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1/4/2008
San Francisco judge nixes Healthy Wisconsin
Well, not quite. But almost. In a surprise ruling the day after Christmas, a federal judge nixed the city of San Francisco’s “groundbreaking health insurance law…, overturning a requirement that employers cover their workers or pay a fee.”
This is an important article to read. U.S. District Judge Jeffrey White described San Francisco's goal as "laudable" but said its ordinance - the first of its kind in the nation, and a potential model for other California cities and the state - conflicted with a 1974 federal law that prohibits state and local governments from regulating employees' benefits.
That says to me that Healthy Wisconsin is in trouble. Undismayed and undeterred, Wisconsin Senate Democrats have recently trumpeted their intention to reintroduce Healthy Wisconsin as stand-alone legislation. Per the Wausau Daily Herald, after an interview with Senate Majority Leader Russ Decker, “…legislators are rewriting parts of the Healthy Wisconsin bill to ease the burden on small business owners and families earning two incomes before they bring the bill back to committee.” As per its last iteration, “the plan would be funded through a $15 billion payroll tax.” So, when the burden is “ease[d]” on small business owners and two-income families (and even if it isn’t…), just who is going to bear the brunt of this program? And how will Healthy Wisconsin control utilization and costs? Throw away any pretense of risk-sharing
That’s scary enough. But this is really scary. Left-wing blogger Michael Mathias asks why even pretend to create a system of insurance and risk-sharing? Mathias says a health insurance mandate isn’t the answer – because it just hasn’t worked. The most prominent recent example is in Massachusetts, where state officials are now seeking comment on new rules that would fine residents who do not purchase health insurance if they are found to be able to afford it under a murky system of formulas and guidelines. The idea that residents there now have to choose between the expense of a fine and the expense of health care that is increasingly unaffordable is about as onerous a restriction as a state can impose.
Michael, Michael, Michael. The fact remains - just who is going to pay for an increasingly unaffordable health care system? And how will these self-same residents be motivated to play a major role in health care utilization and cost control? (Is there an echo here?) Mathias goes on to say: I think most of us are weary of stories of corporations deciding who gets to live and who gets to die under a system that seems increasingly capricious and harsh and irrational and expensive.
So instead of evil corporations making important health care decisions much less (gasp!) informed individuals via the free market system making those decisions (gasp, gasp!!), Mathias advocates “universal health care coverage provided through a government mechanism.” Who is going to pay for this? How would utilization and costs be controlled? (Have I said that before?) Why would corporations hand over billions to a government with no accountability, and having no assurance of cost containment and no input except via the ballot box. Bad, bad, bad.
Until each and every American owns the costs of their own health care, universal this, or mandated that, is not the answer. America has absolutely got to recognize that.
COMMENTS
The only thing that "America has to recognize" is that a system of private insurance paid medical benefits will continue the course of exactly those things you fear from a government program and I quote:
"with no accountability, and having no assurance of cost containment...."
The "let them eat cake" notion of market based selection of 'services' in a time of medical emergency is ludicrous. You must see that, or recognize it, as all Americans must.
Lon Ponschock (Thu Jan 03 23:16:09 2008)
Lon, the mention of medical emergencies is a red herring that you and other libs must stop falling back on. Of course you're not going to spend 3 hours on the phone doing cost comparisons when you need emergency services. But for elective surgery, ongoing preventive care and care of chronic diseases, yes, we've got to do better at monitoring costs as individual consumers.
Jo E. (Fri Jan 04 03:49:27 2008)
Dr. Ron Paul has mentioned that in the late '60's he worked extra shifts as an E.R. doc for $6 an hour.
Look what the government has done to our money AND our healthcare.
Brian (Fri Jan 04 08:35:25 2008)
This is the discussion of the decade. Many would prefer a statewide discussion, with all parties present, not a unilateral, quick fix, one-size fits all, damn the torpedoes(uh! warning signs) approach the Legislature is proposing.
It took us a while to reach this mess and we should expect it could take a certain time period to work our way to some imperfect, but workable plan. After querying physicians and patients alike, no one is pleased and those who have some real skin in the game have reservations with the current proposals. I don't know about y'all but more taxation in these times could be extremely destructive.
