Medicare for All!

[MillCreek]

Do you get the same penalties if they die?

It would be super if they held off dying until at least day 31 after discharge.

[BobR]

Do you get the same penalties if they die?

I am glad you asked this.

Short answer is yes.

The real penalties come if a hospital does not meet required measures for an item called 30 day mortality. If a patient is hospitalized and then dies within 30 days of discharge (any cause of death not just what they were hospitalized for) it is a ding against the hospital. Too many of those and CMS can take a hard look at decreasing or removing funding from your facility until you get your act together. Do a good job and under the Value Based Purchasing system that Medicare uses the hospital could get a little extra, do very poorly and you may get a visit from the CMS inspectors trying to find out why your patients are kicking the bucket after you send them home and subsequently lose federal dollars.

bob

[Strings]

Much of those exorbitant healthcare costs have come about due to the ever expanding pool of insurance dollars available to pay for it.  Increase the available dollars, costs will go up accordingly to absorb those dollars.  Self-perpetuating after a fashion.

Very similar to what was found with college tuition: the more money the feds made available, the higher tuition climbed

[grampster]

I had prostate cancer in 2005.  I went to the University of Michigan hospital in Ann Arbor.  They had the #2 ranked guy (according to the internet) in America who knew how to do the radical prostatectomy using the DaVinci robot.  That machine is awesome.  The doc told me that if we had a DaVinci in Grand Rapids, he could actually do the surgery from Ann Arbor.  They wouldn't actually do that, but he said it would be possible. 

My health care accepted me going to U of M because they were an in network hospital and the fact that DaVinci prostatectomy is less invasive, hospital stay is short, blood loss is less etc.  The surgery was to occur in the AM, but U of M is around 3 hours away.  They actually have a hotel in the hospital, so we checked into the U of M hospital hotel the afternoon before.  They did my surgery at 10AM on the clock the next morning.  They discharged me at 10AM the next day.  24 hours was all I could be hospitalized unless there was a problem.  When they kicked me loose, my wife wheelchaired me back the hotel room where we stayed over night.  I drove home the next day.  Driving home with a pee bag and the remnants of all the wonderful drugs made that experience memorable.  (There was a Meijer Grocery semi on the interstate and I knew he'd be going back to near home, so I put the car on cruise and tailgated him all the way.)   I paid out of pocket for the 3 nights in the hospital hotel at around $100.00 a night.  The whole hospital stay/surgeryrecovery thing cost around $60,000-$70,000 iirc.  I think I had $250.00 out of pocket.

So, I paid for 3 hotel nights and a $250.00 deductible.  I was in the hospital 24 hours.  Took up a bed and attention of a couple nurses and some pre-surgery drugs.  Surgery was done using the DaVinci robot by a skilled surgeon and staff along with whatever else goes on in the operating room.  Then recovery room in the afternoon with another guy who had the same surgery.  Stayed overnight with whatever drugs the machine I was hooked to would allow and when as well as having a nurse stop by now and then.  Then out the door by 10AM in the morning.

[De Selby]

Reading all this, I don’t see a single concrete proposal that is likely to reduce healthcare costs apart from simply copying a medical system that is already proven to reduce costs and deliver quality outcomes.

Lots of blame - illegals, people who use the ER, the requirement to treat the sick and not let them just die, and insurance companies all seem to blame from comments here. The government is mysteriously to blame but apart from not paying the high prices charged by private medicine I’m not sure there’s even been speculation as to how that increases cost.

I think this is a topic where people have been so heavily propagandised by the health insurers that it’s simply hard to have a rational debate. They even managed to convince people that Obamacare was something other than a gift to the largest players in the sector.

[BobR]

Reading all this, I don’t see a single concrete proposal that is likely to reduce healthcare costs apart from simply copying a medical system that is already proven to reduce costs and deliver quality outcomes.

Lots of blame - illegals, people who use the ER, the requirement to treat the sick and not let them just die, and insurance companies all seem to blame from comments here. The government is mysteriously to blame but apart from not paying the high prices charged by private medicine I’m not sure there’s even been speculation as to how that increases cost.

I think this is a topic where people have been so heavily propagandised by the health insurers that it’s simply hard to have a rational debate. They even managed to convince people that Obamacare was something other than a gift to the largest players in the sector.

