In yesterday’s post about a modest effort in Massachusetts to minimize administrative burden, El Dorado raised a good and constant point that I strong disagree with:
issue everyone a card. show the card to the medical clinic or doctor. everything else layered on top of that is just another reason to hate democrats, no matter how much ‘better’ it works
My response to this idea of extreme simplification is “This sounds great — how do we do this? More importantly, how do we get to 218-51-1-5?”
Yeah, that is a bit flippant, but there is a great question of how do the politics work to get a massive change as El Dorado proposes through the veto-strewn minefield of the US government.
If there is text for El Dorado’s bill available this morning, there is likely a 1 in the White House willing to sign a law. There are not 218 votes in the House nor 50 + a cooperative VP in the Senate to get a bill to the White House. There is definitely not 5 on the Supreme Court willing to uphold the law as constitutional. This equation gets worse in a few weeks.
So in the short run, technocratic tinkering is what becomes plausible and available to improve a non-ideal system.
Will it be perfect? FUCK NO.
Will technocratic tinkering that modestly eliminates frictions borne by the individual modestly improve coverage and the lived experience of the law? I think it would.
Is this emotionally satisfying? FUCK NO!
Is this the realm of the current possible? Yeah…
The challenge and disconnect is time frames. Technocratic tinkering is what can be done now. It is what can be done in 2023 and 2024. It is most of what might be done in 2029.
Complete restructuring of the US healthcare system is a generational or more political and constitutional project. It pays off, if it ever does pay-off, in decades. And striving towards an ideal future is a damn good thing, but it is in conflict with people who are operating on shorter time horizons and thus more constrained possibility spaces.
stinger
The distance between the aspirational and the near-term possible is often discouraging. Nonetheless, our reach should exceed our grasp.
Another Scott
Thanks for this.
I’m reminded of the old saw that the “US pays twice as much for heath care as the rest of the modern world”. Some data I saw said that that was true, at some point in the past. But costs are increasing elsewhere, and the US is bending the curve down. (Increasing costs elsewhere may be, at least in part, a consequence of multinationals spreading their tendrils overseas…)
These are human systems with vast complexity and power. Lasting improvements can only come via sustainable smart tinkering.
Cheers,
Scott.
OverTwistWillie
“Common sense solutions” are the political currency of populist hustlers.
Don’t be that.
dnfree
My husband was the director of a public mental health clinic that subsisted on a patchwork of (always inadequate) state funding, grants, and charity. Clients were charged for treatment on a sliding scale based on their income and what insurance they had.
Some on the board and staff wanted to make treatment free for the poorest clients. My husband disagreed. When it was tried, here’s what happened; some people skipped appointments. If it didn’t cost them anything, it seemingly had no value.
Whether you have an empty but expensive psychiatric appointment (you’re paying the psychiatrist regardless of the fee), or an empty hour appointment for a therapist, you’ve got an unused appointment (when you probably also have a waiting list). When the fee was even just a couple of dollars, people took it as a commitment to show up.
There are also people who run to the doctor for any little thing, or nothing. That costs money. People shouldn’t be priced out of service, afraid to go, but they also shouldn’t abuse it because it’s “free”. It’s not free! Everyone who abuses the service means less availability of service for someone who really needs it.
I know not everyone will agree, but medical services are not an unlimited commodity available to everyone who just happens to show up with an insurance card on a given day. It’s a finite resource that has to be managed, and staff have to be paid. Look how crowded emergency rooms get, free or not.
Fake Irishman
@dnfree:
This is one of the underlying arguments in healthcare provision. There are even some very generous universal systems that charge everyone a sliding scale copay (France) while others eschew out of pocket costs entirely for many services (Canada UK). One of the big problems is that you can use co-pays to cut usage of a system because it creates both a financial and administrative cost, but that barrier doesn’t discriminate well between care that is needed and care that is unnecessary.
J R in WV
Well said, brother David.
@dnfree:
Your comment is also well thought out, and makes great sense to this old person on Medicare and a Humana supplemental policy.
I can see how people don’t value things that are free, and won’t be responsible if they don’t have some skin in the game.
