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June 26, 2009

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Meh. Who cares? Obama's plan is designed to fail. Let the right-wingers attack it, and Obama for proposing it, and instead people who care about everyone having access to health care in the US should be openly proposing either single-payer or a national health service. You know: something that will actually work to improve health care, instead of a bashed-up way of keeping health insurance companies in business.

""This is not a trick. This is not single-payer. That's not what anyone is talking about — mostly because the president feels strongly, as I do, that dismantling private health coverage for the 180 million Americans that have it, discouraging more employers from coming into the marketplace, is really a bad direction to go." - Kathleen Sibellius

So in fact, Obama (according to Sibellius) - seems to agree with Ed Morrisey: allow everyone in the US the same choices and the same level of health care as in the UK, and that would be a bad thing. Can't allow people to have a basic level of health care plus their own choice of top-up, because you've got to protect the private health insurance industry!

I hadn't read that interview with Sibellius until this morning: goodness, why even bother defending Obama's health care plan, if you want people to have access to health care?

Well, there are actually some people that do propose that people should be banned from certain medical procedures under certain circumstances, even if they could pay for it.
No, I am not talking about abortion but e.g. hip replacements for people that are 'too old'. Some of those are extremists that follow the 'useless eaters' or the 'if any would not work, neither should he eat.' ideology, others limit that view to limited resources areas (e.g. organ transplants).
But to my knowledge neither group plays a major part in the current discussion.

Medicaid saved my life this week.

I've been putting off seeing a doctor about some persistent problems for several years, in large measure for lack of money. But last week my new counselor (also covered by Medicaid) pointed me at doctors they work with who take Medicaid, and this week I had my checkup. It turns out I have hypertension so high that the doctor said he was genuinely surprised I hadn't already had a stroke or heart attack, and put me on emergency dosage of medication for that and gave me special instructions for how to handle cardiac trouble in case it happens before he can get test results back and set up time with a vascular consultant.

He thinks that if I'd put it off very much longer, I really couldn't have escaped a fatal episode.

I have Medicaid because of systemic illness. But you know, I don't deserve it any more than a lot of my fellow citizens who happen to be healthy, or at least not so sick, and simply not able to afford what good health care costs in America if you can keep it once serious problems develop. There are, I'm sure, people very much like me dying of this kind of crap because unlike me, they either weren't eligible for the coverage or nobody helped them find out that they were.

If this were a just country, people wouldn't have to put off going to the doctor out of fears like mine. It's immoral, as well as ultimately inefficient and socially corrosive.

"Obama should be working to boost the private sector to encourage more care providers, less red tape and expense, and better care for everyone."

I think it's worth pointing out that this is something that you hear a lot, but never with any substance to it, just a vague government-is-the-problem ideology backing it up.

What an incredibly long post avoiding the point, we should spend our time and the opportunity to revamp healthcare solving the problem that rich people can get better care, rather than assume all systems will have that inequity and institutionalize it in a single payer government system. Any "cheaper" government system by default quickly becomes the only system for most people, again except those pesky rich people, so, to be clear, Obama wants to cut the cost of healthcare by providing limited care for all through a government controlled single payer system and NOT solve the real problem.

Thats what he said, in many beautifully articulated words on his best stage, not me. Someone just translated it from Obama to understandable.

Well, we all know where Jes stands on this. Nothing less than and precisely what the Brits must accept. But we have millions of Americans (many, if not most, of whom support the idea of health care for everyone) who prefer many, if not all, aspects of our current approach over anything that would remotely resemble Britain's approach. And it's not as if we don't have a clue regarding the corruption and other unsavory behaviors displayed by our elected officials and corporate health insurance executives.

Those Americans would rather see a serious effort to fix some of the obvious defects in our existing approach and separately take action, through government programs where necessary, to insure coverage for those who somehow don't get needed coverage through market mechanisms. I think there are few thinking and feeling people who like conditions where others cannot get necessary health care.

As one who favors Federalists concepts in our governing approach, I think I see some similarities in this issue. Just as I believe a better result on political issues becomes possible when everything is not decided in Washington, I think many different solutions can emerge in health care insurance under the right conditions. Just one example that I have not heard discussed very seriously by elected officials would be to change the tax benefit for premiums from businesses to individuals. This would changed the relationship between the insured and the insurer in a direction more favorable to the insured. It would lend a more lifelong focus rather than just for the term of one's employment with a particular organization. Individuals could change their coverage to another company which largely does not happen now. The tax system could also be used to provide a more broadly based benefit across all taxpayers and perhaps even to the point of helping induce those now without coverage to get it. Health insurance savings accounts are another component. Regulations that do not allow conditions where individuals can be denied coverage by all sources could be put in place. There are a number of other reasonable things that we can do, among them methods that could influence how we build and sustain our cadre of medical professionals.

If we just throw in the towel and go whole hog for the government solution, it basically says to me that we have given up on our ability to influence what we want these elected officials to do.

I do have to add in response to a few comments here that the UK system does directly control access to treatment based on a cost/benefit system. Old people may not get a transplant if it doesn't statistically add enough years to their life, no hip transplant if the individual good doesn't outweigh the public cost, etc. They have a government board that sets those standards and reviews cases where the value of treatment is in question.

In Canada, where healthcare is expensive enough by virtue of incredibly high taxes, the impact of the same high cost of care is translated into long wait times for care as the system gets overburdened and under funded. The same is true in the UK. Neither has solved the problem, only changed the symptom.

"The point is to put a floor under everyone -- and a decent one."

Precisely. Thank you.

I do have to add in response to a few comments here that the UK system does directly control access to treatment based on a cost/benefit system

Every country in the world rations health care. In the US, we do it based on personal wealth and complete randomness. In the UK, they do it by having statisticians try to think rigorously. Can you explain why the UK system is worse?

the impact of the same high cost of care is translated into long wait times for care as the system gets overburdened and under funded.

Canadians have chosen a system that covers everybody in Canada and is a lot cheaper than ours at the expense of long wait times for some elective procedures. If Canadians wanted to spend an extra $4,000 per person per year, they could dramatically reduce wait times while still paying less than we do. I don't think they want to do that and to be honest, I wouldn't want to do that if I were them either. I'd much rather have an extra $4,000 and have to wait for elective procedures once or twice in a lifetime.

Russell,

I agree, but the floor under everyone can be attained without making everyone subject to a government run system. And even though the language includes denial that's where we are headed, most of us have enough specific experience to know that's where we will wind up if we open the door.