You left out medical litigation where people will sue at the drop of a hat and juries will hand out ridiculously large awards whether deserved or not. IMO, usually not.

bob 

[Firethorn]

You went past my point.  The emergency room should not be free to anyone.  If the hospital was allowed to require people to pay up front or get out, the people who really needed help would come up with the money.

Well, that or they die.  Good luck if you're in a car accident, unconscious, wallet goes missing between the car and hospital, and nobody can confirm your identity/ability to pay.

Those who didn't have an actual emergency would either pay or find a less expensive alternative like they should in the first place.  Right now, all those people using the ER for free health care are a drain on the system and ramping up the cost for everyone else.

Now here you're just agreeing with me.  

We just need to figure out how to get our system back into a rational form.

Indeed.  My point is that people who really need medical care are going to figure out how to get it somehow.  My thought is that we need our incentives to be structured to get them to get treatment earlier, when it is drastically cheaper.

If one goes to an ER and accepts healthcare for what ails them, knowing either, they can't pay, or they are on a government program that won't pay for this visit, that person is a thief.  And should be treated as such.

So we put them in jail or prison where we have to not only provide free medical care, but housing and food as well?

This is a driving factor in many (especially smaller) hospitals closing down the emergency department.

I think that the lack of emergency departments is a problem.  Of course, I'm also wary of hospitals being able to turn people away to basically die on their doorstep.

It is my belief that IF the federal government is going to mandate that emergency rooms provide treatment regardless of ability to pay, THEN it should step in and fund/pay for the requirement.

[Ben]

Well, that or they die.  Good luck if you're in a car accident, unconscious, wallet goes missing between the car and hospital, and nobody can confirm your identity/ability to pay.

Either I'm getting soft in my old age, or I'm becoming a bleeding heart commie, because this is my point as well.

If you're talking about turning people away from the ER because of a sniffle, I'm right there with you, whether they're insured or not. Going to the ER for stuff you shouldn't even need a doctor for is a big part of the problem, IMO.

To Firethorn's point: If you're going to implement "only paying customers" in the ER, for REAL ER cases, how will you do it? The three Bens:

Ben #1: Insured Ben is out running. Ben is hit by a bus, but is brought to the ER conscious. Ben carries nothing but a phone with him while running, and the phone went flying when the bus hit. ER asks Ben if he's insured, and he says yes. Is that good enough to get him through the door?

Ben #2: Same scenario as above, but with uninsured Ben. So if I'm at death's door, is it really tough luck, go die now?  If I chose not to be insured because I'm a tightwad, or because  I use the $1000/mo for the insurance on hookers and blow, then maybe I should die. What about if I'm just temporarily down on my luck? Should I still die?

Ben #3: Insured Ben is out running with no ID and hit by a bus. Insured Ben is brought to the ER unconscious. Now what? If the hospital turns away unconscious insured Ben, and Ben lives, I'm pretty sure he'd be sitting on easy street after the lawsuit. Also what if unconscious, uninsured Ben is "uninsured" because he's a bajillionaire and self-insured?

So we can keep debating about turning people away from the ER for many ailments, but I don't think in a reasonable society, that we can turn away critically injured people at the ER, say after a building is bombed, or a train derails, or if it's just a one vehicle car wreck. Or some shmuck hit by a bus.

[dogmush]

We use the framework that exists already.

Step 1:
You come in to the ER, and are go through triage. 
If you are unconcious and/or need help RIGHT NOW then they do give you help.
If something's wrong but we don't know what then they do some tests to see if it's a heart attack or indigestion.
If it's you came to the ER because you don't have a Primary Care  and you will clearly be fin until business hours they say that.

In any case, at some point you are no longer Emergent Care, and are going to just medical care.  That might be when you get out of surgery, when you hit the triage desk, or when you die.  At some point it's not an emergency.  At that point, there's time to get payment for service rendered, and plan for the payment of the rest of your care.  Sniffles?  Give me a credit card or get out. Ben #2? You just drew the short straw, and are racking up bills while you try and find a government program or charity to help out.  Maybe you want to think about exactly how much surgery you can afford.  8 cutting edge surgeries that 50/50 save the leg, and no insurance? Pay up front.  Otherwise Medicaid will probably cover the amputation and prosthetic.

Paying for treatment up to that Go/No Go point remains an issue, but a smaller one, and Perhaps fed.gov is on the hook for that.  It's their rules that require the care.

