Social Health Insurance – The Moral Healthcare Blog

What Is ‘Socialized Medicine’?: A Taxonomy of Health Care Systems – Economix Blog – NYTimes.com

What Is ‘Socialized Medicine’?: A Taxonomy of Health Care Systems – Economix Blog – NYTimes.com:

“Socialized medicine refers to health system in which the government owns and operates both the financing of health care and its delivery. Cell A in the chart represents socialized medicine.

“Social health insurance, on the other hand, refers to systems in which individuals transfer their financial risk of medical bills to a risk pool to which, as individuals, they contribute taxes or premiums based primarily on ability to pay, rather than on how healthy or sick they are.”
………..
“Former Mayor Rudolph Giuliani of New York has exemplified the perennial confusion in this country over socialized medicine. In his ill-fated presidential bid, and subsequently as a supporter of Senator John McCain’s bid for the presidency, Mr. Giuliani routinely decried as socialized medicine (or “socialist”) any proposal presented by Democratic candidates, because typically the latter advocated tax-financed subsidies toward the purchase of health private insurance or expansions of public insurance programs. But technically none of them advocated socialized medicine.

“Perhaps Mr. Giuliani was unaware that Americans all along the ideological spectrum reserve the purest form of socialized medicine — the V.A. health system — for the nation’s veterans. I find this cognitive dissonance amusing. Indeed, if socialized medicine is so evil, why didn’t Republicans privatize the V.A. health system when they controlled both the White House and the Congress during 2001-06?

“Mr. Giuliani also seems to forget that, in 1996, he found social health insurance a perfect solution to the financial problems faced by former Mayor John V. Lindsay, who fell on financially hard times during the 1990s as a result of chronic illness. “

The chart in the piece is a little tough, the text is better, specifically the first two paragraphs above.

But to me, the key is do we want to continue to decide who can get health care and health insurance based upon their luck? And I don’t mean luck in being financially successful, I mean luck in not getting a chronic, life threatening, debilitating illness. And if we get lucky, and make it to Medicare without a big illness, do we really want to rely on that luck holding out for our children, our nieces and nephews, our grandchildren? I don’t.

Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries — American College of Physicians, — Annals of Internal Medicine

Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries — American College of Physicians,:

When we were talking last week about the lack of single payer advocates at last week’s summit, I didn’t realize that ACP was there. The President of the ACP was there, though I don’t know his persoanl feelings about reform, I did go back and look at the recommendations published by ACP last year.

“Paying for Health Care

“Recommendation 1a: Provide universal health insurance coverageto assure that all people within the United States have equitableaccess to appropriate health care without unreasonable financialbarriers. Health insurance coverage and benefits should be continuousand not dependent on place of residence or employment status.The ACP further recommends that the federal and state governmentsconsider adopting one or the other of the following pathwaysto achieving universal coverage:

“1. Single-payer financing models, in which one government entityis the sole third-party payer of health care costs, can achieveuniversal access to health care without barriers based on abilityto pay. Single-payer systems generally have the advantage ofbeing more equitable, with lower administrative costs than systemsusing private health insurance, lower per capita health careexpenditures, high levels of consumer and patient satisfaction,and high performance on measures of quality and access. Theymay require a higher tax burden to support and maintain suchsystems, particularly as demographic changes reduce the numberof younger workers paying into the system. Such systems typicallyrely on global budgets and price negotiation to help restrainhealth care expenditures, which may result in shortages of servicesand delays in obtaining elective procedures and limit individuals’freedom to make their own health care choices. [CMHMD Note: I guess it shows how complicated this all is. ACP considers Japan single payer and France a hybrid sytem, but most consider both single payer. In any case, neither have significant problems with waiting times.]

“2. Pluralistic systems, which involve government entities aswell as multiple for-profit or not-for-profit private organizations,can assure universal access, while allowing individuals thefreedom to purchase private supplemental coverage, but are morelikely to result in inequities in coverage and higher administrativecosts (Australia and New Zealand). Pluralistic financing modelsmust provide 1) a legal guarantee that all individuals haveaccess to coverage and 2) sufficient government subsidies andfunded coverage for those who cannot afford to purchase coveragethrough the private sector. (See the ACP’s proposal for expandingaccess to health insurance as an example of how a pluralisticsystem can achieve universal coverage [69].)

“Recommendation 1b: Provide everyone access to affordable coverage—whetherprovided through a single-payer or pluralistic financing model—thatincludes coverage for a core package of benefits, includingpreventive services, primary care services—including butnot limited to chronic illness management—and protectionfrom catastrophic health care expenses.

