hours over the last six months dealing with insurance company and doctor screwups relating to a broken arm. All of the mistakes involved underpayment by insurance and/or over-billing of us by the medical facilities (easier than fixing the problem with the insurance company, I guess).

Excuse me, but I refuse to believe there is any efficiency in the private-sector insurance market. I sense an oligopoly that seeks to maximize profits by screwing the end-user.
4.15.2009 2:38pm
SeaDrive:

Govt healthcare with govt officials rationing healthcare based on needs, cost/benefit analysis, etc. is probably the only "acceptable" way of denying care to sick old people so they can die quicker instead of receiving expensive treatments and collecting retirement benefits for too long.


Who exactly are these gov't officials? Do they have written goals to increase mortality among citizens 85 and up by some percentage?

I could wish that people on both sides of these great public debates would reconsider any views that depend on the notion that "the other side" is involved in a great conspiracy or is not working for the public good as they see it.
4.15.2009 2:40pm
Sagar:
SeaDrive,

who exactly are these govt officials?

i don't know yet. when there is a dept ro run the healthcare, that dept will have officials/employees to perform those tasks. that's who.

do you doubt or do you think a federal govt program with billions of dollars of budget will run on auto-pilot?

i am not talking about the conspiracy of someone to kill off the old folks. i was stating my opinion that this is one possible result of govt healthcare - based on the long wait periods and denial of some treatment options experienced in other 1st world countries such as Canada, UK, etc.

you could wish that - no one is stopping you. "public good" is what one defines it to be. i can claim that spending money on our children who are the future is better than wasting it on an old sick guy who will die in a few months anyway, and that is for "public good". you can say that we need to take care of our senior citizens who have contributed so much to the society and deserve our gratitude and their dignity in retirement and you are speaking of "public good" too. but when there are limited resources and we can't have it all, one has to prioritize where the money is spent. which public good will you support?
4.15.2009 2:55pm
Tatil:
Fraud and waste vs. overhead or marketing arguments are quite unnecessary. How much does it cost for private vs. public insurance schemes to cover patients with similar age and health characteristics to get the same quality of life and life expectancy? If we let private companies pick the healthier people, that would give them a huge advantage and constitute a big taxpayer subsidy to these firms.

By the way, if you are not going to be able to afford health insurance premiums along with copays, deductibles etc along with rent and food in case you get too sick to work, you effectively do not have health insurance. I wonder how many people who are supposedly "covered" fall into this category.
4.15.2009 3:11pm
Art Eclectic:
I could wish that people on both sides of these great public debates would reconsider any views that depend on the notion that "the other side" is involved in a great conspiracy or is not working for the public good as they see it.


The Health Insurance providers are almost to a one for-profit corporations. Their job is not to work for the public good, their job is to make money.
4.15.2009 3:12pm
Allan Walstad (mail):

Medicare keeps its costs down by forcing the rest of the health care industry to massively cross-subsidize it.

...which is sort of how doctors used to help indigent patients, by charging them less and making it up on the better-off. And pretty much everyone knew it. Now we have the feds doing the same thing with massive bureaucracy and coercion. Yet people wonder why their bills are so high.

Socialism: government-owned &run.
Fascism: ostensibly private, but under massive control by government, and when trouble crops up it gets blamed on private owners rather than the pols who caused most of it.

Those options seem to represent the general run of "mainstream" views these days.

it is just not possible to tell the average person that 'healthcare' is not a 'right'. so politicians will not do that.

If true, that's just a measure of how far down the general morality of the "average person" has come, not to mention the pols. Health care as a "right" means the right to rob and coerce others via the big gun of government. Straightforward plunder, especially as most of the freight is being paid by a small fraction of the population but allocated via political pandering to the rest.
4.15.2009 3:23pm
Thorley Winston (mail) (www):

Good post about the utility of the supposedly higher "administrative costs" in some private insurance plans compared to Medicare. I think it's also worth pointing out two reasons for the difference.