For those of us lucky enough to have insurance, what Charles Gibson is talking about already exists. You get the care that your insurance agrees to give you, not what the doctors want to give you. If you are rich enough, you go outside the insurance company.

My son lives in Canada and has experienced the two health systems first hand -- he vastly prefers the Canadian system. Of course, that may have had something to do with his parents getting notification from our insurance that our premiums were going up $200 A MONTH effective July. (Neither of us has any health issues.)

Screw Charlie Gibson. Let's cut his salary down to $60,000 a year, still vastly over what most Americans make, and let him buy his own health insurance. Then let him get back to us.

the impact of the same high cost of care is translated into long wait times for care

in my experience (in the US), wait times to see a specialist for a non-emergency matter is measured in months. not days, not weeks, months. allergists, dermatologists, endodontists - months.

also, Canadians live longer than Americans.

Great stats :), "wait a few times in a lifetime for elective procedures" well I waited 8 weeks, in the hospital, for an "elective" CTScan to determine I needed a stent to prevent another heart attack, if I had left the hospital the wait time for that scan would have been 4-6 months.

Please don't waste my time with wait times for a dermatologist....

The UK system is not the same as insurance driven limits, they just say no to available care based on age and overall health and it's fairly draconian.

And in the end there is a floor in the US, emergency care is available to all, lets just raise the floor a little and then solve the problem with a system that those other countries can emulate.

Canadians may live longer than Americans, but how much of that difference can be attributed to the difference in health care available to the residents of the respective countries.

In the US, for example, there is a significant gap in life expectancy between blacks and whites. Some of this gap undoubtedly derives from health care differences just based on economics of demographics, but several other components affecting life span averages come from environmental, behavioral, genetic and possibly other reasons as well. These factors may or may not be present in the Canadian population to similar degrees. I don't know. So a simple comparison of the bottom line may not be enough.

Marty: Old people may not get a transplant if it doesn't statistically add enough years to their life, no hip transplant if the individual good doesn't outweigh the public cost, etc.

Marty is either ignorant or being deliberately misleading.

There are always more people in need of organ transplants than there are people recently dead in such a way that, if they/their family consent, their organs can be used for transplant. This is unlikely ever to change.

To be placed on a waiting list to receive an organ, you must both be in mortal need of the transplant, and you must be otherwise healthy enough to justify your receiving the transplant
- that is, the NHS will not give you an organ transplant if the drugs you will have to take for the rest of your life are likely to kill you.

How possible recipients are decided on when an organ - to put it passively - becomes available, is based on a complex weighting of factors, including the recipient's smoking and drinking habits, their age, how badly they need it - and of course, how close a match they are to the donor.

It's not a perfect system. I don't doubt sometimes it goes wrong. But the intent of it is that donor organs go to the possible recipients who are most likely to live longest as a result of receiving them - and tries not to waste a donor organ on someone who is likely to die as a result of receiving it.

The hip replacement claim is just a lie: hip replacement is always a last resort, but it's never off the table if it is needed as the last resort.

The UK system is not the same as insurance driven limits, they just say no to available care based on age and overall health and it's fairly draconian.

Marty, in which NHS Trust hospital - and when - were you waiting for 8 weeks to get an CTscan?

I agree, but the floor under everyone can be attained without making everyone subject to a government run system.

This is a non-argument, that seems entirely dependent on the phrase "subject to." First, why is it worse to be "subject to" a government run system than a private run system? As hilzoy points out, most of us have very little practical choice about our health insurance coverage under the presence system, the rich accepted. That would also be the case under whatever system emerges from Congress. And, no, a guaranteed public option would not necessarily put private insurers out of business (case in point: Germany), unless one of the explicit goals of the reform is to outlaw private insurance, and for better or for worse nobody in DC is interested in doing this. Finally, the choice most Americans are most interested in maintaining/creating involves care not insurance. Many of the arguments against health insurance reform involve a huge shell game in which opponents invoke "choice." But there's no evidence that most (or even any) Americans will have less choice among insurance plans. And even if they did, less choice among insurance plans has nothing whatsoever to do with less choice among doctors or procedures, which is what most Americans actually care about.

GOB: Some of this gap undoubtedly derives from health care differences just based on economics of demographics, but several other components affecting life span averages come from environmental, behavioral, genetic and possibly other reasons as well.

Huh? So, how is that an argument against trying to level out health care availability for all? True, being poor / being rich would still be a factor, so black people would on average tend to live less long than white people, but there would be less of a gap...

To be placed on a waiting list to receive an organ, you must both be in mortal need of the transplant, and you must be otherwise healthy enough to justify your receiving the transplant

This sounds like exactly the same system we have in the US. In the US, you may not get a transplant that you need if the committee decides that you're too old or too unlikely to survive. It has nothing to do with money or insurance per se. It has everything to do with the fact that organs are scarce and that the medical community rations them.

And in the end there is a floor in the US, emergency care is available to all, lets just raise the floor a little and then solve the problem with a system that those other countries can emulate.

Yes, the emergency care system forms a kind of floor in our system.

But it's a floor with almost nothing going for it. It's incredibly inefficient, both in terms of costs and in terms out individual outcomes. It also has pretty major public health externalities. It's incredibly inequitable. It imposes huge delays in treatment (funny how delays are a big issue when discussing any other system, but not this one). It is not a system in need of minor repair, but rather in need of being scrapped.

Can any defenders of the status quo make a case for the preferability of the emergency care floor that does not boil down to a theological belief that government is always bad?

It has nothing to do with money or insurance per se. It has everything to do with the fact that organs are scarce and that the medical community rations them.

Generally true but money does help.

Take a look at the Steve Jobs case; it's pretty certain his money gamed the system somewhat.

Once again, I must point out that nobody is talking about a government run system of healthcare.

Secondly, the whole purpose of thsi debate is have a system where everybody has access to basic healthcare at a reasonAble cost. Consider that word basic and think of the ramnifications of everybody receiving basic health care as a given.

Think in terms of larger medical problems and more costly treatment being avoided due to that.

Also consider that the UK has one of the least effective plans in Europe, thanks to Thatcher, and is still probably better than ours.

And consider that insurance companies in Europe and Canada are doing quite well covering things the government plan doesn't cover.

Consider the fact that insurance companies are doing quite well in this country offering coverage to seniors to pick up what Medicare doesn't cover.