RichardP (Fri Jan 04 11:14:06 2008)
I could see your point if Healthy Wisconsin mandated that employers give health care benefits. But if the employer is not providing the benefit (the state is), I don't see how it can be a violation of federal law.
folkbum (Fri Jan 04 16:35:13 2008)
Folkbum, the SF judge nixed the city's plan because ERISA forbids state and local governments from regulating employee benefits. If Healthy Wisconsin is telling employers to pay 12% of their payroll to the state for provision of health care benefits, is not the state indeed, regulating employee benefits?
Jo E. (Fri Jan 04 22:07:45 2008)
I admit I know very little about public health policy, but I heard somewhere that one of the reasons healthcare is so expensive is because hardly anybody in this country purchases health insurance for themselves and always relies on an employer to provide it to them.
Is this true? If so, doesn't mandating employee health benefits just make the problem worse?
Stephen Flynn (Sat Jan 05 12:51:32 2008)
Absolutely absolutely it's true. That's exactly the point - before we get into ANY universal this or universal that, we must find a way to control utilization and costs (do I sound like a recording?) - and that's got to involve the consumer. The consumer MUST know what he's paying - and must make as many choices as possible (No, Lon, not emergencies... - but we could all be prepared with cost expectations for those as well) with value - and cost-benefit in mind. We must begin to make rational choices when it comes to health care. We must.
Jo E. (Sat Jan 05 13:39:03 2008)
"is not the state indeed, regulating employee benefits?"
No, Jo, it's not; the state would taxing employers to provide a benefit to the state's residents. The state would not be requiring employers to provide any benefits at all.
folkbum (Sat Jan 05 22:12:58 2008)
I don't buy your parsing of words Jay. Employers would be required to provide health insurance or i.e., to pay into a state insurance system. Sounds like regulating employee benefits to me. If the dems want this thing, they're going to have to create state-sponsored, state-run health care and leave the employers out of it. Good luck.
Jo E. (Sun Jan 06 06:52:17 2008)
Jo, I'm not parsing words; I think you're mis-remembering the mechanism by which Healthy Wisconsin would have covered people.
HW, as it was proposed by the Senate, was not an either-or proposition. It was a payroll tax only, with the revenues used to provide a base level of coverage for every single citizen in the state.
Remind yourself how it works
folkbum (Sun Jan 06 13:34:05 2008)
I see how the parsing of my words was not correct - I edited (in henna) so it's more understandable and explains, indeed, Healthy Wisconsin logistics as I understand them and I think, as you understand them. Your understanding of Healthy Wisconsin is exactly right.
The question remains: when the state taxes an employer to provide health insurance to employees, is the state regulating employee benefits? You and I are disagreeing on that answer - which, I suppose, isn't a surprise.
Jo E. (Sun Jan 06 14:45:46 2008)
Government intrusion caused the whole mess in the first place. Prior to WW II, people paid out of pocket for health care and it wasn't too expensive. My mother's family dr. repaired a torn jugular right in his office--the patient had somehow managed to shoot himself in the neck w-a BB gun. His friend plugged the hole and they walked to the doc. I'm sure the victim by having to pay his own bill, learned a bit more about "gun control" (watch where that muzzle is, buddy!)
During WW II, Congress froze wages, and companies started adding health insurance as carrots to entice scarce workers. In the 50's insurance expanded even more, and prices started rising as people became used to going to the dr. for everything. (Like baby "checkups"...I have never taken my kids to the dr. unless sick or injured--guess what, they all lived. Even for shots, if one believes in them, the public health depts give them for free or nearly so--no dr. visit has to be paid for.)
In fact, if you go back further, around the turn of the 20th C, a certain group of doctors got the government to legislate that they and only they, would be allowed to practice medicine, thus cutting out half of the nation's providers, and enabling those left, to raise their fees.
Perhaps the answer would be to STOP all Medicare, Medicaid, the AMA (one of the US's most powerful unions), over-the-top malpractice pay-outs, AND insurance payments (companies) and return to truly free enterprise.
In fact, I believe in the Chicago area there are a couple of drs doing just that: they do not take any type of insurance, thus saving themselves office staff to do billing. People pay when they come to see them, and despite having lower fees, they still make plenty of money, and their patients love them.