Fake Irishman
@stinger:
Amen. Henry Waxman and his staff always took this to heart in the 1980s as they quietly used budget reconciliation about a half dozen times to expand Medicaid from a limited program whose eligibility standards were constantly getting eaten away by inflation to one that was pretty much universial coverage for all working class kids, most moms of young kids and poor and near poor seniors. I’ve read some of the interviews they did for an HHS oral history project. They’d sit down at the beginning of each congress and literally ask”what can we get away with?” in the face of the Reagan and Bush presidencies and do that. Each reform was small in itself, but together the expansions doubled the size of the program’s coverage of the population and provided a nice road map for the ACA expansions that came two decades later. (Which Waxman played a big role in as well)
The Castle
@Another Scott:
The biggest problem in US health care isn’t the spiraling costs, though that’s bad enough; it’s that we get the worst outcomes in the West despite spending by far the most money. And as bad as out of pocket spending is, most of this waste in the US is actually paid for by the government. It is a scandal and outrageous.
en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita#/media/File:Life_expe…
There are a number of reasons for why this is, but at its core, it’s little different really from our inaction on guns, for example. Our priorities are elsewhere. Plus, old people have government health care already and they vote at the highest rates of any group.
So, sadly, this won’t be fixed just by giving everyone a health care card. The rot is deeper than that.
I don’t know where you see data that suggests the US is bending the cost curve, because that doesn’t seem to be the case, certainly not during the COVID era.
Lobo
What is the low hanging fruit here to grab? But yes the 218-51-1-5 math is always present.
Ohio Mom
@dnfree: Patients/clients playing hooky from meetings with psychiatrists and counselors is I think a category in itself.
These practitioners can’t double-book appointments, which other sorts of practitioners can, and do, for much shorter time slots. It’s probably a relief for other types of doctors to have cancellation, it gives them a chance to catch up and get back on schedule (might not make the bean counters happy but for the person waiting extra for a doctor behind schedule, it’s a gift).
And skipping appointments can be part of the counseling process, a difficult subject is being dealt with so the patient/client ducks out. Haha on them, they are now going to spend at least one session on why they didn’t show up.
So for these reasons, I can see at least a token payment being required. Now I am wondering how this issue is handled in sensible countries with universal coverage.
Another Scott
@The Castle: The data I was thinking of was many years ago in the Before Times. I can’t find it now, but similar graphs are here. E.g. the early-mid1990s to around 2000 percent of GDP numbers. The lesson depends on the time frame, which is probably a function of government policies.
Covid obviously threw a warehouse of monkey wrenches in the trends.
Thanks.
Cheers,
Scott.
CAM-WA
@dnfree: I agree with this, and the cost doesn’t have to be high. It is surprising how people’s behavior changes with even a nominal charge. Take the bag fee that is required by some states. The amount is trivial, but behavior changes. I pretty much always find myself saying to myself, “I’ll be damned if I’ll pay 8 cents for a bag!”
stinger
@Fake Irishman:
Excellent example.
eldorado
‘as long as they spell my name right’ seems to be apropos here
jefft452
“everything else layered on top of that is just another reason to hate democrats”
I think that has proven to be the case
the fact that it cant be changed because of 218-51-1-5 does not mean people wont hate Ds if they have to jump through hoops
And telling pissed off people “218-51-1-5” will just piss them off more
No, I dont have a solution, but i do know its a problem
StringOnAStick
I have a friend from Poland who lived there until her 30’s and then emigrated to the US. She and her husband still have family there, and her FIL gets his daily social interaction by always going to the the doctor’s office, even creating issues just so he can go get some attention from someone. She has some negative things to say about the kind of plan that triggered David’s post, mainly that without some way to make it cost at least a little, there will be patients like this who take up system capacity and don’t need to be there everyday just because they are lonely.
I used to do massage therapy, and for awhile before I was licensed I had to do several hundred uncompensated hours of work as part of the process. When something is free, people will blow you off or not show up; once I could charge, no one ever blew off an appointment because of the fee for doing so. The ones who were used to getting it for free were deeply unappreciative of now having to pay for it and eventually fell off.
Betsy
You make so much sense, as usual!