Tom Coburn's ideas for healthcare reform

[myp]

The Congressman and former physician offers his views on how to improve the medicare system: http://marginalrevolution.com/margi...coburn-samizdat-medicare-reform-proposal.html

When asked why he hasn't introduced it in a bill- because there isn't enough political support.

 

[=Zoomer=]

The Congressman and former physician offers his views on how to improve the medicare system: http://marginalrevolution.com/margi...coburn-samizdat-medicare-reform-proposal.html

When asked why he hasn't introduced it in a bill- because there isn't enough political support.

Interesting way to change the "way" healthcare is paid for, but not necessarily "how much". I can't see the approach lowering costs, but it sounds like a good idea to improve outcomes and make sure every patient a doctor sees gets more attention.

What we really need to lower costs is either a healthy dose of government "competition" via exchanges (which would reduce insurance profits I imagine), or Medicare Part "E" for everyone, and eliminate the middle-man all together.

 

[myp]

I think one of the first things that should happen is to allow for more medical schools to open in the US and to increase immigration for doctors from abroad. The greater supply alone should put downward pressure on prices.

 

[=Zoomer=]

I think one of the first things that should happen is to allow for more medical schools to open in the US and to increase immigration for doctors from abroad. The greater supply alone should put downward pressure on prices.

Yes, that would be great in the long run. Not sure how effective it would be in the short term, but either way it's a good idea.

The combination of single-payor and his idea would be powerful. Ah well, like he says, there's no political will for it at the moment. Instead of trying to cure the problem, they're focused on reducing coverage and limiting access. That will do nothing to cure the cost, and will create collateral problems of it's own.

 

[myp]

I disagree on single payer. I think that it would be tremendously detrimental to health outcomes, especially in the long run. I am for more insurance competition, the continued uncoupling of healthcare coverage and employment, and less perverse incentives for providers.

 

[=Zoomer=]

I disagree on single payer. I think that it would be tremendously detrimental to health outcomes, especially in the long run. I am for more insurance competition, the continued uncoupling of healthcare coverage and employment, and less perverse incentives for providers.

In my opinion, there is no amount of competition that will "force" everyone to be financially responsible for their healthcare needs. It will never be financially equitable to society to be on the hook for their own needs, and then forced to pay taxes to cover those that cannot/will not pay.

Here's the rub...Unless we are willing to let someone die if they cannot pay for care, then there will always be those that don't, and tax dollars used to pay those bills. The only equitable solution is to make healthcare a non-profit concern administered by the government, and paid for though taxes.

Currently, Medicare is running at under a 5% administrative cost versus approx 30% thru the insurance industry. Hard to see any amount of competition accomplishing that.

In addition, the United States ranks 37th (who) in overall healthcare, just after Morocco. That's not such a great outcome considering our care costs over twice as much. I hear all the time "Well, why does everyone come to the U.S. for treatment then?"..... The short answer is, they don't. Of the top 50 countries in the world travelers go to get specialized care, the U.S. isn't even on the list. So, imo, there is nothing advantageous about utilizing the profit model to address the healthcare issue.

There's a reason why the rest of the industrialized world uses socialism to administer it.

 

[myp]

In my opinion, there is no amount of competition that will "force" everyone to be financially responsible for their healthcare needs. It will never be financially equitable to society to be on the hook for their own needs, and then forced to pay taxes to cover those that cannot/will not pay.

Here's the rub...Unless we are willing to let someone die if they cannot pay for care, then there will always be those that don't, and tax dollars used to pay those bills. The only equitable solution is to make healthcare a non-profit concern administered by the government, and paid for though taxes.

Currently, Medicare is running at under a 5% administrative cost versus approx 30% thru the insurance industry. Hard to see any amount of competition accomplishing that.

In addition, the United States ranks 37th (who) in overall healthcare, just after Morocco. That's not such a great outcome considering our care costs over twice as much. I hear all the time "Well, why does everyone come to the U.S. for treatment then?"..... The short answer is, they don't. Of the top 50 countries in the world travelers go to get specialized care, the U.S. isn't even on the list. So, imo, there is nothing advantageous about utilizing the profit model to address the healthcare issue.

There's a reason why the rest of the industrialized world uses socialism to administer it.

You bring up a lot of points, so I will try to address them by splitting them up into major points:

On competition- you take current costs and use it as an example for why competition won't work, but the markets are heavily cut up and regulated as is hindering competition. Insurance companies can't even sell across state lines- not exactly competition friendly. Also the insurance admin costs aren't a good example of anything except the oligopolies they have due to lack of competition.

Financial responsibility- Society will always cover the gaps regardless of system. In the US, emergency medicine is always done without worrying about charges. And it should be that way. Now you can solve this by perhaps having an emergency medicine insurance mandate or something. There are many other solutions than just full-out single payer or even the individual mandate.

US health ranking- There are so many variables that go into this. The US can't be compared apples and oranges to European countries or anyone. We are a different culture with different priorities and different needs. For one we are a much more heterogeneous population than any European country. Now this isn't to say that things can't be improved because they certainly can, but looking at a country a fourth of the size doesn't always make sense.

