Personally I don’t think this country is going to fix our problems. Greg Palast is right, we are an armed madhouse.

MarkW’s (@ # 100) preoccupation with gaining power first before any debate over public policy is a dodo – public policy infrastructure should be a vital component of any metric/benchmark to assess the suitability of elected representatives. He is right @ #102 that over referral or prescription can be a problem. Problems, however, can be tackled. A single payer system usually encourages the adoption of sensible benchmarks to undertake meaningful cost-benefit reviews which should be regular periodic audits of all publicly funded legislative programs. Such audits need to be robust enough, they usually are in many OECD countries, to highlight malpractice. Elected legislators need to specify penalties and be prepared to implement them through open and accountable processes when such malpractices are uncovered. After all, it was the revelation of unusually high incidence of caesarian deliveries on Thursdays and Fridays relative to Saturdays-Wednesdays inclusive that started to see a more even distribution of caesarian and natural deliveries throughout the week. They stll remain somewhat skewed but way better than they were from the mid 1980s to late 1990s.

Also, there is a an entity called the Fringe Benefits Tax (FBT), levied on employers only. There is no reason why employer funded health cover cannot be relegated as a fringe benefit that employers are taxed for. Such an FBT can be tacked onto legislation for a taxpayer funded universal health care legislation that cuts out private corporations from the game. This also has the potential to encourage the inclusion of access to health care as an important determinant of poverty.

Finally, perhaps US needs to reflect that US is ranked 27th in the world by the OECD for access to health care and the French (cheese eating surrender monkeys) as Number 1.

This is beyond EPU’d but I thought I should once more point out: there are limits to false transfer pricing because the IRS looks out for it.

As I understand it (and I certainly could be wrong, being neither a PhD economist nor a tax maven) that means that much of the profits were suddenly in Canada.

Not as much as you might think. The part might only have been $100 wholesale. The value add (wages and profits from the activity of assembly) really did happen in Canada, so not all that $400 markup is fake. And anyway, some of that $400 markup would still accrue to US entities down the production chain, like the distributor and the retail dealer. People tend to overestimate the contribution of materials costs to the “fair” price of a retail item.

And anyway, I’m not sure this is a good example for your argument. Canada isn’t exactly a low-tax haven. Firms moved car assembly there because costs were lower. This reflects a better public education system and (ta da!) lower health care costs, as well as lower absolute wages. The US health system is one of the things killing your car industry.

As I noted earlier, the US already does this citizen-based taxation for individuals for people living overseas. Other countries do not do this. Personally I think it is rude to tax people for income that had nothing to do with the US.

Anyway I’ll stop now coz I doubt anyone is still reading this thread.

Well, the same sort of thing happens in other countries when you move final assembly there. I used Canada, not because it is a low tax domicile (it isn’t) but because I knew this had occured. Same thing happens elswhere, add low tax domicile, voila.

I’m not all that concerned about citizens, I’m concerned with corporate entities, myself.

Which isn’t to say you aren’t necessarily right that I’m, er, wrong, that this is a big issue or that this is a good solution. I’ll look into it more.

As I understand it (and I certainly could be wrong, being neither a PhD economist nor a tax maven) that means that much of the profits were suddenly in Canada.

Not as much as you might think. The part might only have been $100 wholesale. The value add (wages and profits from the activity of assembly) really did happen in Canada, so not all that $400 markup is fake. And anyway, some of that $400 markup would still accrue to US entities down the production chain, like the distributor and the retail dealer. People tend to overestimate the contribution of materials costs to the “fair” price of a retail item.

And anyway, I’m not sure this is a good example for your argument. Canada isn’t exactly a low-tax haven. Firms moved car assembly there because costs were lower. This reflects a better public education system and (ta da!) lower health care costs, as well as lower absolute wages. The US health system is one of the things killing your car industry.

As I noted earlier, the US already does this citizen-based taxation for individuals for people living overseas. Other countries do not do this. Personally I think it is rude to tax people for income that had nothing to do with the US.

Anyway I’ll stop now coz I doubt anyone is still reading this thread.

