Just curious how much would a health insurance plan comparable to what I get for "free" cost in the United States?
My work for example, if we went through my company instead of my wife's for a family the monthly premium is a little over $1,100.00! The company pays $800 or so, and my share would be about $300.
My whole life
was like a picture
of a sunny day
“We can complain because rose bushes have thorns, or rejoice because thorn bushes have roses.”
― Abraham Lincoln
Under a universal health care system the only true cost to us all will be the forfeiture of our basic rights and freedoms to choose ie...shots to take, medication to take, etc... With the government in every other area of our daily lives today, do you really want to invite them into your doctors office too? The current system is by no means any better ,but at least the money that I do pay every month allows me the privilege to make up my own mind in determinining what I think is best. In my opinion, debating over which system is better is so pointless and shallow because regardless of whatever side your on what is really being weighed here are two enormous piles of shit. What everyone should be discussing and demanding is a health care system that is focused on cureing people and not just treating them with overpriced drugs prescriptions that were never intended to completely fix what has been ailing ya from the jump.
FYI-all comments were in no way directed towards the person who posted this thread.
Under a universal health care system the only true cost to us all will be the forfeiture of our basic rights and freedoms to choose ie...shots to take, medication to take, etc...
Who says you forfit your rights? I don't have to get a flu shot if I don't want to, nor do I have to get treatment if I don't want to.
My work for example, if we went through my company instead of my wife's for a family the monthly premium is a little over $1,100.00! The company pays $800 or so, and my share would be about $300.
$1,100 a month? That is crazy. Plus I am sure there is all kinds of other fees on top of that. My entire montly income tax deduction is less than that.
National Health Insurance
Liberal Benefits, Conservative Spending
by Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD
FEW WOULD dispute that our health care system is deeply troubled. Thirty-nine million Americans are completely uninsured and millions more have inadequate coverage. After a brief lull, health care costs have resumed their exuberant growth; health maintenance organizations (HMOs) have fallen to the basement of public esteem and have failed to contain costs; commercial pressures threaten medicine's best traditions; and healing has become a spectator sport, with physicians and patients performing before a growing audience of bureaucrats and reviewers. Opinion on solutions is more divided.
Debate over health care reform has been muted since the defeat of the Clinton Administration Rube Goldberg scheme for universal coverage. But the fast developing health care crisis--business leaders grappling with rapidly rising premiums, workers and unions facing cutbacks in coverage, governments confronting deficits, and a sharp upturn in the number unemployed and uninsured--promises to spur new interest in reform.
We advocate a fundamental change in health care financing, national health insurance (NHI), because we are convinced that lesser measures will fail.
In the 35 years since the implementation of Medicare and Medicaid, a welter of patchwork reforms has been tried. Health maintenance organizations and diagnosis related groups promised to contain costs and free up funds to expand coverage. Billions of dollars have been allocated to expanding Medicaid and similar programs for children. Both Medicare and Medicaid have tried managed care. Oregon essayed rationing in its Medicaid program, Massachusetts and Hawaii passed laws requiring all employers to cover their workers, Tennessee promised nearly universal coverage, and several states have implemented high-risk pools to insure high-cost individuals. For-profit firms pledged to bring business-like efficiency to running HMOs, hospitals, dialysis clinics, and nursing homes. And market competition has roiled health care's waters.
None of these initiatives has made a dent in the number of uninsured, durably controlled costs, or lessened the inexorable bureaucratization of medicine.
All such patchwork reforms founder on a simple problem: expanding coverage must increase costs unless resources are diverted from elsewhere in the system. With US health care costs nearly double those of any other nation and rising more rapidly,1 and the economy gone sour, large infusions of new money are unlikely.
Absent new money, patchwork reforms can only expand coverage by siphoning resources from existing clinical care. Advocates of managed care and market competition once argued that their strategy could accomplish this by trimming clinical fat. Unfortunately, new layers of bureaucrats have invariably overseen the managed care "diet" prescribed for clinicians and patients. Such cost management bureaucracies are not only intrusive but expensive, devouring virtually all of the clinical savings.
Resources seep inexorably from the bedside to the executive suite. The shortage of bedside nurses coexists with a proliferation of RN utilization reviewers. Productivity pressures mount for clinicians, while colleagues who have withdrawn from the bedside to the executive suite rule our profession.
Bureaucracy now consumes nearly 30% of our health care budget.2-4
The latest policy nostrums--medical savings accounts and voucher schemes like President Bush's "premium support" proposal for Medicare--would further amplify bureaucracy and limit care. Medical savings accounts discourage preventive and primary care, while failing to curb the high cost of care for severe illnesses (which account for most health spending). Such plans would also require insurers to start keeping track of all out-of-pocket spending, while retaining their existing bureaucracy, and would slash the cross-subsidy from healthy enrollees to the sick.