Certainly, if the present approach of most private insurance coverage provided by employers (where the contactual terms are between the employer and the insurance provider) were replaced by an approach that allowed the employee to receive in direct compensation the business expense paid for insurance as an employee benefit, and the tax benefit currently enjoyed by the business went directly to the employee instead, then the insurance providers would be dealing with and competing for the business of individuals who could spend a lot more effort evaluating what coverage they could get for their money. I believe this would introduce greater choice for the individual.

Of course, the individual would actually have to expend some energy and effort to try to make a good choice and this might just be too much to expect when they can just let somebody else decide for them. Market-based approaches do not favor the lazy.

One more point. By having greater choices among insurance providers who are competing for the individual's business, the individual should be more likely to be able to increase his/her choices of practitioners, procedures, and medicines, as well.

I don't see any reason at all to believe that we can cover all Americans unless the government does it. Fundamentally, I'm not interested in insurance, but in access to care. This week, what mattered to me is that I could see good professionals and get the medication they prescribed, without an out-of-pocket cost. People are suffering and dying for the lack of such care, and they shouldn't have to. The hell with competition, I want access. I'll be glad to talk about competition on luxuries the very moment I know that no fellow American is going without the opportunity to get help with their health needs....and that's what private insurance will never, ever deliver.

in the end there is a floor in the US, emergency care is available to all,

at enormous cost to society and the taxpayers, not to mention the cost of misusing and overloading a system that's meant for emergencies, nor that of not providing any preventative (cheap!) care to any of the people forced to rely on this "floor".

no. let's build a better floor higher up and save money on the deal while getting more people better healthcare in the bargain. we know this can be done, because numerous other countries do it, and their systems work just fine. why would the USA have to suck so much harder than they?

John Miller: Once again, I must point out that nobody is talking about a government run system of healthcare.

I am. If you mean "nobody in power" well, no, more's the pity.

GOB: then the insurance providers would be dealing with and competing for the business of individuals who could spend a lot more effort evaluating what coverage they could get for their money. I believe this would introduce greater choice for the individual.

Yes, because people need to be able to make the "choice" of how much health care they're going to need over the rest of their life.

One more point. By having greater choices among insurance providers who are competing for the individual's business, the individual should be more likely to be able to increase his/her choices of practitioners, procedures, and medicines, as well.

Whee! Now Americans can decide if they want lung surgery or a hip replacement - absolutely free choice!

Honestly, GOB, do you have any idea how silly this sounds? I had a friend who came down with a virus that destroyed his heart muscle such that he needed a heart transplant, just over 13 years ago. If you had asked him when he was 25 what "choice" he wanted to make about what kind of health care he wanted to receive over his lifetime, he would likely never have thought to list all the health care he did in fact need - because you don't. He always had the choice of refusing the heart transplant: but his "choice" of where to go was zero - he was operated on in the only heart transplant unit in Scotland, by the best-qualified transplant surgeon available. Why substitute "choice" for quality?

The government doesn't provide anything. It takes from some and gives to others. It is only a conduit. The ones it takes from are the providers.

In the US, for example, there is a significant gap in life expectancy between blacks and whites.

Cuba's population is roughly 11% black (compared to our 13%), and they have a higher life expectancy than we do, too.

Puerto Rico also beats us, with 18% black/mulatto. PR also has a strange hybrid public/provate health insurance system.

to me, that suggests that the white/black life expectancy gap is not genetic. which means it's a failure of our health care system.

An example of how the US health care system frustrates patient choice:

She found an OB who she liked, who was associated with the hospital nearest her house. Ahead of time, they knew there would be a pretty good chance she'd need a c-section, and in fact she ended up with one. Knowing she wanted her tubes tied, and knowing they might be rooting around in there already to get the baby out, she thought it would be nice to avoid being opened up a second time, later.

So was she able to plan on getting her tubes tied on the spot, if she ended up having a c-section? No. Because the hospital is Catholic. Her doctor was on board with the procedure, but it's against hospital policy.

One more point. By having greater choices among insurance providers who are competing for the individual's business, the individual should be more likely to be able to increase his/her choices of practitioners, procedures, and medicines, as well.

This would only be true if the individual was young, healthy and with no pre-existing conditions. If you don't fit each of those criteria, then you will end up paying much more because no insurer would want you as a client. Through your employer, the costs are spread out so that the infirmed/older individual doesn't get singled out and dinged with extremely high premiums (the employer can negotiate a bulk rate that is attractive to the insurer). The point of government provided insurance is to spread those costs out over an even larger group. That's also the problem with state by state approaches: bigger risk pools are better. At least if the goal is to see all Americans provided the dignity of health care.

cleek

"to me, that suggests that the white/black life expectancy gap is not genetic. which means it's a failure of our health care system."

It is a complex world. There could be other factors you haven't controlled for.

jesurgislac,

I apologize, in advance of the answer,for my lack of precision in the original comment.

I was told it would be eight weeks and they couldn't release me from the hospital (as that would take me off of the critical priority list), the timing of actually getting the stent was even less clear. The gentleman in the ward with me had been waiting for five weeks already for his scan (I believe his echo had been done) and had his office set up in the room so he could work each day, so I knew he would go before me. So I checked myself out over doctors orders (a three day discussion), went home to the US and in 4 weeks (none in the hospital) I had a stent.

I would prefer not to reference an individual hospital as it is not really the point of this discussion, and I did receive exemplary critical care and am alive today I'm quite sure because of that.

If I had a dime for every time Ed Morrissey declared that Obama had a "Dukakis moment," I could afford a vintage Jaguar.

So I checked myself out over doctors orders (a three day discussion), went home to the US and in 4 weeks (none in the hospital) I had a stent.

You didn't answer; when did this happen?

Also, Marty, I take it since you speak so highly of Emergency Room care, that when you went home to the US, you went home to no health insurance - you simply showed up in the ER of your local hospital 4 weeks after you got back and were promptly provided with a stent?

Or what?

"The hip replacement claim is just a lie: hip replacement is always a last resort, but it's never off the table if it is needed as the last resort"

I suppose one can say it is available as a last resort, but it is the standard protocol for some people and a last resort for others with identical diagnosis. A slippery slope that in the UK has slid on more than once.

Calling something a Lie is a bad accusation, I am occasionally imprecise and very rarely misinformed. But I don't lie.

Marty: I suppose one can say it is available as a last resort, but it is the standard protocol for some people and a last resort for others with identical diagnosis.