“Recommendation 1c: Until there is political consensus for achievinguniversal coverage at a federal level, Congress should encouragestate innovation by providing dedicated federal funds to supportstate-based programs with an explicit goal of covering all uninsuredpersons within the state. (See the ACP position paper, “StateExperimentation with Reforms to Expand Access to Health Care”[70].)

“[ACP]Comment: Universal health care insurance is necessary to ensurethat everyone within the United States has access to neededhealth care services of high quality. The federal governmentshould assure that all persons within the borders of the UnitedStates also have access to health care services without unduefinancial barriers and that health care services provided areadequately reimbursed. The ACP recommends 2 alternatives: asystem funded solely or principally by government (federal andstate), commonly known as a single-payer system, or a pluralisticsystem that incorporates existing public and private programswith additional guarantees of coverage and with sufficient subsidiesand other protections to assure that coverage is available andaffordable for all. The ACP has proposed a step-by-step planthat would achieve universal coverage while maintaining a pluralisticsystem of mixed public and private sector funding.”

^{——————————————}

^{SO, ACP advocates either a single payer model, or a social health insurance model (i.e., a hybrid system) as the path to paying for universal health care. This is where I come down as well. I think it would be very useful if we could get a majority of physicians to accept this either/or approach with the caveat that we vigorously campaign to allow NOTHING LESS than this to be our line in the sand.}

EzraKlein Archive | OBAMA’S HEALTH CARE PLAN EXPECTS AN INDIVIDUAL MANDATE.

EzraKlein Archive The American Prospect:

“Administration officials have been very clear on what the inclusion of ‘universality’ is meant to communicate to Congress. As one senior member of the health team said to me, ‘[The plan] will cover everybody. And I don’t see how you cover everybody without an individual mandate.’ That language almost precisely echoes what Senate Finance Chairman Max Baucus said in an interview last summer. ‘I don’t see how you can get meaningful universal coverage without a mandate,’ he told me. Last fall, he included an individual mandate in the first draft of his health care plan.

“The administration’s strategy brings them into alignment with senators like Max Baucus. Though they’re not proposing an individual mandate in the budget, they are asking Congress to fulfill an objective that they expect will result in Congress proposing an individual mandate. And despite the controversy over the individual mandate in the campaign, they will support it. That, after all, is how you cover everybody.”

While I favor a single payer system as the best solution, it doesn’t take a rocket scientist (or Ezra Klein) to see where the winds are blowing.

I have become comfortable with this approach. Although mandates have not worked out as well as we’d like in Massachusetts, it is hard to argue that they have not worked in Switzerland, Germany, Japan and other countries. I would argue that the chief differences are two:
1.) Spending enough money to actually give everyone a comprehensive benefits package (think Medicare, not Medicaid)
2.) Serious regulation of private insurers so that they cannot cherry-pick, deny, drop, obfuscate, etc

If we spend enough money in some private-public mix and if we regulate the insurers so they function more like the contractors who cut the checks for Medicare (the regional “carriers”) and we subsidize those who cannot afford health care or insurance, we may not have single payer, but we will at least have a truly universal, fair, system.

AND THEN, if we still think we need to, we can work on transitioning to a true single payer system.

OK, let me have it.

Cheers,

Annals of Public Policy: Getting There from Here: Reporting & Essays: The New Yorker

Annals of Public Policy: Getting There from Here: Reporting & Essays: The New Yorker:

“Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” In the battles between Betamax and VHS video recorders, Mac and P.C. computers, the QWERTY typewriter keyboard and alternative designs, they found that small, early events played a far more critical role in the market outcome than did the question of which design was better. Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area—even if prices, taxes, and competition are stiffer. “The long shadow cast by history over location is apparent at all scales, from the smallest to the largest—from the cluster of costume jewelry firms in Providence to the concentration of 60 million people in the Northeast Corridor,” Krugman wrote in 1991.
With path-dependent processes, the outcome is unpredictable at the start. Small, often random events early in the process are “remembered,” continuing to have influence later. And, as you go along, the range of future possibilities gets narrower. It becomes more and more unlikely that you can simply shift from one path to another, even if you are locked in on a path that has a lower payoff than an alternate one.”

It’s actually hard to get a representative paragraph out of this article. It is definitely worthwhile reading, as is everything Gawande writes, and begins with an overview of how universal healthcare took hold in England, France and Switzerland, and then makes the case for “path dependence”, which starts the section I’ve quoted above.