Voucher programs are thinly veiled mechanisms to cut care. The vouchers offered are invariably too skimpy to purchase fully adequate coverage, forcing lower-income individuals into substandard plans. Voucher schemes also posit that frail elders and other vulnerable patients will make wise purchasing decisions from a welter of confusing insurance options. Finally, vouchers would boost insurance overhead by shifting people from group plans (ie, Medicare or employer groups) into the individual insurance market where overhead averages more than 35% of premiums.5
WHY NHI?
The fiscal case for NHI arises from the observation that health care's enormous bureacratic burden is a peculiarly American phenomenon. No nation with NHI spends even half as much administering care, nor tolerates the bureaucratic intrusions in clinical care that have become routine in the United States.
Our biggest HMOs keep 20%, even 25%, of premiums for their overhead and profit6; Canada's NHI has 1% overhead2 and even Medicare takes less than 4%.7 And HMOs inflict mountains of paperwork on physicians and hospitals. The average US hospital spends one quarter of its budget on billing and administration,4 nearly twice the average in Canada. American physicians spend nearly 8 hours per week on paperwork, and employ 1.66 clerical workers per physician,8 far more than in Canada.
Reducing our bureaucratic apparatus to Canadian levels would save 10% to 15% of current health care spending, at least $120 billion annually, enough to fully cover the uninsured and upgrade coverage for those now underinsured. Proponents of NHI,9 disinterested civil servants,10, 11 and even skeptics12 all agree on this point.
HOW NHI? Unfortunately, piecemeal tinkering cannot achieve significant bureaucratic savings. The key to administrative simplicity in Canada (and other nations) is single-source payment. Canadian hospitals (mostly private, nonprofit institutions) do not bill for individual patients. They are paid a global annual budget to cover all costs, much as a fire department is funded in the United States. Physicians (most of whom are in private practice) bill by checking a box on a simple insurance form. Fee schedules are negotiated annually between provincial medical associations and governments. All patients have the same coverage.
Unfortunately, during the 1990s Canada's program was starved of funds by governments responsive to pressure from the healthy and wealthy who sought to avoid cross-subsidizing care for the sick and poor. Where once Canadian and US health care spending were comparable, today, Canada spends barely half (per capita) what we do.1 Shortages of expensive, high-technology care have resulted. Yet, Canada's health outcomes remain better than ours (eg, life expectancy is 2 years longer1), and most quality comparisons indicate that Canadians enjoy care equivalent to that for insured Americans. A system structured like Canada's, but with double the funding, could provide high-quality care without the waits or shortages that Canadians have experienced.
The NHI that we propose would create a single tax-funded comprehensive insurer in each state, federally mandated but locally controlled. Everyone would be fully insured for all medically necessary services, and private insurance duplicating the NHI coverage would be proscribed (as is currently the case with Medicare). The current byzantine insurance bureaucracy with its tangle of regulations and wasteful duplication would be dismantled. Instead, the NHI trust fund would dispense all payments, and central administrative costs would be limited by law to less than 3% of total health care spending.
Each hospital and nursing home would negotiate an annual global budget with the NHI, based on past expenditures, projected changes in costs and use, and proposed new and innovative programs. Many hospital administrative tasks would disappear. There would be no hospital bills to keep track of, no eligibility determination, and no need to attribute costs and charges to individual patients. Cost shifting would be pointless as there would be nowhere to shift costs to.
Clinics and group practices could elect to be paid fee-for-service, or receive global budgets similar to hospitals. While HMOs that merely contract with providers for care would be eliminated, those that actually employ physicians and own clinical facilities could receive global budgets, fee-for-service, or capitation payments (with the proviso that capitation payments could not be diverted to profits or exorbitant executive compensation).
As in Canada, physicians could elect to be paid on a fee-for-service basis, or receive salaries from hospitals, clinics, or HMOs.
Properly structured, NHI would not raise costs; administrative savings would pay for the expanded coverage. While NHI would require new taxes, these would be fully offset by a decrease in insurance premiums and out-of-pocket costs. Moreover, the additional tax burden would be smaller than is usually appreciated, since nearly 60% of health care spending is already tax supported (vs roughly 70% in Canada). Besides Medicare, Medicaid, and other explicit public programs, our governments fund tax subsidies for private insurance that exceed $100 billion annually.13 In addition, local, state, and federal agencies that purchase private coverage for government workers account for 22.5% of total employer health care spending (D.U.H. and S.W., unpublished analysis of Current Population Survey data from the US Census Bureau, 2001).
Demonstration projects in 1 or more states might precede national implementation of NHI. Initially, funding might mimic existing patterns to minimize economic disruption, but all payments would be funneled through the NHI trust fund. Thus, Medicare and Medicaid moneys, as well as current government expenditures for employee health benefits, would go to the trust fund. Employers would pay a tax equivalent to the average now spent for health benefits. In the long run, a shift to a more progressive, income tax funding base would provide a fairer and more efficient revenue stream.
The NHI we propose faces important political obstacles. The virtual elimination of private health insurance will evoke stiff opposition from insurance firms. Similarly, investor-owned hospitals and drug firms fear that NHI would curtail their profits.