One of the reasons that costs are so high here is culture. Americans believe in fighting until the end- this leads to treatment after treatment to extend our lives, even for the elderly. End of life costs are a HUGE chunk of overall healthcare spending and what many studies have found is that in places like France, people are much less likely to fight, seeing death as something that will just happen. They in turn forego a lot of those costs. Atul Gawande has written about this topic in much more detail- I suggest his work in general on the healthcare system.

Another reason costs are high is because of doctor pay structure and risk structure, but that too doesn't haven't to do with single v. multipayer.

As for specialized treatments, we don't have the highest medical tourism numbers because it is quite costly here, but if you look at those for whom money is no object, the US easily has some of the top surgical and medical teams in the world and people do come here for treatment when they can afford it.

 

[=Zoomer=]

You bring up a lot of points, so I will try to address them by splitting them up into major points:

On competition- you take current costs and use it as an example for why competition won't work, but the markets are heavily cut up and regulated as is hindering competition. Insurance companies can't even sell across state lines- not exactly competition friendly. Also the insurance admin costs aren't a good example of anything except the oligopolies they have due to lack of competition.

I believe you've just given me your opinion that competition would be more efficient if given the chance. There has never been any evidence to support it (or refute it for that matter), so it has to be an opinion.

Medical costs have never gone down. Before healthcare became a "benefit of employment", cost still rose. Before there "was" health insurance, costs continued to rise. In fact, costs have continually risen since doctors "unionized" and the AMA was created in the early 1900's. Before the doctor's union, medicine was a humanitarian occupation (not making a value judgement on quality of care here). My point is, capitalism as applied to healthcare has never shown the propensity to be cost effective.

Financial responsibility- Society will always cover the gaps regardless of system. In the US, emergency medicine is always done without worrying about charges. And it should be that way. Now you can solve this by perhaps having an emergency medicine insurance mandate or something. There are many other solutions than just full-out single payer or even the individual mandate.

The fact that society WILL always cover the gaps does not change the fact that the burden of cost is on those that do pay to have to make up for those that don't. The difference in single payor is, a) it's not an "option" to not be covered, and you pay your "equitable" share of the costs and nothing more. In a free market approach, there is ALWAYS the option not to buy, which puts the extra burden of cost on those that do pay. You may *think* that because someone doesn't pay the hospital just absorbs it, but that is not true. They write it off their taxes, which amounts to reduced tax revenue, and ultimately higher taxes on others.

US health ranking- There are so many variables that go into this. The US can't be compared apples and oranges to European countries or anyone. We are a different culture with different priorities and different needs. For one we are a much more heterogeneous population than any European country. Now this isn't to say that things can't be improved because they certainly can, but looking at a country a fourth of the size doesn't always make sense.

I'm not quite sure how you're trying to separate the U.S. from other countries. Seems a bit vague. I realize social morays are different country by country, and lifestyles i suppose as well. I can see this leading to "different" healthcare needs and outcomes. Where I'm confused is, the WHO rankings evaluate every country on the same basis. There are many categories ranked individually, but always equally against other countries. How is this not an accurate appraisal? I believe everyone in the world cares about healthcare in much the same way. I've lived in Europe, Asia, Australia, and the U.S., and I've yet to see anyone fail to seek medical care when they need it.

I still feel the important point is that, no matter what the culture is, it has it's own unique set of medical "issues". It should not cost more than necessary just to satisfy some ideological predisposition to capitalism. The rankings attempt to compare how each country deals with them. That is all.

One of the reasons that costs are so high here is culture. Americans believe in fighting until the end- this leads to treatment after treatment to extend our lives, even for the elderly. End of life costs are a HUGE chunk of overall healthcare spending and what many studies have found is that in places like France, people are much less likely to fight, seeing death as something that will just happen. They in turn forego a lot of those costs. Atul Gawande has written about this topic in much more detail- I suggest his work in general on the healthcare system.

Another reason costs are high is because of doctor pay structure and risk structure, but that too doesn't haven't to do with single v. multipayer.

There is one overriding reason costs are high. Greed. That is the domain of capitalism. And it should be. It just shouldn't be applied to healthcare on many levels.

As for specialized treatments, we don't have the highest medical tourism numbers because it is quite costly here, but if you look at those for whom money is no object, the US easily has some of the top surgical and medical teams in the world and people do come here for treatment when they can afford it.

Yes, cost is one reason they don't come, but surprisingly the majority of that travel is for highly specialized procedures in which the country excels. For example, Thailand is recognized for certain heart surgeries. Austria and other European and S. Africa for other treatments. Mexico is highly regarded in some bone disorders. One of the primary reasons for this is the very fact that these doctors are doctors more often for humanitarian reasons (over money). Not that they are poor of course....

 

[myp]

I believe you've just given me your opinion that competition would be more efficient if given the chance. There has never been any evidence to support it (or refute it for that matter), so it has to be an opinion.