You really have no idea what you're talking about, do you? Age is a factor in recommending a hip replacement; the younger and more active a person is, the less likely a surgeon is to recommend this operation, because the more likely it is that the artificial joint will wear out and have to be replaced again - and a hip replacement is major surgery.

Hip replacement or resurfacing surgery is not needed by everyone with arthritis of the hip joint – it is only recommended when the pain and disability are having really serious effects on your daily activities. Your doctors will always try other measures before they consider surgery (e.g. painkilling tablets, a walking stick, physiotherapy). There are also less major types of surgery which will be considered, such as 'cleaning out' the joint through a surgical tube (an arthroscope). And remember that you, the patient, will always have the final decision on whether to go ahead if hip surgery is being offered. If the pain and disability justify surgery, there is no age limit – either young or old. However, the younger the patient the greater is the likelihood of revision surgery being needed at some time in the future. cite
Individual diagnostic assessments will differ between NHS Trusts, probably between individual consultants, and always depending on the patient's individual needs.

Calling something a Lie is a bad accusation, I am occasionally imprecise and very rarely misinformed. But I don't lie.

Fine: I accept that your blethering about transplants and hip replacements in the UK is due to your arrogance in thinking you can give others the benefit of your ignorance, rather than actual malicious misinformation.

So, when did you go back to the US, that time you just walked into the ER to ask for your stent - no waiting around required?

"You didn't answer; when did this happen?

Also, Marty, I take it since you speak so highly of Emergency Room care, that when you went home to the US, you went home to no health insurance - you simply showed up in the ER of your local hospital 4 weeks after you got back and were promptly provided with a stent?

Or what?"

Hmmmm, not sure what the point is here, 4 years ago, no I had insurance, that they gladly billed in Canada as well as the US. I went to a cardiologist recommended by my primary care physician, they scheduled and echocardiogram and CTScna of my heart over a three week period and then scheduled the angio for the next week. All on an outpatient basis except for the last night I stayed in the hospital because the angio was done very late in the day.

But, again, I'm not sure the details here are more revealing to support or debate my position that we can do better, even Canada believes it can do better. Health care is not even a level playing field there as Alberta and Ontario have very different delivery networks.

My question is always, why are we copying someone else who isn't in some ways better, when theeir are good things about what we have.

I've said this a couple of times before, and it's a little off topic here, but:

I don't buy that the problem with US health care stem from health insurers operating under the profit motive; non-profit health care providers (e.g. blue cross) frequently behave in very similar fashion, and other nations with UHC have providers that can operate for profit (e.g Netherlands).

That said, I also think (as I've said before) that HC hyperinflation stems from the private sector, and that von is wrong about his high spending in the public sector point.[from a thread with von commenting]

Jes

Am I correct that you live in the UK? If so, why do you have such an interest in the US health care system?

"It takes from some and gives to others."

Let me introduce you to the concept of "spreading risk".

"to me, that suggests that the white/black life expectancy gap is not genetic."

Amazing that this even needs pointing out, isn't it?

Hmmmm, not sure what the point is here,

You asserted that "And in the end there is a floor in the US, emergency care is available to all" - so I take it that you went home to the US and walked into the nearest emergency room to get care?

I went to a cardiologist recommended by my primary care physician, they scheduled and echocardiogram and CTScna of my heart over a three week period and then scheduled the angio for the next week.

Your "primary care physician" being the doctor from the nearest ER? That's the standard of care you are recommending as superior to the UK system, remember?

My question is always, why are we copying someone else who isn't in some ways better, when theeir are good things about what we have.

If you think there are "good things" about getting health care by just showing up at an emergency room, how often - besides this time when you needed a stent - have you done that?

I just used to have a "Sucks to be you" attitude to the US health care system - aside from the frightening terrorist/political campaign against reproductive health care, as any feminist would care about that.

Then a few years ago, a friend I'd never met got cancer. She was involved with another friend, who lived in the UK: they were in the middle of a complex set of decisions about which of them moved where: she was unhappier at her job, he had a more portable set of skills.

But as soon as she developed cancer, all those options got shut down - she had to stick with the job she had because without that job, she didn't have health care: this wasn't the kind of cancer you can afford to take chances with.

To cut a long story short: she died, dave. Maybe she would have died no matter what. But she died without her chosen partner, in a place she wouldn't have chosen to die in, after sticking with a job she was unhappy with that kept her far from where she wanted to be, because of the sucky US health care system that gave her no goddamned choice at all. And I never did get to meet her face-to-face, which I still regret.

But that did kind of awake me to US friends who make very careful and worried comments online about how they can't really afford a checkup, but there's this rather worrying lump...

I suspect that my friends average out at a lot poorer than your friends, d'd'd'dave - rich people, and you've claimed to be very rich, tend not to make or keep friends a lot poorer than they are.

But whatever. I have friends who have health problems and money problems you clearly never have had. And they don't go on about how much they love having choice and quality health care in the US: they worry - and they're right to - about how to balance not having enough money with wanting to stay alive.

Oh, I do have one friend who is very affirmative about the choice and quality of health care available to her family in the US. I think it's no coincidence at all that she's also the wealthiest friend I have, with old money on both sides of her family.

I love her dearly and I'm glad her (relation) got the health care he needed to survive - but she's the only close friend I have in the US where cost was not, ever, going to be a factor in how much health care her (relation) could have.

Who said that in the US we get our primary care in the emergency room?

I recognize that if one does not explain each reference in detail at this site, there will likely be an effort to put a negative twist on the point. My reference to genetics as a possible factor in the black/white longevity gap was meant to take into account that ethnic groups who are minorities in the US sometimes have higher incidences of medical conditions for which R & D expenditures for pharmaceutical, medical devices, and treatment regimes are less than for medical conditions that are more common across the general population. This has an effect that in some way could be attributed to a country's health care system, but would not necessarily be negative as to the US system since many medical advances are developed here that would not be available to other countries if they weren't. If this is not statistically significant, I can accept that.

"I agree, but the floor under everyone can be attained without making everyone subject to a government run system."

I have no problem with that. I have absolutely no investment in health insurance being provided either by the private sector, the public sector, or both.

Whatever gets the job done.

And, in fact, we currently have a model where both are available. The public offering is just not available to everyone.

The only problem I see with your point of view here is that, in fact, the private offerings currently available DO NOT make a reasonable floor available to everyone, and show no inclination to do so.