Practical problems in implementing NHI also loom. The financial viability of the system we propose is critically dependent on achieving and maintaining administrative simplicity. Canada's macromanagement approach to cost control -- enforcing overall budgetary limits is inherently less administratively complex than our current micromanagement approach, with its case-by-case scrutiny of billions of individual expenditures and encounters. However, even under NHI, vigilance (and statutory limits) would be needed to curb the tendency of bureaucracy to reproduce and amplify itself.
National health insurance could solve the cost-vs-access conflict by slashing bureaucratic waste. It would reorient the way we pay for care, and eliminate financial barriers to access. National health insurance could restore the physician-patient relationship, offer patients a free choice of physicians and hospitals, and free physicians from the bonds of managed care.
How many more failed patchwork reforms, how many more patients turned away from care they cannot afford, how many trillions of dollars squandered on malignant bureaucracy, before we adopt the only viable solution: NHI?
Steffie Woolhandler, MD, MPH
Cambridge
David U. Himmelstein, MD
1493 Cambridge St
Cambridge, MA 02139
REFERENCES
1. Organization for Economic Cooperation and Development. OECD Health Data 2001 [computer database]. Paris, France: Organization for Economic Cooperation and Development; 2001.
2. Woolhandler S, Himmelstein DU. The deteriorating administrative efficiency of US health care. N Engl J Med. 1991;324:1253-1258.
MEDLINE
3. Himmelstein DU, Lewontin JP, Woolhandler S. Who administers? who cares? medical administrative and clinical employment in the United States and Canada. Am J Public Health. 1996;86:172-178. MEDLINE
4. Woolhandler S, Himmelstein DU. Costs of care and administration at for-profit and other hospitals in the United States. N Engl J Med. 1997;336:769-774. MEDLINE
5. Pauly MV, Percy AM. Cost and performance: a comparison of the individual and group health insurance markets. J Health Polit Policy Law. 2000;25:9-26. MEDLINE
6. Special report. BestWeek Life/Health. April 12, 1999.
7. Heffler S, Levit K, Smith S, et al. Health spending growth up in 1999: faster growth expected in the future. Health Aff (Millwood). 2001;20:193-203. MEDLINE
8. Remler DK, Gray BM, Newhouse JP. Does managed care mean more hassles for physicians? Inquiry. 2000;37:304-316. MEDLINE
9. Grumbach K, Bodenheimer T, Woolhandler S, Himmelstein DU. Liberal benefits, conservative spending: the Physicians for a National Health Program proposal. JAMA. 1991;265:2549-2554. MEDLINE
10. US General Accounting Office. Canadian Health Insurance: Lessons for the United States. Washington, DC: US Government Printing Office; 1991. Publication GAO/HRD-91-90.
11. Congress of the United States Congressional Budget Office. Universal Health Insurance Coverage Using Medicare's Payment Rates. Washington, DC: US Government Printing Office; 1991.
12. Sheils JF, Haught RA. Analysis of the Costs and Impact of Universal Health Care Coverage Under a Single Payer Model for the State of Vermont. Falls Church, Va: Lewin Group Inc; August 2001.
13. Sheils J, Hogan P. Cost of tax-exempt health benefits in 1998. Health Aff (Millwood). 1999;18:176-181. MEDLINE
Under a universal health care system the only true cost to us all will be the forfeiture of our basic rights and freedoms to choose ie...shots to take, medication to take, etc... With the government in every other area of our daily lives today, do you really want to invite them into your doctors office too? The current system is by no means any better ,but at least the money that I do pay every month allows me the privilege to make up my own mind in determinining what I think is best. In my opinion, debating over which system is better is so pointless and shallow because regardless of whatever side your on what is really being weighed here are two enormous piles of shit. What everyone should be discussing and demanding is a health care system that is focused on cureing people and not just treating them with overpriced drugs prescriptions that were never intended to completely fix what has been ailing ya from the jump.
FYI-all comments were in no way directed towards the person who posted this thread.
i currently live in Canada that has universal health care and i am not forced to take any shots or what meds to take. i talk to my doctor and we make a decision about what is good for me. i don't like any medication but i have to take one for a rare condition that i have. i talked with my doctor abotu this med and agree to take it for a trial run. this medication has saved my life.
now i agree with you that we should be demanding a health care system that cures people but i will go one step further and say that we need a health care system that prevents people from getting sick. PREVENTION IS THE KEY.
Demand that pop is not served to our children, have healthy food in schools. bring gym classes back to schools. clean the enviroment so that our food and ourselves don't have all the toxins. the best way to cure something i sto not having affect us any more.
People demand freedom of speech to make up for the freedom of thought which they avoid."
- Soren Aabye Kierkegaard (1813-1855)
If you haven't got anything nice to say about anybody, come sit next to me."
- Alice Roosevelt Longworth (1884-1980)
I really think the biggest problem is that we have a fairly small population and a huge area. So places like Manitoba only have one medical school for the whole province (or Alberta which only has 2. When you consider that more and more doctors are retiring if the new doctors can't fill the need there will be a problem. Plus I hear all the time about people who are super smart but can't get into medical school because there are not enough spaces. I think trying to create more doctors at home is a way more efficient solution than to try and compete with American salary rates.