So we put them in jail or prison where we have to not only provide free medical care, but housing and food as well?

That same point can be made about literally every other form of thievery.  And yet we still prosecute and imprison thieves.  Yes, we should lock-up people that willfully steal medical care.  Or seizing assets to pay for the care. If nothing else, people seem to value their freedom.  If a trip to the ER for stitches you can't pay for had a real risk of losing a tax "return"* or 6 months in jail for fraud, perhaps some first aid would be learned.

*Return is in quotes in case the folks in question didn't actually pay all that money, but were getting some wealth redistribution.

[Pb]

Reading all this, I don’t see a single concrete proposal that is likely to reduce healthcare costs apart from simply copying a medical system that is already proven to reduce costs and deliver quality outcomes.

Lots of blame - illegals, people who use the ER, the requirement to treat the sick and not let them just die, and insurance companies all seem to blame from comments here. The government is mysteriously to blame but apart from not paying the high prices charged by private medicine I’m not sure there’s even been speculation as to how that increases cost.

I think this is a topic where people have been so heavily propagandised by the health insurers that it’s simply hard to have a rational debate. They even managed to convince people that Obamacare was something other than a gift to the largest players in the sector.

What system do you think we should copy?  I'm open to ideas.  It seems like single payer options tend to have serious problems with rationing and/or quality though.  I don't know the best thing to do.  I do know that costs are in the US system are a serious problem that congress is refusing to address.

[De Selby]

You left out medical litigation where people will sue at the drop of a hat and juries will hand out ridiculously large awards whether deserved or not. IMO, usually not.

bob 

Those awards are largely based on actual medical expenses

[De Selby]

What system do you think we should copy?  I'm open to ideas.  It seems like single payer options tend to have serious problems with rationing and/or quality though.  I don't know the best thing to do.  I do know that costs are in the US system are a serious problem that congress is refusing to address.

How about we copy France? Or Canada to make the manuals easier? Both have equivalent quality

[De Selby]

We use the framework that exists already.

Step 1:
You come in to the ER, and are go through triage. 
If you are unconcious and/or need help RIGHT NOW then they do give you help.
If something's wrong but we don't know what then they do some tests to see if it's a heart attack or indigestion.
If it's you came to the ER because you don't have a Primary Care  and you will clearly be fin until business hours they say that.

In any case, at some point you are no longer Emergent Care, and are going to just medical care.  That might be when you get out of surgery, when you hit the triage desk, or when you die.  At some point it's not an emergency.  At that point, there's time to get payment for service rendered, and plan for the payment of the rest of your care.  Sniffles?  Give me a credit card or get out. Ben #2? You just drew the short straw, and are racking up bills while you try and find a government program or charity to help out.  Maybe you want to think about exactly how much surgery you can afford.  8 cutting edge surgeries that 50/50 save the leg, and no insurance? Pay up front.  Otherwise Medicaid will probably cover the amputation and prosthetic.

Paying for treatment up to that Go/No Go point remains an issue, but a smaller one, and Perhaps fed.gov is on the hook for that.  It's their rules that require the care.

That same point can be made about literally every other form of thievery.  And yet we still prosecute and imprison thieves.  Yes, we should lock-up people that willfully steal medical care.  Or seizing assets to pay for the care. If nothing else, people seem to value their freedom.  If a trip to the ER for stitches you can't pay for had a real risk of losing a tax "return"* or 6 months in jail for fraud, perhaps some first aid would be learned.

*Return is in quotes in case the folks in question didn't actually pay all that money, but were getting some wealth redistribution.

So your theory is that if debt collection for medical expenses was more like what you’d see in a Dickens novel, costs of healthcare would go down???

Or do you not care about price per service?  Seems to me the purpose of capitalism is to make life better for people, not to make an essential service like medicine so expensive that only by threatening Dickensian punishments can it be rationed to serve even some people

[TommyGunn]

DeSelby,  even if all the other countries did -- or have -- adopt (ed)  a wonderfully efficient single payer socialized medical system,  it would not happen in America.  The closest we have is the VA Administration and that has been an embarrassing mess for decades. 
After five decades of watching the American Government  adopt one program after another,  and projecting it's costs into the future only to actually find that, decades later, the real expense was five, ten times or more than original estimates,  I cannot believe that it is possible for us to do it right (accepting, a priori, that other countries actually do it right) given demonstrated history.
Obamacare was promised to cut health insurance costs.  I'm told for a few, maybe it did.  My costs, however, have skyrocketed,  and everyone I know has experienced the same.