One, the administrative costs are calculated as a percentage of the amount paid in the claim and Medicare claims tend to be larger on average than for most private insurance. So if a Medicare claim is for $4000 but a private insurance claim is for $2000 but both include $200 worth of administrative costs, Medicare appears to be twice as "efficient" even though it spent the same amount in processing a claim as the private insurer.

The other reason is that when supporters of socialized medicine cite Medicare's supposedly lower administrative costs, they're only including the administrative costs that are paid out of Medicare's budget and not the administrative costs that support Medicare but which come out of the budgets of other parts of the federal government. If a private insurer has to collect premiums from its customers, that gets included as part of its "administrative costs." If the IRS does essentially the same thing for Medicare by collecting the payroll tax, it's not counted as part of Medicare's administrative costs because it's paid for by the Department of the Treasury.
4.15.2009 3:26pm
Goliath of Gath:
Art:

You are right that private insurers do not exist as altruistic entities. The way the insurers make money is by cutting deals with the providers. If the insurers did not force down the "in network" rates, the end user/insured/patient would be at the mercy of the provider and the ridiculous amounts they charge. It is similar to what Medicare does, only the private insurer and provider actually negotiate a deal that works for both. Medicare dictates the reimbursement it will pay. That's why many providers opt out, and the rest charge private payers higher rates to cover the claimed shortfall of serving Medicare folks. This is a far higher dollar amount than providing care for the uninsured.

Denying claims inappropriately is not a money-making venture in the long run for insurers (though it can be in the short-run).

Houston's questions are good ones. I wonder what the government plans to do about the moral hazard of those who sign up for the government "insurance" plan after they are already sick. Private insurers must deal with this all the time in the current system.
4.15.2009 3:27pm
Tom952 (mail):
The U.S. can benefit from the experience of the government run Canadian health plan if we are open-minded enough to study it.
4.15.2009 3:28pm
Alan Gunn (mail):
The politicians who push for government plans are, for the most part, the same ones who make the rules for private plans, requiring them to cover fringe providers, like chiropractors, and to pay for particular treatments. President Obama has said, among other things, that private plans ought not be allowed to "discriminate" against people with pre-existing conditions. Once you make that rule, there's no such thing as private insurance, so it won't be a surprise if the public plan "wins" the competition. Hey, I could beat Mike Tyson in boxing if I could make up the rules that would apply to him.
4.15.2009 3:41pm
Dan Weber (www):

The current model dominating almost all of US health care is that you see a doctor, who does things to you, and he then gets paid by someone for the things he does to you.

If we're going to reform health care, we need to change that model.

Note that "private" vs "public" is irrelevant.
4.15.2009 3:57pm
John Moore (www):
Government bureaucracies whose job IS the public good frequently act in a way contrary to that goal, for many reasons not requiring any conspiracy theories.

Both government and private insurance approaches have serious problems with them. It isn't an "us" vs "them" sort of thing.

Looking around the world, we can see that generally government systems are cheaper and deliver worse care - to the extent of jeopardizing the lives of those covered (Canada and UK are well known for this). The US system is extremely expensive, capable of rapidly delivering superb care, but has huge gaps (try buying insurance if you have pre-existing conditions - at any price).
4.15.2009 4:07pm
Connie:
Thorley--every comparison I have seen of administrative costs in health care shows them as a percent of premium, not a percent of claims. Percent of claims would be a very odd way to present such information. In addition, why would Medicare have average claims that are so much higher than private insurer claims, if Medicare receives all this discounting?
4.15.2009 4:11pm
John Moore (www):

Houston's questions are good ones. I wonder what the government plans to do about the moral hazard of those who sign up for the government "insurance" plan after they are already sick. Private insurers must deal with this all the time in the current system.


This "moral hazard" (adverse selection is the industry term) only exists if you allow people to opt out of insurance until they get sick, and people are irresponsible enough to do so.

Other uninsured sick people are not uninsured by choice, but because they cannot buy insurance due to pre-existing conditions (requirements designed to fight adverse selection) or for some other reason.