My point was that as long as the opportunities are there for them, they'll take them. Why wouldn't they? Once that incentive is gone, it's a much less attractive option. If the U.S. institutes a similar system to ours, the majority of the doctors who leave for the money won't have a reason to anymore.
That report is definitely good news but it only refers to the last few years. What about the previous 30? According to that report, 207 doctors left last year, so if 207 doctors leave every year (some years have been as high as 550), that's well over 6,000 doctors and that's a very conservative estimate. I'm sure they all didn't leave for the same reason, but the majority left for financial opportunities/gain. Wouldn't you agree that if we had 6,000 more doctors in Canada right now, we'd be in a lot better shape?
I never said we need to try and compete with American salaries. That's impossible in a non-profit driven medical system and I agree 100% that we need to train more doctors, but keeping them is the trick.
#==(o )
You are not your job.
You are not how much money you have in the bank.
You are not the car you drive.
You are not the contents of your wallet.
You are not your fucking khakis.
Under a universal health care system the only true cost to us all will be the forfeiture of our basic rights and freedoms to choose ie...shots to take, medication to take, etc... With the government in every other area of our daily lives today, do you really want to invite them into your doctors office too?
Who would be taking away any freedoms??? The doctor experience wouldn't be much different, but instead of the doctor being reimbursed by the insurance company, they will get reimbursed from the gov't. I think you are confused and paranoid by what universal health care is.
Right not you don't really have total freedom anyway... if your insurance company won't pay for a procedure, chances are you're not getting it.
My whole life
was like a picture
of a sunny day
“We can complain because rose bushes have thorns, or rejoice because thorn bushes have roses.”
― Abraham Lincoln
it'll never happen in the us. those with money control the government and we'll never stand for the high taxes. let the poor work like we had to.
I don't really buy that argument. Based on the premium cost that blackredyellow gave he pays more for health insurance than I do for income tax (and my income taxes cover more than just health care).
My point was that as long as the opportunities are there for them, they'll take them. Why wouldn't they? Once that incentive is gone, it's a much less attractive option. If the U.S. institutes a similar system to ours, the majority of the doctors who leave for the money won't have a reason to anymore.
That report is definitely good news but it only refers to the last few years. What about the previous 30? According to that report, 207 doctors left last year, so if 207 doctors leave every year (some years have been as high as 550), that's well over 6,000 doctors and that's a very conservative estimate. I'm sure they all didn't leave for the same reason, but the majority left for financial opportunities/gain. Wouldn't you agree that if we had 6,000 more doctors in Canada right now, we'd be in a lot better shape?
I never said we need to try and compete with American salaries. That's impossible in a non-profit driven medical system and I agree 100% that we need to train more doctors, but keeping them is the trick.
the us cannot limit a persons earnings. that's our basic freedom. why do you think it's hard to find an american doctor in america? people come here for the money. and that's the bottom line.
I don't really buy that argument. Based on the premium cost that blackredyellow gave he pays more for health insurance than I do for income tax (and my income taxes cover more than just health care).
but is your population equal to the us? is your income over $60K or $100K? if you make $25K/year; it's a great deal for you. how are your businesses taxed? how many unemployed people do you have that don't contribute anything? there are many factors that most people don't see. if my business is taxed by profits; i won't show any profits. i do that every tax season. when i take a holiday; i talk to someone about buffalo meat and write the trip off as a business trip. in 2006 i bought a 1 ton truck to knock $50K off my profits then depreciate it every year. i'll reinvest in more land or more buffalo. there's so many loopholes that a million dollar business can come out looking like it breaks almost even.
my state; nevada; doesn't tax people or businesses. so the federal government will have to go about this alone.
i just don't see it happening. what ever happened to hillarycare from the 90's?
but is your population equal to the us? is your income over $60K or $100K? if you make $25K/year; it's a great deal for you. how are your businesses taxed? how many unemployed people do you have that don't contribute anything? there are many factors that most people don't see. if my business is taxed by profits; i won't show any profits. i do that every tax season. when i take a holiday; i talk to someone about buffalo meat and write the trip off as a business trip. in 2006 i bought a 1 ton truck to knock $50K off my profits then depreciate it every year. i'll reinvest in more land or more buffalo. there's so many loopholes that a million dollar business can come out looking like it breaks almost even.
my state; nevada; doesn't tax people or businesses. so the federal government will have to go about this alone.
i just don't see it happening. what ever happened to hillarycare from the 90's?
Wow with that many loopholes it is no wonder the US runs massive deficits every year.
fuck no. worst idea ever. standing in long lines. not being able to choose who I go to. higher taxes. tons of red tape. fuck that fuck that fuck that.
ever been to the DMV?
you have absolutely no idea what you're talking about. perhaps this is the problem with many americans when it comes to this issue. they don't understand how things actually work outside their own country.
you can choose where you go. you do pay tax. there's no red tape. show your health card and you're in. simple.