Because I haven’t written it in a while, Ill repeat a story. At a debate among single payer advocates and antagonists at Duquesne University last year, I asked the representative of the very right wing Fraser institute of Canada, which of the world’s nations systems he could live with us modeling ourselves after. Switzerland was the answer, and he conceded that the hybrid of using competing insurers and providers while requiring universal coverage with subsidies may be the second best solution for America. After laissez–faire capitalism, of course.

But it does make the point that the combination of path dependence and bits of common ground could lead us to real change.

FORA.tv – Zeke Emanuel: Scrapping the Health Care System

FORA.tv – Zeke Emanuel: Scrapping the Health Care System (Audio only here– You may have to register.)

A lecture done for the Commonwealth Club of California on January 8, 2009.

As in his book, “Healthcare Guaranteed“, he lays out his case for Health Care reform, which is for a social health insurance program. I actually agree with him, and he makes his case well. I think he gets a couple things wrong, in a way that is not helpful.

First, he spends some time being very dismissive of the single payer option. His arguments are two-fold. First, making a system work for 300 million people is impossible. Second, that continuing a fee for service system makes cost control impossible.

I happen to agree that working for a social insurance model is the best way to go, for a variety of reasons, that he covers well.

However, he is almost patronizing of those who advocate for single payer. This wouldn’t be so bad if he hit the mark on his criticisms, but he does not. And it irritates and antagonizes those who would naturally on his side, if he persuaded instead of ridiculed.

Regarding managing 300 million accounts/people/policies: Our current Medicare system does not attempt to manage all of its members within a single entity. Medicare functions as the central agency, but regional carriers handle the day to day operations. And in Canada, the single payer system is broken into manageable chunks by province. There is no reason we could not implement our system in such manageable chunks.

His second argument is that fee for service is the real problem, not insurance company waste, and that we will get the most bang for our buck with payment reform rather than cracking down on insurers.

Maybe there are single payer advocates who advocate for the current reimbursement system, but I don’t know any of them. So, in that sense, it is a straw man, but he really loses me when he he argues that we cannot have high performing, efficient organizations like the Cleveland Clinic or the Mayo Clinic under fee for service. I’m sorry, but those systems operate in a fee for service payment system. They have done some unique things within that system, but they are a model of how to make a fee for service system work properly. So, attacking single payer because it mandates no reform in payment models is silly and it antagonizes people who should be engaged, not belittled.

He additionally makes the case that insurance companies are not to blame for our problems and indicates that most of us would behave as these execs and employees would if placed in the same circumstances. Fine, I’ll concede that, but the problem, single payer advocates point out is that the circumstances are the problem, not the employees. A system that rewards denial of care leads to massive bureaucracies designed to deny care. So, sorry, they are a big part of the problem.

And, while I’m in a critical mood, I do have a problem with suggesting VAT as a method of payment. We already have the most byzantine taxation system in the world. Why add another layer of complexity that will surely be more regressive into the mix. If you want to fund via taxes, fund via taxes. At least the income tax is somewhat progressive. And people are not completely stupid: if you tell them their taxes will go up $8000 but they won’t have to pay $12,000 in health insurance premiums and another $1000 or two or three out of pocket, they’ll get it.

This is intended in a spirit of constructive criticism so that we can advance the debate together.

A Structural Description of Social Health Insurance

A structural description

When one moves from this inside view to a more detached, outsider

’s perspective, SHI systems can be described in more structural terms. This structural understanding incorporates seven core components that exist across all eight studied countries, and that can be considered to comprise the organizational kernel of an SHI system.

Risk-independent and transparent contributions

The raising of funds is tied to the income of members, typically in the form of a percentage of the member’s wages (sometimes up to a designated ceiling). This has two equally important characteristics. First, contributions or premiums are not linked to the health status of the member. If a member has a spouse and/or children, they are automatically covered for the same income-related premium and under the same risk-independent conditions. Second, contributions or premiums are collected separately from state general revenues. Health sector
funding is transparent and thus insulated from the political battles inherent in public budgeting.

Sickness funds as payers/purchasers Premiums are either collected directly by sickness funds (Austria, France, Germany, Switzerland) or distributed from a central state-run fund (Israel, Luxembourg, the Netherlands) to a number of sickness funds (Belgium employs both methods). These funds are private not-for-profit organizations, steered by a board at least partly elected by the membership (except France and Switzerland), and usually with statutory recognition and responsibilities (Israel is an exception). The rules under which these sickness funds operate typically are either directly established by national legislation (Austria, France, Germany, Luxembourg, the Netherlands, Switzerland) and/or tightly controlled through a state regulatory process (Israel) (Belgium is an exception). The sickness funds use the revenues from members’ premiums (health tax in Israel) to fund collective contracts with providers (private not-for-profit, private for-profit, and publicly operated) for health services to members.