Imagine if every dr. operated like that. Wow, all of a sudden people might have to stop eating themselves to death, or using drugs...if they had to pay for it, they maybe wouldn't make so many doctor visits, then drs would have to cut their fees a bit, to get customers. Word would soon get around on who was a good or bad dr, without a cozy state licensing board to protect the bad ones. (Yes, they are out there; I personally have worked with a couple drs addicted to narcotics, one that sent home a patient w-a dissecting aneurysm, another an overdosed toddler...they're still working!)
You'd be surprised how many people already misuse ERs, whether they have "private" insurance, or "public". As long as they do not perceive themselves as having to pay, they will continue to come. In Britain, which also has a health care system it can't afford despite being govt-funded, a lot of people that come to our ERs would be kicked out--I know, I lived there.
I can only imagine how much worse things would get if Nanny Congress took over the entire health care scene. It was bad enough in Britain, and they didn't waste nearly as much as we do.
Emily Matthews (Wed Jan 09 08:48:35 2008)
I pose the following questions:
A) which countries (other than South Africa) have a health care system substantially like ours
B) how do our costs stack up compared to all other industrialized countries
C) how does our overall public health delivery stack up against other industrialized countries
D) which countries in the world want to copy our "system"?
dave allen (Sun Jan 13 07:52:09 2008)
So what are you getting at Dave?
My questions:
What was the FULL cost of the last prescription your family paid for?
What was the FULL cost for the last radiographic service (e.g., mammogram) your family paid for?
What was the FULL cost for the last doctor's visit your family paid for?
What was the FULL cost for the last laboratory test your family paid for?
Did you have the answers at the tip of your tongue or your brain?
When was the last time you "shopped" for the best price for a non-emergency medical service, i.e., prescription drug, lab test, doctor visit, procedure of some kind, etc.?
Jo E. (Sun Jan 13 11:47:27 2008)
My point is that our healthcare "system" is nothing of the sort. It is the laughing stock of the rest of the world which gets far more value for what they pay for then we do. Do other countries get more value for their cost than we do? Absolutely. Do those countries want to privatize their system ? Absolutely not! Do the people in those countries ask their doctor what things cost? Nope, not that I've heard. Should they? Maybe and that would make their systems even more efficient I suppose. But at least they have a system. No one in their right mind would ever design something like what we have.
Do I have to ask what things cost here? You bet, I have an HSA and am also the employer and I can say that the paperwork is astounding and the rules are astounding and , I pay roughly 30% of every dollar delivered for the "pleasure" of the paperwork and I pay more for service rendered than in the other industrialized countries. And, no, I can't get a straight answer about costs and it's not because of the government, its because of the lack of government. Private industry will never provide what is NEEDED unless enforced via a huge inefficient bureaucracy, which is what we have now except the services still aren't provided. No, the answer isn't less government we've been in that mode for 50 years. The answer is that we have a government system as efficiently as social security, or Medicare, or the VA. Look it up, those programs are far more efficient in their cost per unit of service delivery than any of the private providers of equivalent services.
Have no time to respond at the moment Dave; will do so before tomorrow. Several of your points are well made and well-stated - we're coming from the same place of frustration concerning lack of transprency. Grrr. JE
dave allen (Sun Jan 13 13:15:07 2008)
Dave, your points are well made. I appreciate that you indeed know exactly what you're spending for health care. Yes, because of the depths this "third party pay" system has gotten us into, it indeed is a role of government to provide for transparency in pricing. FAST! Absolutely. I agree with you too, about VA efficiency; don't agree on Medicare. So, thanks to the VA, add to the need for transparency, the need for a uniform system of medical information recording and sharing (unbridled adequately - whatever that means - from privacy laws). We're almost on the same page....
What will it take for Americans to not feel entitled to unlimited health care? What will it take for Americans to decrease utilization? - as we are way past pampered in that regard, thanks to absolutely no awareness of costs.