Yay in the sense that I would love to see every individual in this countryhave to ability to obtain affordable healthcare coverage. Nay in the sense that i do not want our federal government within a 1,000 miles of providing healthcare coverage to the people.
"When one gets in bed with government, one must expect the diseases it spreads." - Ron Paul
I was watching a documentary recently and a man from Germany was being interviewed. He revealed that he made around 40,000 euros a year and paid less in taxes than the average American in the same income bracket. Germany has universal health care. It goes to show when you shift your priorities from meddling in world affairs and deploying troops throughout the globe to taking care of your own how easy universal health care can be.
Yay in the sense that I would love to see every individual in this countryhave to ability to obtain affordable healthcare coverage. Nay in the sense that i do not want our federal government within a 1,000 miles of providing healthcare coverage to the people.
but is your population equal to the us? is your income over $60K or $100K? if you make $25K/year; it's a great deal for you. how are your businesses taxed? how many unemployed people do you have that don't contribute anything? there are many factors that most people don't see. if my business is taxed by profits; i won't show any profits. i do that every tax season. when i take a holiday; i talk to someone about buffalo meat and write the trip off as a business trip. in 2006 i bought a 1 ton truck to knock $50K off my profits then depreciate it every year. i'll reinvest in more land or more buffalo. there's so many loopholes that a million dollar business can come out looking like it breaks almost even.
my state; nevada; doesn't tax people or businesses. so the federal government will have to go about this alone.
i just don't see it happening. what ever happened to hillarycare from the 90's?
...
So... you admit to not paying you fair share by cheating the system. and you complain, "How many unemployed people do you have that don't contribute anything?"
...
Gee... thanx.
...
for nothing.
Allen Fieldhouse, home of the 2008 NCAA men's Basketball Champions! Go Jayhawks!
Hail, Hail!!!
if my business is taxed by profits; i won't show any profits. i do that every tax season. when i take a holiday; i talk to someone about buffalo meat and write the trip off as a business trip. in 2006 i bought a 1 ton truck to knock $50K off my profits then depreciate it every year. i'll reinvest in more land or more buffalo. there's so many loopholes that a million dollar business can come out looking like it breaks almost even.
For being such a business savy person you're terminology could use some work...
It is not a loophole you describe, rather common tax law that every business adheres to. As far as the government is concerned either invest your income or get taxed on them it is very simple.
Yay in the sense that I would love to see every individual in this countryhave to ability to obtain affordable healthcare coverage. Nay in the sense that i do not want our federal government within a 1,000 miles of providing healthcare coverage to the people.
The problem is that you can't have the first part without the second part. As long as private insurance companies can decide who they want to insure and what procedures they want to insure, you will never have affordable healthcare to everyone.
My whole life
was like a picture
of a sunny day
“We can complain because rose bushes have thorns, or rejoice because thorn bushes have roses.”
― Abraham Lincoln
The problem is that you can't have the first part without the second part. As long as private insurance companies can decide who they want to insure and what procedures they want to insure, you will never have affordable healthcare to everyone.
Unfortunetly that is true but I will never support government funded or managed healthcare. Not because I don't want my taxes going to insure someone else, but because anything our government touches will undoubtly become this over-blown beaucratic cluster-fuck that will end up costing the public more.
"When one gets in bed with government, one must expect the diseases it spreads." - Ron Paul
Comments
My work for example, if we went through my company instead of my wife's for a family the monthly premium is a little over $1,100.00! The company pays $800 or so, and my share would be about $300.
was like a picture
of a sunny day
“We can complain because rose bushes have thorns, or rejoice because thorn bushes have roses.”
― Abraham Lincoln
FYI-all comments were in no way directed towards the person who posted this thread.
Who says you forfit your rights? I don't have to get a flu shot if I don't want to, nor do I have to get treatment if I don't want to.
$1,100 a month? That is crazy. Plus I am sure there is all kinds of other fees on top of that. My entire montly income tax deduction is less than that.
Liberal Benefits, Conservative Spending
by Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD
FEW WOULD dispute that our health care system is deeply troubled. Thirty-nine million Americans are completely uninsured and millions more have inadequate coverage. After a brief lull, health care costs have resumed their exuberant growth; health maintenance organizations (HMOs) have fallen to the basement of public esteem and have failed to contain costs; commercial pressures threaten medicine's best traditions; and healing has become a spectator sport, with physicians and patients performing before a growing audience of bureaucrats and reviewers. Opinion on solutions is more divided.
Debate over health care reform has been muted since the defeat of the Clinton Administration Rube Goldberg scheme for universal coverage. But the fast developing health care crisis--business leaders grappling with rapidly rising premiums, workers and unions facing cutbacks in coverage, governments confronting deficits, and a sharp upturn in the number unemployed and uninsured--promises to spur new interest in reform.
We advocate a fundamental change in health care financing, national health insurance (NHI), because we are convinced that lesser measures will fail.