A system which requires all to pay in, sick or not, eliminates the moral hazard.
4.15.2009 4:14pm
FWB (mail):
No one has mentioned that many folks run to emergency rooms for sniffles and such costing the system whether public or private huge amounts of money. Ignorance of health management methods that were used for decades has led us to the idea that one needs a doctor for everything.

No one has mentioned that doctors often see the medicare payment as the bottom end and price their services upward from there.

No one has mentioned that many insurance companies are publicly held and must pay dividends,etc. Should the govt restrict companies by not allowing any stock offerings for private insurers thus reducing the profit requirements.

No one has mentioned that our medical system is not free market where goods and services are bought and sold at a fair market price. Why not eliminate all insurance and all government subsidized health care? Why not put everyone in the position of paying for their own care as they use it?

No one mentions that certain national organizations lobby for controls on every part and parcel of medicine.

No one mentions that in order to get basic medicines one must jump through a number of hoops. In both Canada and Mexico it is possible to purchase a number of basic
"prescription" medicines such as penicillin w/o a doctor's prescription.

I hate government regulation. I really don't want to see the government running things because generally when the government runs things the problems are gigantic. If you want to see government run health care, look at the VA. If the government made wheels they'd all be square but at least we'd be "safe".

Tiochfaidh ar la!
4.15.2009 4:15pm
Dan Weber (www):

Pretend I file for 500 $1000 payments, 100 of which are fraudulent.

System X doesn't care about fraud and so just pays me $500,000. It's admin overhead is $20,000.

System Y does care about fraud and spends $10,000 to find the fraud. It's admin overhead is $20,000 and it pays $10,000 to its shareholders.

System X has paid out $520,000 with overhead of $20,000.
System Y has paid out $440,000 with overhead of $40,000.

Which is "more efficient"?
4.15.2009 4:29pm
Andrew J. Lazarus (mail):
In both Canada and Mexico it is possible to purchase a number of basic "prescription" medicines such as penicillin w/o a doctor's prescription.
Yes, more penicillin-resistant germs are definitely what the United States needs.
President Obama has said, among other things, that private plans ought not be allowed to "discriminate" against people with pre-existing conditions. Once you make that rule, there's no such thing as private insurance, so it won't be a surprise if the public plan "wins" the competition.
OK, but let's abandon the pretense that private insurance is more "efficient" as that word is usually understood. It's just cherry-picking, and to keep up the fruit metaphor, we'd have to compare it to how public insurance did with just the healthiest enrollees, or we would be comparing apples to oranges. And while we are at it, let's abandon the pretense that private insurance will be universally available: those with pre-existing conditions will either have a government program (which will of course look very expensive, dealing by and large with the least healthy to begin with) or we will have residents unable to get care and dying prematurely, which is supposedly such a big problem in the UK and other national health plans.
4.15.2009 4:36pm
Abdul Abulbul Amir (mail):


The U.S. can benefit from the experience of the government run Canadian health plan if we are open-minded enough to study it.



The Jepp quads are a great example to study. The Canadian system had to ship Mrs. Jepp from Calgary (big rich city of neatly a million pop) to Great Falls (!) Montana, a city of about 50,000.

You can run a cheaper system by skimping on capacity like the Canadians, but that may not work well for the US as we have no close neighbor with good capacity to take up our slack.


Lynda Phelan, a spokesperson with CHR, said no other Canadian NICU had space for Jepp's four babies.

4.15.2009 4:45pm
Dan7:
John Moore said:

Looking around the world, we can see that generally government systems are cheaper and deliver worse care


That is absolutely false. The truth is, looking around the world, we see that government systems are always far cheaper, and for the most part provide better care.

See, e.g. wapo
and
newsweek

Indeed, this fact alone makes you have to question all the conclusions of the Weems/Sasse article cited by the OP. If private plans are efficient, then why do they provide more expensive and lower quality results?