Please stop telling me about other countries' wonderful systems.   I suppose a few countries can pull it off.   Years ago my parents spent several years in Scotland, and had need to use their system.   I wouldn't wish what they went through on a mortal enemy. 
Well,  maybe I would if they could do it more efficiently ..... but they couldn't.   Okay, that's one story.  I could tell you what their Scottish friends said if you like anecdotal horror stories,  but then I cannot provide the footnotes and ibids  you hold so dear,  so I'll  save myself the effort.

[MillCreek]

Those awards are largely based on actual medical expenses

Speaking as the only person on this board who actually does medical malpractice claims, from the defense side, not so much.  As you know, part of the special damages allocation may well be based on actual medical expenses; but the general damages allocation (pain and suffering and emotional distress) are granted on whatever basis the judge or jury chooses.  In some cases, juries like to pick a multiple of the special damages amount (medical expenses, loss of earnings, additional expenses, impairment of future earning capacity) and in other cases, they seemingly pull a number out of the hat.

Speaking from an overall perspective however, the costs of medical litigation (insurance, legal indemnity and legal expenses) are a small contributor to overall medical costs.  There is lots of reputable literature on this.

[makattak]

Speaking from an overall perspective however, the costs of medical litigation (insurance, legal indemnity and legal expenses) are a small contributor to overall medical costs.  There is lots of reputable literature on this.

I note your list doesn't take into account "defensive medicine".

[MillCreek]

I note your list doesn't take into account "defensive medicine".

Attempts have been made to quantify defensive medicine and have generally failed miserably.  You usually aren't going to find providers who will say 'I ordered that test only to keep from being sued'.  What they say instead is 'I ordered that test to reduce diagnostic uncertainty' or 'to refine my diagnosis and treatment plan'.  So trying to put a number on defensive medicine, as opposed to doing your clinical due diligence is difficult.

[dogmush]

So your theory is that if debt collection for medical expenses was more like what you’d see in a Dickens novel, costs of healthcare would go down???

Or do you not care about price per service?  Seems to me the purpose of capitalism is to make life better for people, not to make an essential service like medicine so expensive that only by threatening Dickensian punishments can it be rationed to serve even some people

Was it a "Dickensian punishment" when we sent Enron Executives to jail for fraud?

There are multiple issues driving our healthcare costs, and each issue will need it's own solution.  One of the issues is people using healthcare services (I even separated emergency services in the post you quoted, to be more egalitarian) with no intention of paying for them.  That drives up costs for those of us that do pay, because those expenses have to be recouped.  That should be treated like a crime.  As I said in my post (again, that you quoted, so one assumes you read) that we emergent up to stabilization care should be provided before we hit the paywall, but that shouldn't be "Whatever you want the Doctors to try" or "The ER was convenient so I went in for a sprained ankle."

You need food to live, but we don't pretend it's OK to just go into a grocery store and take whatever you want.  We arrest people for shoplifting.

[Scout26]

The other problem with Medicare for All is my mother (and there are many like her).  She has a supplemental policy that covers what Medicare doesn't, so her hobby for the past 15 years has been "Let's go to the Doctor."  So she's visiting one type of doctor or another at least once a month, sometimes twice or three times a month.  All for mostly BS reasons.  But hey, it's free and the place she stays at has a shuttle that will take the residents pretty much anywhere, so even though we tell mom that one of us kids needs to go with her, she'll make her own appointments and take the shuttle without telling us.

Anyway, her answer to all the doctor visits is "It's free, so why shouldn't I use it."  Which is why Medicare for all will collapse/run up costs very quickly.  If people think "It's Free" then they'll use more of it. 

[Andiron]

The other problem with Medicare for All is my mother (and there are many like her).  She has a supplemental policy that covers what Medicare doesn't, so her hobby for the past 15 years has been "Let's go to the Doctor."  So she's visiting one type of doctor or another at least once a month, sometimes twice or three times a month.  All for mostly BS reasons.  But hey, it's free and the place she stays at has a shuttle that will take the residents pretty much anywhere, so even though we tell mom that one of us kids needs to go with her, she'll make her own appointments and take the shuttle without telling us.