In the 35 years since the implementation of Medicare and Medicaid, a welter of patchwork reforms has been tried. Health maintenance organizations and diagnosis related groups promised to contain costs and free up funds to expand coverage. Billions of dollars have been allocated to expanding Medicaid and similar programs for children. Both Medicare and Medicaid have tried managed care. Oregon essayed rationing in its Medicaid program, Massachusetts and Hawaii passed laws requiring all employers to cover their workers, Tennessee promised nearly universal coverage, and several states have implemented high-risk pools to insure high-cost individuals. For-profit firms pledged to bring business-like efficiency to running HMOs, hospitals, dialysis clinics, and nursing homes. And market competition has roiled health care's waters.
None of these initiatives has made a dent in the number of uninsured, durably controlled costs, or lessened the inexorable bureaucratization of medicine.
All such patchwork reforms founder on a simple problem: expanding coverage must increase costs unless resources are diverted from elsewhere in the system. With US health care costs nearly double those of any other nation and rising more rapidly,1 and the economy gone sour, large infusions of new money are unlikely.
Absent new money, patchwork reforms can only expand coverage by siphoning resources from existing clinical care. Advocates of managed care and market competition once argued that their strategy could accomplish this by trimming clinical fat. Unfortunately, new layers of bureaucrats have invariably overseen the managed care "diet" prescribed for clinicians and patients. Such cost management bureaucracies are not only intrusive but expensive, devouring virtually all of the clinical savings.
Resources seep inexorably from the bedside to the executive suite. The shortage of bedside nurses coexists with a proliferation of RN utilization reviewers. Productivity pressures mount for clinicians, while colleagues who have withdrawn from the bedside to the executive suite rule our profession.
Bureaucracy now consumes nearly 30% of our health care budget.2-4
The latest policy nostrums--medical savings accounts and voucher schemes like President Bush's "premium support" proposal for Medicare--would further amplify bureaucracy and limit care. Medical savings accounts discourage preventive and primary care, while failing to curb the high cost of care for severe illnesses (which account for most health spending). Such plans would also require insurers to start keeping track of all out-of-pocket spending, while retaining their existing bureaucracy, and would slash the cross-subsidy from healthy enrollees to the sick.
Voucher programs are thinly veiled mechanisms to cut care. The vouchers offered are invariably too skimpy to purchase fully adequate coverage, forcing lower-income individuals into substandard plans. Voucher schemes also posit that frail elders and other vulnerable patients will make wise purchasing decisions from a welter of confusing insurance options. Finally, vouchers would boost insurance overhead by shifting people from group plans (ie, Medicare or employer groups) into the individual insurance market where overhead averages more than 35% of premiums.5
WHY NHI?
The fiscal case for NHI arises from the observation that health care's enormous bureacratic burden is a peculiarly American phenomenon. No nation with NHI spends even half as much administering care, nor tolerates the bureaucratic intrusions in clinical care that have become routine in the United States.
Our biggest HMOs keep 20%, even 25%, of premiums for their overhead and profit6; Canada's NHI has 1% overhead2 and even Medicare takes less than 4%.7 And HMOs inflict mountains of paperwork on physicians and hospitals. The average US hospital spends one quarter of its budget on billing and administration,4 nearly twice the average in Canada. American physicians spend nearly 8 hours per week on paperwork, and employ 1.66 clerical workers per physician,8 far more than in Canada.
Reducing our bureaucratic apparatus to Canadian levels would save 10% to 15% of current health care spending, at least $120 billion annually, enough to fully cover the uninsured and upgrade coverage for those now underinsured. Proponents of NHI,9 disinterested civil servants,10, 11 and even skeptics12 all agree on this point.
HOW NHI? Unfortunately, piecemeal tinkering cannot achieve significant bureaucratic savings. The key to administrative simplicity in Canada (and other nations) is single-source payment. Canadian hospitals (mostly private, nonprofit institutions) do not bill for individual patients. They are paid a global annual budget to cover all costs, much as a fire department is funded in the United States. Physicians (most of whom are in private practice) bill by checking a box on a simple insurance form. Fee schedules are negotiated annually between provincial medical associations and governments. All patients have the same coverage.
Unfortunately, during the 1990s Canada's program was starved of funds by governments responsive to pressure from the healthy and wealthy who sought to avoid cross-subsidizing care for the sick and poor. Where once Canadian and US health care spending were comparable, today, Canada spends barely half (per capita) what we do.1 Shortages of expensive, high-technology care have resulted. Yet, Canada's health outcomes remain better than ours (eg, life expectancy is 2 years longer1), and most quality comparisons indicate that Canadians enjoy care equivalent to that for insured Americans. A system structured like Canada's, but with double the funding, could provide high-quality care without the waits or shortages that Canadians have experienced.
The NHI that we propose would create a single tax-funded comprehensive insurer in each state, federally mandated but locally controlled. Everyone would be fully insured for all medically necessary services, and private insurance duplicating the NHI coverage would be proscribed (as is currently the case with Medicare). The current byzantine insurance bureaucracy with its tangle of regulations and wasteful duplication would be dismantled. Instead, the NHI trust fund would dispense all payments, and central administrative costs would be limited by law to less than 3% of total health care spending.