One answer is that health insurance in the U.S. demonstrates a type of market failure. See, e.g., http://content.nejm.org/cgi/content/full/358/6/549

Another answer is that markets maximize wealth, but our goal with healthcare is to maximize health, so markets simply cannot achieve that goal by themselves.
4.15.2009 4:56pm
Dan Weber (www):
Indeed, this fact alone makes you have to question all the conclusions of the Weems/Sasse article cited by the OP. If private plans are efficient, then why do they provide more expensive and lower quality results?

You aren't making the proper comparison. A lot of the US system is public.

The real problem is that the US follows a pay-for-procedure model. Most other countries have their doctors on a salary.
4.15.2009 5:04pm
Dan7:
Dan Weber writes:

The real problem is that the US follows a pay-for-procedure model. Most other countries have their doctors on a salary.

I don't have any good links for this, and I'm not sure about "most," but it's my impression that the countries that get the best results have private doctors (presumably paid per procedure) and public insurance. E.g. Canada.
From a market standpoint that may make sense: I want private doctors competing for patients. But I don't want private insurers competing for the healthiest risk pool.
4.15.2009 5:27pm
Crust (mail):
Dan7:
The truth is, looking around the world, we see that government systems are always far cheaper, and for the most part provide better care. See, e.g. wapo and newsweek...


That couldn't possibly be correct. Didn't you see the dispositive anecdote about the Canadian quads who had to go to the US for medical treatment? ;)
4.15.2009 5:59pm
Dilan Esper (mail) (www):
Denying claims inappropriately is not a money-making venture in the long run for insurers (though it can be in the short-run).

Ever heard of markets with imperfect information?

In any event, if there's ever an issue where Keynes' "in the long run, we are all dead" applies, it's this one.
4.15.2009 6:09pm
John Moore (www):

That is absolutely false. The truth is, looking around the world, we see that government systems are always far cheaper, and for the most part provide better care.



There are lots of comparative studies, and they rarely take into account the differences in demographics between the countries, not to mention significantly different metrics (on infant mortality, for example).

Furthermore, if those systems are so great, why is medical tourism to the United States so popular - even with our high prices?

We have a Mayo Clinic and Hospital here in Scottsdale, AZ that has a large staff of translators for the folks from those countries with "better care." They also do a booming business with Canadians. States along the Canadian border have clinics that cater to Canadians just as the Mexican border has dental clinics that cater to Americans (because lots of Americans can get medical care but not afford dental care).
4.15.2009 8:10pm
Andrew J. Lazarus (mail):
Denying claims inappropriately is not a money-making venture in the long run for insurers (though it can be in the short-run).
Yes, we see that AIG and Lehman Brothers and Washington Mutual and definitely IndyMac and Enron were all run with the long term in mind, not the short term. What color is the sky on that planet?

I wonder if most Volokh commenters are single and young, because any middle-aged parent is full of nickel-dime-and-dollar chiseling by health insurance companies (assuming, of course, that the parent has insurance and isn't a charity case).

This sort of free-market cult worship reminds me of Christian Science in its anti-empirical bias.
4.15.2009 8:41pm
Dan7:
John Moore, thanks for contradicting my links to actual studies with your unsupported anecdotes. Very convincing.

Here's another actual source in response to your unsupported claim that there is lots of "medical tourism to the United States." Even if it is true that some Canadians come to the U.S. for treatment, it's not exactly a one-way street (see, e.g. the well-known phenomenon of U.S. residents going to Canada for prescriptions. This source shows that, actually, there is lots of medical tourism from the United States.
4.15.2009 8:42pm
Brett A. (mail):
First, private insurers must build provider networks. These networks can include high-value providers and exclude low-quality providers. Except for certain circumstances, including criminal acts, Medicare is forbidden from excluding poor quality providers. It lets in everyone who signs up. So one question to ask is, will the public plan have Medicare's indifference to quality — or invest in the cost of a network?


Sort of. This is only the case when the insurers happen to be HMOs - and they often aren't.