It might be helpful for employers to simply pay employees the money they currently pay for health insurance on their behalf, and then give the tax writeoff to the employees.

That doesn't help all of the people who work for themselves, or who work for folks who don't currently offer health insurance, or who don't work at all.

What about them?

The history of public intervention into private industry and commerce in this country is, to an incredibly consistent degree, one of government response to enormous if not catastrophic failure in the private sector.

It's extremely rare, so much so that it's hard for me to think of examples, for government to simply decide to take on responsibilities that are effectively being borne by the private sector.

The reason we're even having this conversation is because the private sector *is not getting it done*.

If you have a magic wand to wave and change that, great. Have at it. If not, then our choices are getting it done through a public effort, or not getting it done.

I vote for getting it done through a public effort.

Wow. Jes gets more worked up, in my view, than almost anyone else here, and it's not even from first hand experience as a victim of our heartless system.

GOB: The US places almost no emphasis on preventive care. As a result, many of the uninsured or underinsured use the ER as their primary care. Of course, this is far more expensive and, often, situations have deteriorated so what was once a minor condition becomes more serious.

By having greater choices among insurance providers who are competing for the individual's business, the individual should be more likely to be able to increase his/her choices of practitioners, procedures, and medicines, as well.

No. All insurance is based on the ability to spread risk. A greater number of insurers would shrink the capability to spread risk.

Currently, the healthcare insurance industry is run by about 6-7 companies. However, these companies may own hundreds of subsidiaries. The reason for this is to maximize profit (or shareholder profit). In this case, the market solution has caused insurers to very, very well while the consumer is jobbed.

The government doesn't provide anything. It takes from some and gives to others.

Accepting this moronic assertion for the sake of argument, isn't this exactly what private insurers do, except their goal is to skim profits rather than improve access to health care?

The government doesn't provide anything. It takes from some and gives to others. It is only a conduit. The ones it takes from are the providers.

That's right. They should go Galt to get away from those parasites in government.

Please?

Good Ole Boy: Jes gets more worked up, in my view, than almost anyone else here, and it's not even from first hand experience as a victim of our heartless system.

Yeah. The friend who died of cancer - she didn't get particularly worked up about the situation, at least not to me. I suspect she couldn't afford to - why get emotionally energised about something you can't change when you've got strictly limited time and energy?

But d'd'd'dave asked why I cared about your sucky health care system when it didn't affect me directly, and the short, very short answer is ... friendship and death.

However. It's Friday. It's nearly 5pm where I am. I do believe I will go mellow out with a glass of wine and a sandwich, and I wish you all welll for the weekend.

Well, Russell, I think it would help all those who work for themselves and those who work for employers who don't provide medical benefits precisely because the insurance business environment will have changed to one where the dealings are between the individual being insured and the insurer. The need for COBRA would go away and workers would have greater employment mobility since their coverage would no longer be tied to their employer. Attention potentially could shift toward greater emphasis on preventive care since the insured/insurer relationship would endure longer than just the employee/employer relationship.

This subject area is very complex and we are only touching a few aspects in this thread. I just don't like the idea of giving up when we haven't made any real efforts to change and improve the approach we have been living with. The employer provided medical benefit took off over half a century ago and has only been tweaked since. And almost no progress in individual medical insurance has occurred. So, to me, reform means to try a fix on known problems in the current approach, not to throw everything out and opt for something completely foreign to our experience.

And the closest thing we have that we could call on as experience with state control of medical care is Medicare. Many of us think Medicare operates in strange and costly ways and the future is dim.

Jes,

Actually, my closest and longest kept friends are almost all schoolteachers. Well, the males are mostly school teachers and the females are nurses.

Inner circle
A: secondary school administrator/former teacher
B: secondary school administrator/former teacher
Z: secondary school teacher
B2: nurse
J: Speech therapist
Next circle
S: Can't seem to keep any job for long. Seriously.
C: nurse
M: nurse
D: secondary school administrator
B3: Banker
B4: Industrial magnate
A2: architect
J: engineer
C2: Office manager
B5: Project manager/real estate
K: Project manager/real estate

B4 Is very wealthy, having started with nothing.
B3, J, and B5 are probably in the top 5% income-wise
S: is poor.
Everyone else is probably around median income.

"But we have millions of Americans (many, if not most, of whom support the idea of health care for everyone) who prefer many, if not all, aspects of our current approach over anything that would remotely resemble Britain's approach."

Cite, please? Actual polls:

A clear majority of Americans -- 72 percent -- support a government-sponsored health care plan to compete with private insurers, a new CBS News/New York Times poll finds. Most also think the government would do a better job than private industry at keeping down costs and believe that the government should guarantee health care for all Americans.

The new poll shows the idea of a government-sponsored plan, or "public option," to be fair non-controversial, though Democrats in the Senate have considered nixing the proposal in order to win Republican support for the bill.

[...]

While many have criticized Mr. Obama's proposal for a public option, Americans generally see government involvement in health care in a positive light, and most support it. Fifty percent think the government would be better than insurance companies at providing medical coverage (up from 30 percent in 2007), and 59 percent think the government would be at better holding down costs (up from 47 percent in 2007).

More generally, 64 percent of Americans say the government should guarantee health insurance for all Americans. Just 30 percent think this is not its responsibility. Those percentages have been stable for many years.

When presented with the option of a government-administered health insurance plan similar to Medicare to compete with private health insurance companies, 72 percent are in favor and just 20 percent oppose. Even 50 percent of Republicans favor that option.

[...]

Reactions are mixed as to whether the government should go as far as requiring all Americans to have health insurance, as long as it provides financial help to those who can’t afford it on their own. Forty-eight percent think the government should require this, while 38 percent think it should not.

The public, however, has acknowledged the need for sweeping changes to U.S. health care, with 51 percent saying it needs fundamental changes and another 34 percent saying there is so much wrong with it that it needs to be completely rebuilt. Just 13 percent think only minor changes are necessary.

[...]

Overall, 57 percent of Americans would be willing to pay higher taxes so that all Americans would have health insurance they can’t lose.

Full poll. Now, where's your cite to actual facts about what "millions of Americans" think?

Wow. Jes gets more worked up, in my view, than almost anyone else here, and it's not even from first hand experience as a victim of our heartless system.

Losing a friend to cancer is not "first hand experience?" Since when?

Of course, the individual would actually have to expend some energy and effort to try to make a good choice and this might just be too much to expect when they can just let somebody else decide for them. Market-based approaches do not favor the lazy.