Anyway, her answer to all the doctor visits is "It's free, so why shouldn't I use it."  Which is why Medicare for all will collapse/run up costs very quickly.  If people think "It's Free" then they'll use more of it.  

Yep.

Got a grandfather who does that because he's just bored.  And then he bitches when the diagnosis is "you're 90 and there's nothing wrong with you,  it's simply high millage"

[De Selby]

Speaking as the only person on this board who actually does medical malpractice claims, from the defense side, not so much.  As you know, part of the special damages allocation may well be based on actual medical expenses; but the general damages allocation (pain and suffering and emotional distress) are granted on whatever basis the judge or jury chooses.  In some cases, juries like to pick a multiple of the special damages amount (medical expenses, loss of earnings, additional expenses, impairment of future earning capacity) and in other cases, they seemingly pull a number out of the hat.

Speaking from an overall perspective however, the costs of medical litigation (insurance, legal indemnity and legal expenses) are a small contributor to overall medical costs.  There is lots of reputable literature on this.

I do a fair amount of research on how judgments affect insurance markets. I find data like this report useful for keeping track:  https://www.insurance.wa.gov/sites/default/files/documents/2017-med-mal-annual-report.pdf

Certainly there are random cases, but on average general damages are not the majority of costs.

Economic loss payments totaled $363 million, an average of $150,520 per paid claim. On average, insurers and self-insurers
attributed 58.7 percent of each claim payment to economic loss.

[De Selby]

Was it a "Dickensian punishment" when we sent Enron Executives to jail for fraud?

There are multiple issues driving our healthcare costs, and each issue will need it's own solution.  One of the issues is people using healthcare services (I even separated emergency services in the post you quoted, to be more egalitarian) with no intention of paying for them.  That drives up costs for those of us that do pay, because those expenses have to be recouped.  That should be treated like a crime.  As I said in my post (again, that you quoted, so one assumes you read) that we emergent up to stabilization care should be provided before we hit the paywall, but that shouldn't be "Whatever you want the Doctors to try" or "The ER was convenient so I went in for a sprained ankle."

You need food to live, but we don't pretend it's OK to just go into a grocery store and take whatever you want.  We arrest people for shoplifting.

How would you feel about the free food market if routine food was unaffordable to half the population?

This is actually a good comparison. Food production is heavily regulated and subsidised - more so than in most of the rest of the world. US farming is as close to socialist medicine as our economy gets, and as a result we have some of the cheapest and most available food in the world.

So that’s an excellent example but not for the moralising you’re trying to do with it.

[MillCreek]

I contribute data to the Washington Insurance Commissioners annual medmal report and I helped set up the reporting format and data!  The one sticky wicket in the figure you cited is that in many of the settlements and verdicts, the special damages figure is an estimated allocation by the insurer.  It is more straight-forward when you have a jury verdict form and the jury actually allocates a known figure for special damages.  In many cases, however, I would argue that wage loss and impairment of future earning capacity is more of a driver of the total special damages figure than medical costs. If my provider kills a 35 year old Boeing engineer making $ 150,000 a year, 30 years wage loss increasing at 3% per year, will make up a larger chunk of special damages than the $ 55,000 hospital bill.

[Andiron]

How would you feel about the free food market if routine food was unaffordable to half the population?

This is actually a good comparison. Food production is heavily regulated and subsidised - more so than in most of the rest of the world. US farming is as close to socialist medicine as our economy gets, and as a result we have some of the cheapest and most available food in the world.

So that’s an excellent example but not for the moralising you’re trying to do with it.

Capitalism builds a system with a huge surplus and you want to attribute that to a few subsides?  I farm.  The "regulated and subsidized" bits are the exception.  You're delusional.

[De Selby]

Capitalism builds a system with a huge surplus and you want to attribute that to a few subsides?  I farm.  The "regulated and subsidized" bits are the exception.  You're delusional.

https://www.ers.usda.gov/topics/farm-economy/farm-sector-income-finances.aspx

Theres data on this. $20 billion in direct subsidies and $172 billion worth of other investment and value seems pretty significant to me. And this is in an industry that was basically entirely revolutionised by Roosevelt.

To suggest capitalism built US farming is delusional. People get paid subsidies in socialist systems - just because some folks get billions in payments and then get to sell a product on top doesn’t make it capitalism.