Second, private insurers must negotiate rates. Medicare just fixes prices using a statutory and regulatory scheme. And anyone who imagines a public plan would be less costly than private plans must keep the following issue front and center: In the many procedure categories where Medicare's statutory price does not cover full provider costs, shortfalls are shifted to private payers who end up subsidizing the public program. So, will a public plan negotiate rates or simply use fiat as a means of gaining subsidies from private insurance?


Hopefully, it will negotiate a rate schedule, then run with it.


Third, private insurers must combat fraud — or go out of business. Indeed, these payers have every incentive to invest in antifraud personnel and strategies down to the point where return and investment are equal. But anyone who thinks that a public plan could serve as a "yardstick" for the private sector needs to consider Medicare's dismal record with regard to fraud, waste and other abuse.


How much does this actually cost in terms of care?


Fourth, private insurers must incur the administrative cost of marketing. Medicare, of course, does not need to market. A public plan competing with other alternatives would have to market itself to the public, and this means tax dollars used to advertise against private plans. Or the public plan could "compete" by using heavily subsidized marketing channels not available to private insurers, such as Social Security mailings, welfare offices, unemployment check stuffers, and the constellation of government-funded "advocacy organizations."


Why would the Public Plan even need to market? Just require that a basic health care plan cover a minimum of such-and-such conditions, then make the Public Plan the "default" option if people don't otherwise have or buy private insurance.
4.15.2009 9:13pm
John Moore (www):
Dan7

Here's another actual source in response to your unsupported claim that there is lots of "medical tourism to the United States." Even if it is true that some Canadians come to the U.S. for treatment, it's not exactly a one-way street (see, e.g. the well-known phenomenon of U.S. residents going to Canada for prescriptions. This source shows that, actually, there is lots of medical tourism from the United States.

I don't bother to provide cites that are readily available for anyone who cares. It is, in fact, a well known phenomenon.

US residents go to Canada for prescriptions because the Canadians have price controls on drugs - they are free riders (as is the rest of the world) on US drug companies and consumers. The idea that Americans going their for drugs says anything about the quality of their system is truly laughable.

And yes, there is medical tourism from the US, for price reasons.

The tourism TO the US is for the reasons appropriate to this discussion: availability and quality.
4.15.2009 9:21pm
Dan7:

I don't bother to provide cites that are readily available for anyone who cares. It is, in fact, a well known phenomenon.


It was "well-known" in certain circles a few years ago that 9/11 was instigated by Saddam Hussein. I prefer sources.

Even if it is true that some people come to the U.S. for care, you fail to show whether it's enough people to allow one to conclude that it's an indictment of Canada's system. It can be a "well-known phenomenon" just because there was one article about one family on CNN.com (or even on worldnutdaily). One or two anecdotes on random websites doesn't indict Canada's system.


The tourism TO the US is for the reasons appropriate to this discussion: availability and quality.


Actually (as shown in the articles I linked to), the reason that people go to India or Mexico for care is exactly because of the unavailability of care here.

And (as shown in the other articles I linked to), people traveling outside the U.S. for their care will often receive better care than they would here at home. Numerous studies, including those I posted, show that quality of care is better in other countries than in the U.S. Although many people (including you), complain that this just can't be true, nobody has ever cited a study that shows the opposite (that U.S. care is better than abroad).
4.15.2009 10:03pm
John Moore (www):

It was "well-known" in certain circles a few years ago that 9/11 was instigated by Saddam Hussein. I prefer sources.

Then dig 'em up. That you dispute the well known and obvious is pathetic.

Even if it is true that some people come to the U.S. for care, you fail to show whether it's enough people to allow one to conclude that it's an indictment of Canada's system.

It is routine in Canada to wait a long time for diagnostic services. Even now that they bought some imaging equipment, you still may have to wait a while and go at 2AM for your MRI. People wait long periods of time for non-lifesaving surgery - waiting in pain - which is one reason they come here.