Each hospital and nursing home would negotiate an annual global budget with the NHI, based on past expenditures, projected changes in costs and use, and proposed new and innovative programs. Many hospital administrative tasks would disappear. There would be no hospital bills to keep track of, no eligibility determination, and no need to attribute costs and charges to individual patients. Cost shifting would be pointless as there would be nowhere to shift costs to.
Clinics and group practices could elect to be paid fee-for-service, or receive global budgets similar to hospitals. While HMOs that merely contract with providers for care would be eliminated, those that actually employ physicians and own clinical facilities could receive global budgets, fee-for-service, or capitation payments (with the proviso that capitation payments could not be diverted to profits or exorbitant executive compensation).
As in Canada, physicians could elect to be paid on a fee-for-service basis, or receive salaries from hospitals, clinics, or HMOs.
Properly structured, NHI would not raise costs; administrative savings would pay for the expanded coverage. While NHI would require new taxes, these would be fully offset by a decrease in insurance premiums and out-of-pocket costs. Moreover, the additional tax burden would be smaller than is usually appreciated, since nearly 60% of health care spending is already tax supported (vs roughly 70% in Canada). Besides Medicare, Medicaid, and other explicit public programs, our governments fund tax subsidies for private insurance that exceed $100 billion annually.13 In addition, local, state, and federal agencies that purchase private coverage for government workers account for 22.5% of total employer health care spending (D.U.H. and S.W., unpublished analysis of Current Population Survey data from the US Census Bureau, 2001).
Demonstration projects in 1 or more states might precede national implementation of NHI. Initially, funding might mimic existing patterns to minimize economic disruption, but all payments would be funneled through the NHI trust fund. Thus, Medicare and Medicaid moneys, as well as current government expenditures for employee health benefits, would go to the trust fund. Employers would pay a tax equivalent to the average now spent for health benefits. In the long run, a shift to a more progressive, income tax funding base would provide a fairer and more efficient revenue stream.
The NHI we propose faces important political obstacles. The virtual elimination of private health insurance will evoke stiff opposition from insurance firms. Similarly, investor-owned hospitals and drug firms fear that NHI would curtail their profits.
Practical problems in implementing NHI also loom. The financial viability of the system we propose is critically dependent on achieving and maintaining administrative simplicity. Canada's macromanagement approach to cost control -- enforcing overall budgetary limits is inherently less administratively complex than our current micromanagement approach, with its case-by-case scrutiny of billions of individual expenditures and encounters. However, even under NHI, vigilance (and statutory limits) would be needed to curb the tendency of bureaucracy to reproduce and amplify itself.
National health insurance could solve the cost-vs-access conflict by slashing bureaucratic waste. It would reorient the way we pay for care, and eliminate financial barriers to access. National health insurance could restore the physician-patient relationship, offer patients a free choice of physicians and hospitals, and free physicians from the bonds of managed care.
How many more failed patchwork reforms, how many more patients turned away from care they cannot afford, how many trillions of dollars squandered on malignant bureaucracy, before we adopt the only viable solution: NHI?
Steffie Woolhandler, MD, MPH
Cambridge
David U. Himmelstein, MD
1493 Cambridge St
Cambridge, MA 02139
REFERENCES
1. Organization for Economic Cooperation and Development. OECD Health Data 2001 [computer database]. Paris, France: Organization for Economic Cooperation and Development; 2001.
2. Woolhandler S, Himmelstein DU. The deteriorating administrative efficiency of US health care. N Engl J Med. 1991;324:1253-1258.
MEDLINE
3. Himmelstein DU, Lewontin JP, Woolhandler S. Who administers? who cares? medical administrative and clinical employment in the United States and Canada. Am J Public Health. 1996;86:172-178. MEDLINE
4. Woolhandler S, Himmelstein DU. Costs of care and administration at for-profit and other hospitals in the United States. N Engl J Med. 1997;336:769-774. MEDLINE
5. Pauly MV, Percy AM. Cost and performance: a comparison of the individual and group health insurance markets. J Health Polit Policy Law. 2000;25:9-26. MEDLINE
6. Special report. BestWeek Life/Health. April 12, 1999.
7. Heffler S, Levit K, Smith S, et al. Health spending growth up in 1999: faster growth expected in the future. Health Aff (Millwood). 2001;20:193-203. MEDLINE
8. Remler DK, Gray BM, Newhouse JP. Does managed care mean more hassles for physicians? Inquiry. 2000;37:304-316. MEDLINE
9. Grumbach K, Bodenheimer T, Woolhandler S, Himmelstein DU. Liberal benefits, conservative spending: the Physicians for a National Health Program proposal. JAMA. 1991;265:2549-2554. MEDLINE
10. US General Accounting Office. Canadian Health Insurance: Lessons for the United States. Washington, DC: US Government Printing Office; 1991. Publication GAO/HRD-91-90.
11. Congress of the United States Congressional Budget Office. Universal Health Insurance Coverage Using Medicare's Payment Rates. Washington, DC: US Government Printing Office; 1991.
