Saturday, September 15, 2007

The elephant in the health care room

Over at economist Angry Bear's site, a hypothetical 67 year old former carpet installer named "Joe" with a bum knee was presented, and the hypothetical question was asked by a free market ideologue, "in a universal health care system, does Joe get his knee replacement?" The entire question is stupid, of course, because Joe already is part of a universal health care system -- Medicare, which is universal health care for all those who are age 65 or above. You don't need to ask a hypothetical question. All you have to ask is, "does Medicare pay for knee replacements for 67 year old men?" (The answer, BTW, is "Yes"). The only reason to invent a new fictitious "universal health care" system for Joe is to push a particular ideological line. Simply look at the data for the existing REAL universal health care system that Joe is a member of, and tell me whether it pays for his knee. Don't make shit up when we have real data!

My point: We have numbers for Medicare, a universal health coverage system for all those age 65 and up. So what's the big deal about giving us those numbers, rather than giving us hypothetical scare stories about some hypothetical universal health care system that isn't Medicare? It's as if Medicare is the elephant in the room that nobody wants to admit exists. Whenever a discussion of universal health care breaks out, it's as if everybody goes out of their way to ignore the elephant in the room -- the already existing universal health care system for all those age 65 and up. Ideologues of all stripes, whether carrying Little Green Books (free market ideologues) or Little Red Books (socialist/Marxist ideologues) seem to suddenly lose track of their entire chain of thought whenever you bring up Medicare as a universal health coverage system (which it most assuredly is), or like a blind man in a room with an elephant, come up against the trunk of the elephant, feel it with their hands, and say "An elephant is like a snake."

The current system of private health insurance is in a death spiral, as increasing costs force people to drop their insurance coverage which in turn raises the cost of insurance coverage for the remainder since they're paying for the cost of the uninsured too which in turn forces more people to drop their insurance coverage etc. Within ten years the majority of Americans will be uninsured and as I explained in my posting The Coming Epidemic the likelihood of a public health disaster such as a plague that uses this pool of unhealthy Americans as its vector (and kills insured Americans too) will be approximately 100%. We have three choices: 1) figure out some way to stop the death spiral in the private health insurance industry (thus far the only way I've seen proposed to do that is the Massachusetts plan, which forces people at government gunpoint to subsidize the private health insurance industry but which thus far has had limited success due to the inability of government to have enough guns to force enough people to buy health insurance at gunpoint), 2) extend a still-working, if creaky, system (Medicare) to all Americans to at least provide some baseline coverage which would require an increase of the Medicare insurance payroll tax but at least we know whether it works or not and "Medi-gap" private insurance could be bought to fill the primary care gaps, or 3) invent some new system with unknown implications and unknown drawbacks and flaws. Of the three, #2 is the cheapest and has the least risk -- we *know* Medicare. It already exists. We know it would provide a sufficient baseline of catastrophic health coverage to make it possible to patch up the existing health care system to the point that it functions again. We *know* that its administrative overhead costs (less than 3%) are less than 1/3rd of private insurer's administrative overhead costs, and that's not even counting the administrative overhead costs that doctors have when it comes to dealing with private insurers. Of the three options, the second one is the least risky, in that we know its flaws, we know its benefits, it doesn't require excessive amounts of government force to obtain compliance the way that the Massachusetts plan is currently working out, and unlike option 3 we don't have to jump off a cliff and just hope that some new system won't kill us all.

What irritates me is that ideologues of both stripes hate option b because it doesn't comply with their Little Green Book or Little Red Book ideological beliefs. But as a sane project manager, the conservative choice (extending an already-working system that, while flawed, is at least going to provide the baseline functionality required by our customers) is the one I would make every day as compared to the risky choice of a complete re-implementation of the system. And indeed, this is exactly the choice that my employer is making in the context of a specific software system -- we have decided to abandon system (a) which is horribly expensive to maintain and doesn't provide all the features that our customers want, extend system (b) to provide those features of system (a) that it doesn't already provide where system (b) is a somewhat clumsy and creaky system but far less expensive to maintain meaning we can provide it to our customers at a much lower cost, and defer option (c) (an entirely new "ideal" system) into the far future. Why is this okay if private enterprise does it in the context of designing software systems, but horrible if we as a society do it in the context of designing a medical care system? If I ran my business the way that ideologues suggest, I'd try to prop up option a) forever and go bankrupt, or spend an outrageous amount of money and time on option (c) which may not work in which case we go bankrupt, rather than do the sensible thing which is to extend option (b) to provide the core functionality of option (a) in a much more cost-effective manner. But what's good for a business apparently, according to the ideologues, is not good for making societal decisions.