A couple of years ago the CBC made a two part miniseries on him, appropriately titled “The Tommy Douglas Story”. I recommend it to all.

One thing of note about that conversion in Canada, which politician’s touch at their peril, is that it wasn’t easy. The VRWC spread every lie imaginable against Douglas, and for the record, that involved very much a sad, negative US influence in Canadian affairs. Even Canada’s federal government behaved quite shamefully to those ends.

But Tommy started something special. He’d lived through the depression, and experienced first hand, in his family, and in the church where he preached, the pain many families had to bear when medical attention wasn’t available due to cost. Many people were too proud to seek (or submit to) the charity of private hospital administrators, and suffered due to lack of care.

Saskatchewan was not a wealthy province at the time Douglas brought in his vision of a government funded system, and perhaps that’s what made it so necessary. After it began, and the nightmare scenarios never played out, any politician in the entire country who wanted to be elected had to deal with citizens who demanded that Saskatchewan’s model was what their province needed. Douglas ran the system so well that not only did the sky not fall, nor the Commies take over, nor did all of the medical professional flee screaming, but the value he delivered to his constituents was undeniable. On top of that, there was plenty of work for the medical professionals, since so many more were now covered.

For all of its faults, I assure you that the negative HMO-Insurance industry spin on Canada’s health care system is just that — spin. Health care is expensive without excessive profit-taking and massive marketing campaigns to pay for. Our wait times are longer for some surgeries (hip replacements, for instance), and some of our wealthier citizens do cross the border for faster service, but we cover all of our country’s citizens (and landed immigrants) without asking directly for money. As experimental treatments become accepted, the provinces (health care is a provincial jurisdiction) begin to pay for them. They also, as any insurer, deal with disappointing amounts of fraud.

My hope for the future is that the cost of pharmaceuticals will be covered, as the increase in their costs is too substantial to be ignored. Currently our drug costs are covered by the US style system — if you or a family member get coverage through employment. This is getting harder to find for the lower skilled workers in our country. There is also talk about covering some dental care…and I support reasonable coverage wholeheartedly.

Please don’t construe this as a Canada vs USA competition…I’ll even hand ya the blue ribbon myself. This is about a common good — and it seems more of the wealthy don’t subscribe to shared values unless it involves lining their pockets.

I love FDL, and what a great post, Ian. I was really pulling for Ned Lamont in November, along with so many of you. Here’s a wealthy guy who put himself out there when he didn’t need to, and talked about subjects so many in Washington, like Conneticut for Lieberman, seem to laugh at in private. Lamont talked about health care, and other issues, not just the Iraq mistake. I hope he runs again. He’s a leader, not a status quo prick trolling for bucks.

Come into the single-insurer water…the temperature is fine. For all of the talk about a two tier system in Canada, the overwhelming majority of Canadians are repulsed by the thought. When Douglas first spoke about his vision, he had a tough fight against the doom & gloom crowd. The best part about imagining a similar system in the US is that there’s nowhere for the doctors to flee. THAT must make it a bit easier, if only a bit.

For example, how easy it is to overeat even healthy caloricly dense foods like nuts or dried fruit, and how less dense foods may be more filling. Or how eating less more often, and eating fiber, protein, or fats with simple carbohydrates, may help keep your blood sugar (and hence insulin) from spiking and plummeting. Or how limiting one macro-nutrient group (such as fat or carbs) can help some people lose weight (it leads to overall reduction of caloric intake) but why it often fails, too.

Saying it’s simple also ignores how undiagnosed/untreated endocrine and other medical problems may make it next to impossible for some people to lose weight. I say this as someone who, despite diets and lots of exercise, could never lose even five pounds… until they diagnosed one of those problems.

I’ve lost seventy pounds since then.

I know that’s not what this post was about, but that erroneous belief is one held by a lot of people, including many who could benefit from a more detailed (complicated) understanding. Thank you for your patience.

Thank you, Mike @ 95. I’m glad that you agree. I have a few more comments on health insurance.