12. Sheils JF, Haught RA. Analysis of the Costs and Impact of Universal Health Care Coverage Under a Single Payer Model for the State of Vermont. Falls Church, Va: Lewin Group Inc; August 2001.
13. Sheils J, Hogan P. Cost of tax-exempt health benefits in 1998. Health Aff (Millwood). 1999;18:176-181. MEDLINE
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i currently live in Canada that has universal health care and i am not forced to take any shots or what meds to take. i talk to my doctor and we make a decision about what is good for me. i don't like any medication but i have to take one for a rare condition that i have. i talked with my doctor abotu this med and agree to take it for a trial run. this medication has saved my life.
now i agree with you that we should be demanding a health care system that cures people but i will go one step further and say that we need a health care system that prevents people from getting sick. PREVENTION IS THE KEY.
Demand that pop is not served to our children, have healthy food in schools. bring gym classes back to schools. clean the enviroment so that our food and ourselves don't have all the toxins. the best way to cure something i sto not having affect us any more.
- Soren Aabye Kierkegaard (1813-1855)
If you haven't got anything nice to say about anybody, come sit next to me."
- Alice Roosevelt Longworth (1884-1980)
My point was that as long as the opportunities are there for them, they'll take them. Why wouldn't they? Once that incentive is gone, it's a much less attractive option. If the U.S. institutes a similar system to ours, the majority of the doctors who leave for the money won't have a reason to anymore.
That report is definitely good news but it only refers to the last few years. What about the previous 30? According to that report, 207 doctors left last year, so if 207 doctors leave every year (some years have been as high as 550), that's well over 6,000 doctors and that's a very conservative estimate. I'm sure they all didn't leave for the same reason, but the majority left for financial opportunities/gain. Wouldn't you agree that if we had 6,000 more doctors in Canada right now, we'd be in a lot better shape?
I never said we need to try and compete with American salaries. That's impossible in a non-profit driven medical system and I agree 100% that we need to train more doctors, but keeping them is the trick.
You are not your job.
You are not how much money you have in the bank.
You are not the car you drive.
You are not the contents of your wallet.
You are not your fucking khakis.
Who would be taking away any freedoms??? The doctor experience wouldn't be much different, but instead of the doctor being reimbursed by the insurance company, they will get reimbursed from the gov't. I think you are confused and paranoid by what universal health care is.
Right not you don't really have total freedom anyway... if your insurance company won't pay for a procedure, chances are you're not getting it.
was like a picture
of a sunny day
“We can complain because rose bushes have thorns, or rejoice because thorn bushes have roses.”
― Abraham Lincoln
it'll never happen in the us. those with money control the government and we'll never stand for the high taxes. let the poor work like we had to.
I don't really buy that argument. Based on the premium cost that blackredyellow gave he pays more for health insurance than I do for income tax (and my income taxes cover more than just health care).
the us cannot limit a persons earnings. that's our basic freedom. why do you think it's hard to find an american doctor in america? people come here for the money. and that's the bottom line.
but is your population equal to the us? is your income over $60K or $100K? if you make $25K/year; it's a great deal for you. how are your businesses taxed? how many unemployed people do you have that don't contribute anything? there are many factors that most people don't see. if my business is taxed by profits; i won't show any profits. i do that every tax season. when i take a holiday; i talk to someone about buffalo meat and write the trip off as a business trip. in 2006 i bought a 1 ton truck to knock $50K off my profits then depreciate it every year. i'll reinvest in more land or more buffalo. there's so many loopholes that a million dollar business can come out looking like it breaks almost even.
my state; nevada; doesn't tax people or businesses. so the federal government will have to go about this alone.
i just don't see it happening. what ever happened to hillarycare from the 90's?
Wow with that many loopholes it is no wonder the US runs massive deficits every year.
read the bold print in post #35. in fact read the whole post.
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you have absolutely no idea what you're talking about. perhaps this is the problem with many americans when it comes to this issue. they don't understand how things actually work outside their own country.
you can choose where you go. you do pay tax. there's no red tape. show your health card and you're in. simple.
true enough.
excellent point, roland.
amen. that says it all.
So... you admit to not paying you fair share by cheating the system. and you complain, "How many unemployed people do you have that don't contribute anything?"
...
Gee... thanx.
...
for nothing.
Hail, Hail!!!
For being such a business savy person you're terminology could use some work...
It is not a loophole you describe, rather common tax law that every business adheres to. As far as the government is concerned either invest your income or get taxed on them it is very simple.
You got to spend it all
The problem is that you can't have the first part without the second part. As long as private insurance companies can decide who they want to insure and what procedures they want to insure, you will never have affordable healthcare to everyone.
was like a picture
of a sunny day
“We can complain because rose bushes have thorns, or rejoice because thorn bushes have roses.”
― Abraham Lincoln
Unfortunetly that is true but I will never support government funded or managed healthcare. Not because I don't want my taxes going to insure someone else, but because anything our government touches will undoubtly become this over-blown beaucratic cluster-fuck that will end up costing the public more.