So it's only out of laziness that people wouldn't be able to make good choices about health insurance, aye? Or is it laziness that makes people say such things? This whole notion of people individually bargaining with many competing insurance companies is completely unrealistic and goofy. If you want a system that's even worse than the empoyment-based system we have now, you've found it.

I don't pretend that government health insurance will be perfect or that all of the problems with our health-care system are even due to the way in which we're insured, but it's pretty clear that we need a public option, probably among other things. And it's even more clear that the last thing we need (other than the sun exploding or something like that) is individuals trying to work this out on their own.

...not to throw everything out and opt for something completely foreign to our experience.

What does this even mean?

Oh I get it, you want to argue about the floor and whther I needed it blah blah,

"And in the end there is a floor in the US, emergency care is available to all"

Quite off the point, someone said there wasn't one, I pointed out there was. I have family and friends who have useed, family it has not served well, it is certainly not a great floor, just an established one. I believe the relevant part of the statement you didn't quote was that we should raise the floor.

Enough for this, I have multiple experiences some good and bad in different places, when it works here it is the best health care in the world, I don't want to give that up to fix the rest. I want both.

Jes takes exception to Sebelius's statement :
dismantling private health coverage for the 180 million Americans that have it, discouraging more employers from coming into the marketplace, is really a bad direction to go.

Jes, I read this as a statement of political reality rather than as an expression of the desired or best outcome, and as probably correct: it's a political calculation that an insufficient fraction of US voters who currently have health insurance are willing to support single-payer, and that this eliminates single-payer one of the achievable outcomes at this time.

And I read this as an indictment of the damage that thirty years of Republican political rhetoric have done to the moral fabric of this country -- that those of us who have much are too fearful of losing what we have to be willing to risk a change that will help those who have not. Our sense of national community, of the common good, has been replaced by a fearful, selfish clinging to personal advantage, with the zero-sum conviction that "if others gain, I must necessarily somehow lose".

"Am I correct that you live in the UK? If so, why do you have such an interest in the US health care system?"

"Wow. Jes gets more worked up, in my view, than almost anyone else here, and it's not even from first hand experience as a victim of our heartless system."

When substance isn't available, use ad hominem.

Gary, I know the comment is yours if it starts with 'Cite, please'. I'll just use your cites, thank you.

Seriously, if you believe that we cannot achieve substantial improvements in quality, access, and costs of health care in the US by making major (not minor) reforms in our private sector based system, some of which have been discussed in this thread and some that have not been brought up here, then just stay on that position.

I believe we should try the reforms before giving into the state solution.

To be fair, Mr. Farber, support for adding the US government as a player in the health insurance market could be plausibly construed as favoring aspects of our current approach, especially as opposed to support for an NHS. Remember, it's "Medicare for all," not "VA for all."

I know, I know, I'm trying too hard to justify an argument by someone who asserts:

Many of us think Medicare operates in strange and costly ways and the future is dim.

which adds to the reams of evidence of an almost total lack of understanding about health care issues.

GOB, I don't know that having a public option and improving the private sector-based system are mutually exclusive. There are (at least) two things at work that have to be considered: insurance and health care-delivery systems. The private side that needs to be worked on in any case is the delivery system. So far, I haven't seen any major proposals under serious consideration for government delivery, just insurance. And even on the insurance side, it think even single-payer for basic coverage can coexist with private insurance for other-than-basic coverage.

"I believe we should try the reforms before giving into the state solution."

The thing is, this kind of assumes that there is something inherently wrong with public involvement as part of the solution.

In this context, I don't see that there is.

"Gary, I know the comment is yours if it starts with 'Cite, please'. I'll just use your cites, thank you."

Have you considered the possibility that a methodology of believing without checking facts, let alone instead first checking facts, and then deciding what it makes sense to believe, isn't a methodolgy to go through life with if you want to actually understand reality?

Belief unconnected to facts is what we call "fantasy." Or, perhaps, "wishful thinking." It seems to be the basis of your general approach to politics. You might want to reconsider the usefulness of it.

GOB, it's not that we disbelieve improvements are possible. It's that we disbelieve they will happen, for practical reasons: they would require insurance companies to settle for less wealth and privilege than they have now, and they always fight to the best of their ability against any such change, even slight ones. Their comments on recission illustrate the point.

It's in light of this half-century-long history that we say, "Since even minor changes would require as much political and social effort as a complete overhaul, let's do it right rather than settling for patches. Use political capital wisely."

An effective counter-argument would have to show insurers acting constructively to broaden rather than restrict coverage, to simplify administration, to provide greater openness about their decision-making, and to do all these things without the threat of imminent litigation and legislation. It's not the possibilities in the system we're concerned with but the possibilities of actually existing entities and the people within them who make decisions.

As it is, you're in exactly the position of communist apologists telling us that just because Stalin and Tito and Mao and all the rest have been awful people is no reason to give up yet on the dictatorship of the proletariat.

GOB: I'm all for reforms and improvements, but thus far you haven't offered any. The one change you posited was doing away with employer based coverage and replacing it with each individual for his/herself.

But I raised a counterargument that you completely ignored. One that gets at the fundamental weakness of your proposition. I'll repeat, again, why individualizing health insurance acquisition will be problematic:

This would only be true if the individual was young, healthy and with no pre-existing conditions. If you don't fit each of those criteria, then you will end up paying much more because no insurer would want you as a client. Through your employer, the costs are spread out so that the infirmed/older individual doesn't get singled out and dinged with extremely high premiums (the employer can negotiate a bulk rate that is attractive to the insurer). The point of government provided insurance is to spread those costs out over an even larger group. That's also the problem with state by state approaches: bigger risk pools are better. At least if the goal is to see all Americans provided the dignity of health care.

"Market-based approaches do not favor the lazy."

It's not that insurance companies fail the people; it's that people fail the insurance companies.

Straighten the great revolutionary unity of the insurance companies!

I'll try to get some more understanding of health care issues. Regarding the 'public option' that some opponents have criticized variously as the first step on the slippery slope to the UK model, as an unfair competitor to the private entities, and as a competitor that is also the referee, I've heard its defenders saying not true to these criticisms, that government rule-making or regulation would be completely separated from the 'public option' entity, that the government would not represent an unlimited source of funding for the 'public option', that this option is not a strategy to eliminate private sector insurers, and Barack Obama himself has said that we will not be forced to change our insurance coverage and our choice of caregivers if the 'public option' is in place.