Bah. Ideology, whether free-market Little Green Book ideology or marxist/socialist Little Red Book ideology, has no place in the decision process. We should focus on facts. And when it comes to Medicare, we have plenty of facts showing that despite its many flaws and limitations it is a more cost-effective way to provide universal health insurance as compared to attempting to patch up the current employer-provided system to be universal, without the risks of trying to devise an entirely new system from scratch. But when it comes to facts, suddenly Medicare becomes the elephant in the room that nobody seems to see because it's not ideologically correct to acknowledge that we already have a working universal health coverage system here in America, albeit only for those age 65 or older. But disease doesn't care about ideology. Ideology is going to kill us, in the end. And as long as we allow our decision makers to ignore the elephant in the health care room, ideology is going to kill us sooner rather than later.

-- Badtux the Health Care Penguin
Crossposted at Mockingbird's Medley


  1. Interesting post. Lots of reading:) Yes, I agree. Medicare is a universal healthcare system.

    The program has bugs, though. Of the medical bill, they decide what they're going to pay on what, disallow another portion, then the consumer gets a bill for their remaining percentage of the amout medicare allows. Now, if the provider doesn't participate in the medicare assignment, they get to charge the consumer for the disallowed amount along with their percentage, too - I'm just thinking about medicare part B that handles outpatient. I'm sure Inpatient (part A) is a different story. I think that has an extreme deductible.

    Of course, so many insurance companies do the same thing if the consumer didn't go to an approved medical facility, if it wasn't pre-approved, etc.

    Following the medicare idea would be a good start, anyway.

  2. Long post and I don't have time to read it all. The reason Medicare is here is because older people have the time to work on making sure it is in the system.

    But old people are afraid of dying so they want the younger tax payers to keep them alive for as long as they can.

    Yup, this country is full of old people that are as worthless as tits on bore hogs, but hey, they are still alive, and the younger folks are paying for it all.

    All of that will have to end someday though. How? I don't know, but I do know that I don't want anyone or any system to try to keep me alive if all I can do is sit around on my ass anyway.

    That is not living, that is just sitting on your ass.

  3. Thanks for that evaluation. I'll keep it in mind when my time finally comes of age to receive it. I'll have to hope that I make it as an old fart in decent condition and not make use of it much. My husband provides good insurance for us now...if he cacks on me...I'm so screwed!

  4. It can't possibly work because it is too simple, would save too much money, has very little room for graft, and would cost politicians too much in insurance pac donations.

    Oh, yeah, it would also prevent the looming autoworkers strike, provide funding to non-profit health care facilities, and allow doctors to work for themselves instead of insurance companies.

    It's obviously totally unworkable.

    Who would hire the thousands of people who do nothing all day but code medical claims for the different companies and plans?

  5. Well, Bryan, the farmers are saying they have a shortage of laborers to pick their crops. I say we send all these medical records coders to the fields to harvest guacamole and spinach, that ought to solve that labor shortage nicely :-).

    - Badtux the Snarky Penguin

  6. I did some quick math on this... and quick math is usually wrong... but here goes...

    Current medicare costs are about $350B/year. And that covers about 11% of the population. So, to cover the rest it will cost us roughly $3.2 trillion. Trillion. Take a look at your last paycheck and multiply the Medicare tax by 10... YIKES!

    Plus, medicare A only covers "most" of the first 100 days of a hospital stay. I guess we would be hoping people die off in the first 99.

  7. Yes, your math is wrong. Old people are the most expensive people to cover with health insurance, because they're old and sick a lot. Young people are the cheapest to cover. All in all, health care spending accounts for 15% of the U.S. GDP, of which 7.5% is already taken care of either via direct taxation or Medicare/Medicaid. What that means is that covering the other half, generally the less expensive half to insure, would require doubling the current Medicare/Medicaid tax from its current 2.9% to 5.8%, and require Medicare insurance fees of approximately the same amount as the current Medicare fee of $96 to $238 a month on a sliding scale according to income. That combined with the lower administrative expenses of Medicare For All would suffice to pay for medical care for all Americans for no more out of pocket than is currently paid (since the money is already being taken out of our pockets for health insurance, it's just being taken out by our employer or by the insurance company, not by the government... but really, it isn't in my pocket anyhow, so why do I care who takes it out?!).

    - Badtux the Health Care Penguin


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