I am self-employed and pay for my own health insurance. Last year I switched to a high-deductible insurance plan that allows me to use a Health Savings Account. I love it for many reasons. One reason is this … My premium plus what I contribute to my HSA is almost exactly what my premium would be under my old plan. I can pay for any medically necessary product using my HSA. What I don’t spend stays in my HSA, and if I do spend it all, my insurance covers the rest 100%.

I thought long and hard before I switched because I couldn’t see a downside, and I found that hard to believe. I finally decided there isn’t one.

Also, my doctor stopped accepting HMO and PPO plan reimbursement and I pay out of pocket when I see him. Now I pay from my HSA with pre-tax dollars. He gets the money directly from me without the insurance company taking a cut. I am covered for big things, like ER visits and surgery, and self-insure for the smaller expenses. I think this is ideal.

Compare our health insurance system (and Canada’s too, I presume) with auto insurance. My auto insurance doesn’t pay for routine maintenance. If it did, I’ll bet a tune-up would cost $1,000. As P.J. O’Rourke said, “If you think health care is expensive now, wait until you see what it costs when it’s free.”

As you might suspect, I do not favor a single-payer system. I think that letting health consumers decide how to spend their own money, or to keep it, would provide a lower cost and fairer system.

Tying this back to the original post, I doubt this is “simpler” than a single-payer system, but I’m convinced it would lower the national cost of health care while allowing individuals to tailor the health care they consume.

Mark

As P.J. O’Rourke said, “If you think health care is expensive now, wait until you see what it costs when it’s free.”

Look at the chart. Medical care does not lend itself to markets. Back in the early 80s, I supported PPGP, because it was clear that fee for service was broken. People were being overtreated because it made money for doctors. Unneeded hysterectomies and tonsillectomies were pandemic.

But privatizinng care through PPGPs hasn’t worked either. Profit motives have led to HMOs cherry picking, and to undertreat. Undertreating, one would think, would save money, but it doesn’t. They spend a lot of money trying to not pay for treatment, that still has to be paid for. So instead of just the fee, you’ve got the fee, the CPT code reviewers at the insurance companies, the extra staff in the doctors’ offices and just lots and lots of expensive administrative costs.

I can see, as a transitional program, a mandatory high deduction insurance program provided by the US government. But it’s nonetheless the case that the best medical care is being delivered by single payer plans.

A while ago, Brad Delong had discussion up about the left vs the right on medical care issues. He said (or quoted someone saying) that really what this breaks down into is people who worry about adverse selection vs people who worry about moral hazard. People on the left want universal coverage, because they fear adverse selection– people not partipating during the periods of their life when they are not at risk of getting really sick. People on the right fear moral hazard–that people, given “free” medical care will demand overtreatment.

So lefties advocate free universal care, while righties advocate HSAs. Universal care means that everybody’s covered, even if they happen to be very unlucky, while HSAs means that people don’t go to a doctor whenever they have a hangnail.

I’ve never found the moral hazard argument persuasive. I hate to go to the doctor. I hate taking pills. I hate having my lifestyle choices reviewed by someone who barely knows me. My brother’s a pediatrician, and if anybody is going get patients who want to overtreat, it’s gonna be pediatricians, because the decision maker over care is not the one who has to get poked and prodded. Overtreatment really is not a problem, but dealing with insurance companies is a constant problem.

It’s true that there are people who go to see their doctor for, essentially, entertainment value, but those patients are rare and they have been dealt with under other health care regimes.

And, at the end of the day, you have to recognize that this system, as a whole, is failing to cover a large fraction of the population, and is doing an awful, very expensive job on the fraction it does cover.

People look forward to being on Medicare. Now you, concerned about moral hazard, may think that’s because they’re going to demand overtreatment. But in fact, they look forward to it because it so much less hassle. They don’t have to negotiate every visit, deal with rejected meritlessly rejected claims, hoard thie ration of pills for chronic, but not constant conditions.

Everybody hates the system as it is–patients, doctors, employers–except the insurance companies, big Pharma, and politicians who keep that money flowing.