Well there is a ton of evidence that competition is more efficient in markets in general. When it comes to healthcare, there are two paths you can take- your single payer idea is also an opinion. There isn't going to be empirical evidence for any potential solution in this case. But it comes down to statistics and facts and in practice also experimentation. I say we experiment with more competition before being bogged down to single payer.

Medical costs have never gone down. Before healthcare became a "benefit of employment", cost still rose. Before there "was" health insurance, costs continued to rise. In fact, costs have continually risen since doctors "unionized" and the AMA was created in the early 1900's. Before the doctor's union, medicine was a humanitarian occupation (not making a value judgement on quality of care here). My point is, capitalism as applied to healthcare has never shown the propensity to be cost effective.

Actually there is some newer data suggesting at least the rate of growth in medical costs is coming down. I forgot where I saw that, I'll link it if I remember. But that is besides the point. Yes, med costs have gone up a lot, but so has med knowledge and treatment options. With more complex options and more options in general for more diseases, obviously costs will go up. There are some costs we can bring down, but not all costs.

The fact that society WILL always cover the gaps does not change the fact that the burden of cost is on those that do pay to have to make up for those that don't. The difference in single payor is, a) it's not an "option" to not be covered, and you pay your "equitable" share of the costs and nothing more. In a free market approach, there is ALWAYS the option not to buy, which puts the extra burden of cost on those that do pay. You may *think* that because someone doesn't pay the hospital just absorbs it, but that is not true. They write it off their taxes, which amounts to reduced tax revenue, and ultimately higher taxes on others.

First of all, who do you think pays for the poor's healthcare even in single payer? Let me tell you, it is still others You aren't really going to be able to get around that.

Economically, the argument for single payer is in increasing the pool of cash (and risk). The well-off (both money and healthwise) still subsidize the worse-off (those without money and in bad health). Insurance works this way too, but with several, smaller pools of cash.

I'm not quite sure how you're trying to separate the U.S. from other countries. Seems a bit vague. I realize social morays are different country by country, and lifestyles i suppose as well. I can see this leading to "different" healthcare needs and outcomes. Where I'm confused is, the WHO rankings evaluate every country on the same basis. There are many categories ranked individually, but always equally against other countries. How is this not an accurate appraisal? I believe everyone in the world cares about healthcare in much the same way. I've lived in Europe, Asia, Australia, and the U.S., and I've yet to see anyone fail to seek medical care when they need it.

My point with apples and oranges was more about the costs. My point with the WHO rankings was that it is harder to implement a system for 300 million people vs. 50 million people. It is even harder when the 300 million live in vastly different regions with vastly different risks and come from vastly different gene pools. Risk assessment is a lot easier in a homogeneous population.

I still feel the important point is that, no matter what the culture is, it has it's own unique set of medical "issues". It should not cost more than necessary just to satisfy some ideological predisposition to capitalism. The rankings attempt to compare how each country deals with them. That is all.

I am not making an ideological argument. Are you making one with single payer?

There is one overriding reason costs are high. Greed. That is the domain of capitalism. And it should be. It just shouldn't be applied to healthcare on many levels.

I disagree. Insurance companies make money on investments from the pool, not on premiums. The government operates at a deficit. A large portion of the country's hospitals are non-profits. Doctors are incentivized to order more tests as it reduces their chances of a malpractice suit if they throw a million darts at the board. The US subsidizes the world in drug innovation with its patent policies. And on and on. I don't think the major issue here is greed. I think it is a broken system with perverse incentives. If doctors were all about greed, they probably would have gone into finance- much more money to make there and a lot less stress

Yes, cost is one reason they don't come, but surprisingly the majority of that travel is for highly specialized procedures in which the country excels. For example, Thailand is recognized for certain heart surgeries. Austria and other European and S. Africa for other treatments. Mexico is highly regarded in some bone disorders. One of the primary reasons for this is the very fact that these doctors are doctors more often for humanitarian reasons (over money). Not that they are poor of course....

Lol, I don't think doctors here are the evil, greedy robber barons you make them out to be. It just isn't true.

If you look at the best-of-the-best on the aggregate, I'd say the US easily has the best docs.


One point that we haven't brought up, but is important is rationing. It is a sticky subject, but when you look at things like wait times for certain procedures (especially orthopedic like hip replacements) in a country like the UK- it is horrible. There are plenty of people that can't get hip replacements at all just because the government doesn't want to pay for it. In the US on the other hand, you can walk in and probably get one scheduled within the month. Of course this leads to another question on whether Americans overuse healthcare too. A very complex situation with very complex variables and a lot of noise. Makes it hard to come up with a solution, but certain things standout in the data.

 

[tecoyah]

Someone take this, and tell me how the ACA is a not a step in the right direction?

 

[myp]

Someone take this, and tell me how the ACA is a not a step in the right direction?

I think in some areas it is a step in the right direction, in others not (overall not in my opinion as I would have preferred more cost-cutting measures and no individual mandate). The thing with the ACA is what it will be in practice is still yet to be seen as states decide on the SCOTUS-fueled ultimatum for medicaid, how the exchanges actually get set up, and legal challenges continue.