Solidarity in population coverage, funding, and benefits package Depending on the country, 63 per cent (the Netherlands) to 100 per cent (France, Israel, Switzerland) of the population are covered by the statutory sickness fund system. In countries with less than 100 per cent mandatory participation, typically it is the highest-income individuals who are allowed (Germany) or required (the Netherlands) to leave the statutory system to seek commercial
health insurance on their own (small exceptions exist for illegal immigrants, for people with objections by principle and for civil servants). Funding for all members is equalized either within national state-run pools (Israel, the Netherlands); within regional government (Austria) or foundation-based (Switzerland) pools; through mandatory risk-adjustment mechanisms (Belgium, Germany, Israel, the Netherlands); or through state subsidies (Belgium, France). In all eight SHI systems, the state requires the same comprehensive benefits package for all
subscribers.

Pluralism in actors/organizational structure SHI systems incorporate a broad range of organizational structures. Both within as well as between SHI countries, the number and provenance of sickness funds may vary widely, based on professional, geographic, religious/political and/or non-partisan criteria. Nearly all hospitals, regardless of ownership, and nearly all physicians, regardless of how they are organized (solo practice, group practice etc.) have contracts with the sickness funds and are part of the SHI system. Professional medical associations, municipal, regional and national governments, and also suppliers such as pharmaceutical companies are all seen as part of the SHI system framework.

Corporatist model of negotiations
Negotiations typically occur at regional and/or national level among ‘peak organizations’ representing each health sub-sector involved. This corporatist framework enables the self-regulation and contract processes to proceed more smoothly, with substantially more uniformity of outcome and substantially lower transaction costs. A corporatist approach among a group of ‘social partners’ (sick funds, health professionals, provider groupings and supplier groupings)
is also consistent with policy-making arrangements in other parts of the social sector in the seven studied European countries (less so in Israel).

Participation in shared governance arrangements
As befits the pluralist configuration described just above, SHI systems typically incorporate participation in governance decisions by a wide range of different actors. The most visible manifestation is the traditional process of selfregulation by which sickness funds and providers negotiate directly with each other over payment schedules, quality of care, patient volumes and other contract matters. Medical associations, hospital associations and other professional groups frequently have some decision-making responsibilities as well.

Individual choice of providers and (partly) sickness funds
Members of sickness funds can usually seek care from nearly all physicians and hospitals. In six of the eight studied systems, a referral to see a specialist is not required (Israel and the Netherlands are exceptions). Increasingly, members can also choose to change their sickness fund (Austria, France and Luxembourg are exceptions).

These seven characteristics – risk-independent contributions, sickness funds as
payers, solidarity, pluralism, corporatism, participation and choice – comprise
what is described in many writings about SHI systems as the ‘core structural
arrangements’ (Glaser 1991; Hoffmeyer and McCarthy 1994; Normand and
Busse 2002). Combined, they can be taken as the institutional mechanics of how
an SHI system is organized.

Mayo Clinic Health Policy Center Recommendations

IV. Provide Health Insurance for All

Provide guaranteed, portable health insurance for all individuals, giving them choice, control and peace of mind.

Requires action from: Insurers, employers, the government and individuals

Require adults to purchase private health insurance for themselves and their families. Employers could continue to participate by buying insurance for their employees or giving them stipends to purchase it. However, the individual could own the insurance.
Appoint an independent health board (similar to the Federal Reserve) to provide a simple coordinating mechanism for individuals to select a basic
private insurance option. Allow people to purchase more services or insurance,
if they choose.
Provide sliding-scale government subsidies to help people with lower incomes
buy insurance.
Realign the health system toward improving health in addition to treating
disease.

This is, more or less, a Bismarckian or “sickness fund” type system. I would argue against leaving the employers in the loop, as salaries/wages can easily be designed to provide appropriate compensation without including it as a benefit. Just makes it easier to administrate.

I’d further argue that a more strenuous effort needs to be made to make the benefits provide and the cost to consumers of a “standard” policy uniform accross the nation. The way other countries have done this is to stricly regulate the costs and benefits of the basic plan very rigidly, and then allow insurers to compete in the non-basic elements of a plan, such as optical, dental, wellness, etc.

I think this approach will win support from essentially all Democrats and more than a few Republicans. It seems to already be in the works.