The question this leads me to ask is, what is the essential difference between 'public option' and a not-for-profit entity similarly capitalized and chartered?

I have yet to see a practical reform to the current market based, private insurance system offered.

Having individuals do their own bargaining is a non-starter. The whole issue of cost of insurance is based upon size of the pool. An individual is a very small pool, thus increasing risk to the insurer, thus increasing cost.

Plus, for all those people who believ in state's rights, remember most of the laws surrounding health insurance are developed at the state level. There are only a few based upon Federal law.

Increasing coverage (and the only practical way of doing that is through a public option) so that most people have access is the best way to reduce overall cost.

In fact, the more people who have coverage, the lower private insurance costs will be as providers will be able to charge less (speaking of hospitals and hospital based doctors) as they do not have to cover as much "free" care.

With a single payor, mandatory coverage, of course, overall costs for employers and individuals would drop significantly as workers' comp insurance costs would be drastically reduced, as would automobile insurance, and a whole lot of other things people tend not to think about.

The question this leads me to ask is, what is the essential difference between 'public option' and a not-for-profit entity similarly capitalized and chartered?

GOB, are you suggesting a private entity that would behave the same as the proposed public entity, but that wouldn't be, strictly speaking, part of the government? If so, why? I'd ask the same question to you - what's the difference?

Shorter GOB:

Surely individual persons will be able to secure a better deal from insurers than a corporation!

To echo Eric's and part of John Miller's comment, the single-payer, universal-coverage system is ideal in terms of the risk pool. It's the ultimate insurance scheme. With individuals going out for their own insurance, you get pools of young, healthy people paying very little for insurance, and you get old, sick people paying lots. The individual scheme begins to approach not having insurance at all and simply paying for your health care out of pocket. It defies the whole point of insurance. Under single-payer, universal-coverage, yes, young health people will put more into the system than they will take out. But old, sick people will take out more than they put in. Maybe this sounds unfair. But young, healthy people, as a group, get to be old, sick people, as a group. It all comes out in the wash over the course of one's lifetime. And if you spend your life putting into the system without taking much out of it, you can consider yourself lucky for being so damned healthy (or unlucky for being hit by a bus something, at which point it won't much matter). Insurance is about security, not about absolute equality or fairness. (Not that anyone is making that argument, but it seems to underly people's thinking at times, as though having a neighbor down the street with the same homeowners' insurance company as you should make you envious if his house burns down, since he gets to take advantage of the insurance and you don't.)

All you really needed to write is "Ed Morrisey is an idiot."

No additional explanation is needed.

Gary

I fail to see how my question to Jes is ad hominem.

dietalics.

I used to harbor secret elation when a neighbor's house burned to the ground, under the religious heading of "There but for the grace of God go I", figuring God's grace was a rationed commodity (oddly shunted my way, but why lookagifthorse without insurance in the mouth) and if everyone wants the same amount of grace as I possess, they can damn well pay for it out of their own pockets.

It says so in the Constitution.

Then, I found out they weren't paying the full cost of the damage to their property because they were in the same insurance pool (starts with "p", rhymes with socialism, I'd say we've got trouble) as I am.

You can imagine how my feeling of grace-tinged superiority turned to one of anger, envy, and regret as I came to understand that I was paying for my neighbor's misfortune and yet my house had not burned down and I certainly wasn't getting an insurance settlement.

I later learned that the same neighbor's post-fetal little daughter had a tumor the size of a cantalope removed from her brainstem at no cost despite her previous short life of shiftless recreation in the front-yard of the aforementioned burned-out shell of a house.

This again, despite the fact that I pay my insurance premiums every month and haven't benefited one bit (not so much as a suspected melanoma).

I did receive a barium enema once but I complained all the way through it that I was sure that part of that procedure was subsidized somehow, somewhere along the way.

That enema didn't sit well with me.

My ideological underpinnings had been corrupted. I have a pristine colon but I don't feel that I deserve it, the state somehow finding its way up there.

The worst part of it is that had to remove my head from my on to allow this subsidized test.

"... remove my head from my colon to allow this..."

GoodOleBoy, this is why sensible people favor universal coverage: so that there aren't points to be scored in cutting people off. The pressure should be to demonstrate that people are getting the help they need and that the program is well administered with that as its goal, and that doesn't happen in the private market.

The history of 1994-2009 is instructive in this regard. That's fifteen years. Three full presidential terms, and parts of two more. Clinton's effort at health care gave warning to the insurance industry that there was substantial public interest in such a thing, and took a very extensive, very dishonest campaign to defeat. In the intervening years, the rising costs and declining reliability of care have been ongoing topics of interest, with polling showing growing public support for public guarantees of coverage. Obama came into power in part on a promise of attending to that desire.

And what do the insurance companies do, fifteen years after their warning? They testify with pride about recission.

You and other advocates of continuing to trust them really need to show us why. In particular, why should we trust them more than, oh, Taiwan's successful step into universal coverage in the 1990s, with its improved outcomes and reduced cost. Show us any point where what we've done compares favorably to that, or any other public plan. Give us reason to believe that the insurers will ever do anything but minimize their outlays at every step, honestly and dishonestly, legally and illegally, while maximizing profits likewise. What have insurers done to warrant this amazing confidence you have in them? What policies show their commitment to public health?

"I fail to see how my question to Jes is ad hominem."

You didn't address any substance of what she said; you simply questioned why she should be interested, because of her location. Your point wasn't about substance, it was about her.

That at 2:09 PM is not me!

What a low business, trolling as someone else. And what a low comment the troll GOB made. I don't want to break posting rules, but the term for that is, first-part 'rat' and second part - well you know....(check with Dick Nixon if you aren't sure).

And yes, I *am* conjuring a reason to resurrect Nixon's moldering political body and drag it around a little. Nixon is the gift that keeps on giving; his political legacy is enormous.

I am feeling very left out. That ubiquitous troll has yet to use my name. You can tell who the troll thinks are the more cogent voices.

'GOB, are you suggesting a private entity that would behave the same as the proposed public entity, but that wouldn't be, strictly speaking, part of the government? If so, why? I'd ask the same question to you - what's the difference?'

Don't we already have not-for-profit health insurance cooperatives around the country? Many complaints in this thread relate to the perceived greed associated with private sector profit motive. I really am in question mode here because I have no knowledge regarding the pros and cons of these cooperatives. But it seems as if you would get something resembling the 'public option' once you figured out a regulatory approach to insure coverage regardless of pre-existing conditions and not allowing removal because of deteriorating health. What does the 'public option' offer that a regulated not-for-profit does not?