You can dig up all the studies you want, although your first sources were both from public news outlets, not studies - outlets that are both in favor of single payer health care - so hardly credible.

Actually (as shown in the articles I linked to), the reason that people go to India or Mexico for care is exactly because of the unavailability of care here.


So tell me what care is unavailable here but available in India or Mexico?

And (as shown in the other articles I linked to), people traveling outside the U.S. for their care will often receive better care than they would here at home

Boutique care is often good - it's a fine business, and India is taking advantage of it (even the UK is into it). So what?


Numerous studies, including those I posted, show that quality of care is better in other countries than in the U.S.

Simply repeating your points is useless. But since you're doing it, I guess I'll respond again: those studies do not control for different conditions. Many that I have seen cite infant mortality, for example, ignoring cultural and demographic differences, and the practice in some countries of not counting the deaths of babies under 2 days old.
4.16.2009 2:12am
Ricardo (mail):
No one has mentioned that our medical system is not free market where goods and services are bought and sold at a fair market price. Why not eliminate all insurance and all government subsidized health care? Why not put everyone in the position of paying for their own care as they use it?

What is free market about prohibiting an adult from signing an insurance contract to cover certain kinds of medical care? Do you have $20,000 available at a moment's notice to pay to remove an infected appendix? Or > $100,000 to pay for a family member's bypass surgery? What if you are on a camping trip in a remote area and break a leg requiring helicopter evacuation? Got a $50,000 credit limit on your Visa to pay for that?

How could there ever be a true "fair market price" for some medical services anyway? Are you going to go price shopping and negotiating at 10 different ERs while experiencing a heart attack?
4.16.2009 4:39am
Andy Freeman (mail):
If US govt healthcare actually is superior, all we have to do is open it up, at cost, to everyone.

And, if we're really sure that government healthcare is better, we'd give vouchers to folks that it currently covers and give them the option of buying private.

Folks who actually believe that they have a superior product welcome competition.
4.16.2009 11:00am
Jimmy W (mail) (www):
It is interesting that, as everyone is touting the advantages of Medicare, federal employees are not under the Medicare system. Instead, they are under a "private insurance" system.

If Medicare is so great, perhaps we should include federal employees in Medicare first. Include the military &retirees if you feel like. If these people do not complain about Medicare, then perhaps we can open it up to the rest of the population.

We don't have to argue in a vacuum here. We have the time and funds to experiment. Let empirical results speak for themselves. Besides, we need to make sure that Medicare can handle the increase in subscriber volume, and the federal employees make a good ramp up exercise.

On another note, please keep in mind that Medicare and Medicaid are fast rising in their share of the federal budget, far in excess of the oft-noted Social Security rate. The present value of Medicare and Medicaid projected shortfall far exceeds that of the Social Security, and the present value of the US economy. Moving to an all-public health care system will temporarily slow down the health care budget train wreck, but it will not stop it.
4.16.2009 11:53am
Brian K (mail):
Folks who actually believe that they have a superior product welcome competition.

That explains why insurance companies do everything they can to prevent government from entering the healthcare market and why pharm companies lobby like crazy to prevent the government from negotiating.
4.16.2009 7:08pm
Peter Donis (mail) (www):
I'm not sure comparing private insurers to Medicare is the right comparison to be making. President Obama has said he wants to make available to all Americans the same kind of plan that members of Congress get. That's basically the same kind of plan that I have as a federal employee, Federal Employee Health Benefits (FEHB)--which is certainly *not* Medicare. FEHB has to negotiate rates with health plans just as private companies do; it offers members a choice of providers with various combinations of premiums and benefits, just as private companies do; in fact, FEHB is similar in almost all respects to the insurance I had when I was working for a private company before I became a Federal employee.

The major difference? FEHB can negotiate rates on behalf of the entire population of federal employees, which is a larger risk pool than any private corporation can muster. Imagine how much better a negotiating position it would be if something like FEHB could negotiate rates on behalf of all American citizens as a single risk pool.
4.18.2009 8:32pm

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