The 2:28 and 2:34 pm posts were mine, sent by me.

I admit to conflating myself and someone else's colon for, well, for amusement.

I think we should all fess up and emulate the health insurance industry executives who proudly recited their policies before Congress of paying bonuses to lower level employees for denying coverage to lymphoma sufferers.

Under future Republican administrations, after Obama successfully institutes universal coverage, government will not do that sort of thing.

Government employees will be expected to deny services to lymphoma patients even without the benefit of bonus incentives.

Now that the financial industry executives, health insurance industry executives, and our elected representatives have been completely discredited, if we can figure out what to do with the lawyers, we should be able to commence our recovery.

Just a query: Where were these "single payer or nothing" folks when Dennis Kucinich was scrambling for even the minimum of funding and press attention?

d'd'd'dave:

A: secondary school administrator/former teacher (public service plan)
B: secondary school administrator/former teacher (public service plan)
Z: secondary school teacher (public service/union plan)
B2: nurse (health care plan)
J: Speech therapist (health care plan)
Next circle
S: Can't seem to keep any job for long. Seriously. (no plan, apparently)
C: nurse (health care plan)
M: nurse (health care plan)
D: secondary school administrator (public service plan)
B3: Banker (wealthy)
B4: Industrial magnate (wealthy)
A2: architect (private or employer plan)
J: engineer (wealthy)
C2: Office manager (private or employer plan)
B5: Project manager/real estate (wealthy)
K: Project manager/real estate (private or employer plan)

B4 Is very wealthy, having started with nothing.
B3, J, and B5 are probably in the top 5% income-wise
S: is poor.
Everyone else is probably around median income."

So, from my experience (and I do not know if it it exact), I have added where your friends get their health coverage, and I would say that they all get above average access to health care. Nurses and other health care practitioners usually get good insurance through their employers, and (where my wife works) the practice/hospital waives any out of pocket costs, including deductibles, if you get treated at their facility. School administrators often get public plans, which tend to cover better (or had better with the property taxes continually rising), and only 3 of your group has employer or personal plans, plus the one with no apparent plan.

Your circle is better covered than average.

In mine, only one could be considered wealthy/good employer based, about half have employee plans, one is VA, the rest are private coverage with high ($5000) deductibles and/or public and/or none. And I'm a top quintile type of income distribution.

Sometimes what you see is what you think everyone else has; and I often see that they don't have it. And don't get me started on transitioning between employer based plans. Coverage to COBRA to coverage is a nightmare depending on when the bills are sent.

John Thullen's 2:28 comment is a masterpiece. But damn him for fumbling the punchline and having to correct it at 2:29. If it's technologically possible, I implore the editors to incorporate the correction into the original comment so that when future Google searches for "insurance pool and socialism" turn it up, Thullen's gem will be displayed in its full brilliance.

One point even John overlooks is that a fraction of his insurance premium (his contribution to the pot called "health care spending") pays the residuals of the actors in all those boner pill commercials. Whether that makes John feel better or worse, I can't say.

--TP

"Don't we already have not-for-profit health insurance cooperatives around the country?"

Yes, those do exist. I'm aware of some related to religious denominations, I'm sure there are others.

"What does the 'public option' offer that a regulated not-for-profit does not?"

Universal availability.

Hilzoy:

Why use Bill Gates as a hypothetical example when we have Steve Jobs as a living, breathing, actual example? If he didn't have the means to "relocate" to Tennessee, where the transplant waiting list was the shortest, he'd be without a liver right now. It's a perfect example of the "yes to me, no to thee" phenomenon you're talking about, even if it's not a "highly experimental" treatment.

Group Health Cooperative in Washington is one of the non-profit wholistic systems that is apparently being used as an example of how health care can be changed using non-profits(according to our Governor, anyway). I had surgery there once, and while it reminded me of jiffy lube in the OR, I received good care and easy access to specialists.

Group Health

What does the 'public option' offer that a regulated not-for-profit does not?

GOB - I couldn't really say, but why is that so important? If you're looking for something that does what the government would do, but that isn't government, I'd ask why. I don't see how this highly regulated non-profit wouldn't be subject to as much potential political influence as a government entity. It just seems like you think the government doing anything that could otherwise be done by the private sector is to be avoided. Period. Just because governement is bad, even if it's doing the same thing. What am I missing? Where's the beef?

tgirsch

How much does it cost to catch a flight to Tennessee? $200 dollars? It's one of the lowest cost of living states. How can you seriously say it is not possible for most americans to relocate there?

fraud guy

"Your circle is better covered than average."

I don't quibble with this. However, for the record, the teachers/school administrators are not in the public system and therefore don't get the gold plated benefits that most public employees get.

How much does it cost to catch a flight to Tennessee? $200 dollars? It's one of the lowest cost of living states. How can you seriously say it is not possible for most americans to relocate there?

Wow, either you're missing something very basic and obvious and simple, or I am. How rich do you have to be to move to a new state without a new job lined up, especially with mushrooming medical bills? Do you honestly believe the plane ticket is the only problem, or are you just trolling?

You know, I wasn't as, you say, "stupid" enough to support Kucinich, esp. since I consider myself a moderate.

But all this handwringing over our limited health care reform options begs the question of what exactly self-ID'd "progressives" were prioritizing during the election and why they think single=payer should be on the table at all since the one guy who supported it was given the rhetorical shaft.

-- Paula 2

How can you seriously say it is not possible for most americans to relocate there?

because most americans need jobs to pay their way, and those aren't just handed out on landing at any tennessee airport.

nor can most americans pack their homes and belongings into a carry-on bag to go along on that $200 flight ticket. moving costs real money.

John Thullen, 2:28

If you go back and look at my various healthcare related comments you'll find that I said I am not opposed to a government plan or pooled risk in principle. What I am opposed to is plans where a particular set of coverages is priced to different persons based on income rather than an identical premium amount being charged to each person.

IMHO a government plan is more likely to conflate the tax subsidy aspect of a program with the actual cost savings of a program, so that one cannot determine what is the true price of the thing. The government will sell it to the population as 'i"m saving you money'. Some will hear it as 'the government is efficient and has pushed down overall costs' when in fact, they have lowered the costs to most people by subsidies rather than actual cost reductions.

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