Jo E. (Tue Jan 15 10:20:13 2008)
I have read that there are many reasons why our costs are out of control. Utilization is part of the answer. But what utilization. I suppose you know that the most intensive costs are incurred at the end of life, often when there is no reasonable hope of any meaningful extension of life. (27% in the case of Medicare) I have observed this with a close friend of mine who had cancer. The facts don't show that the majority of people simply over use health care as a normal occurrence although it does happen. Far more impact cost wise is the lack of basic care that leads to intensive care later. Consumer awareness of costs is part of equation. Restriction on heroic measures is a big part of the equation.
dave allen (Wed Jan 16 17:18:56 2008)
I agree 100%. Let's just talk about "restriction of heroic measures." How do we get that done? Via government fiat? Or via family choice? I don't know the answer... except to say, government fiat isn't it. Does it mean if you have extra money and care to use it on end-of-life health care (beyond palliative care), that you can live 6 months longer than the elderly genteman on Medicaid? Yes, in some cases, I guess it does. And that has to be ok. It has to be a matter of choice - similar to the Oregon system. Oregon Medicaid will pay for only certain procedures (hundreds of procedures - but not infinite), ranked by a form of cost-effectiveness. Do you know of the system to which I refer?
Jo E. (Wed Jan 16 17:26:18)
Jo, I have heard a bit of Oregon but will look it up to study. I like your concept(if I interpret it correctly) that health care plans (whether government paid or not) shouldn't be required to pay for non-palliative care. As cruel as that sounds it does in fact happen today but not systematically. Today the care is based on your health plan and how much you or your proxies fight,not what makes sense and therefore costs are driven up overall (from that reason amongst others).
We may differ on the point that I'm going to make next but here it is:
I would rather trust an open government-required or government-run system when it comes to end of life care than the luck of the draw with private. At least you are treated as equals with others.
By the way my friend received tens of thousands of dollars of care under Medicaid (not Medicare) for end state ovarian cancer. As much as I wished she could be with us I knew (as did the doctors) that it was hopeless yet they continued trying different therapies, all to no avail. I couldn't help thinking how much that money could have otherwise helped someone who had a chance. I don't think she lived any longer from the therapies and she sure as hell wasn't any more comfortable. This was in New Jersey.
dave allen (Wed Jan 16 18:42:56 2008)
Several well-stated points. The genesis of our disagreement may be your statement "At least you are treated as equals with others." Life is not fair. Life is not equal. Yes, specified levels/standards of care must be demanded, expected, by our society. But that doesn't mean that one wouldn't be allowed to choose to spend dollars (yes, only if they had the dollars) on whatever procedures or care were individually desired, but deemed non-mandatory by, in the Oregon case, the Medicaid gods. Surely, we have found much common ground.
Jo E. (Wed Jan 16 19:43:15)
I'm with you 100% on everything said
dave allen (Thu Jan 17 07:03:02 2008)
Dave, I don't believe you ever lived in another country or you wouldn't ask such questions, or make such comments. ("How do other countries stack up?" "They get more value")
I can tell you that many un-reported instances of other people coming to America for care they couldn't get elswhere, do indeed happen. I.e. a German baby who needed a repair of a congenital problem; all German drs. REFUSED to do the surgery, as "it cost too much"--the parents took the baby to the US where a dr operated for free. Yet the German papers continually attacked the US system.
Same in the UK, where I lived. Guess what their fastest-growing industry is? PRIVATE HEALTH INSURANCE. Those who can afford it, go for it, beacuse then they can at least get treatment. I had a friend whose child's tonsils were so infected she couldn't eat. She was seen year after year and mom was told "We'll just wait and monitor". Meanwhile, that kid was the sickest, pastiest, most underweight kid you ever saw. Finally they bought health insurance, had the tonsils out, and the kid started gaining weight and looking normal, almost immediately.
Do you really want to know what their system is like?
1. Old Victorian buildings that look like prisons. Patients in wards of 20-30. No decor, dirty floors. I know, this does not health care make--but a lot of Americans are so spoiled that they'd be horrified to "have to put up with" such surroundings.
2. An extremely depressed economy, as NOTHING comes free. When "the government" (ie, taxpayers and industry) have to pay for everyone, the economy CANNOT grow. When I left in 1993, gasoline there was over 2-3 pounds PER LITER. My husband's wage would have topped out at 20,000 per year--he was a teacher.
Think low wages, high prices. We were a family of 6 stuffed into 4 12 x 12 rooms--and we were better off than a lot of folks. When I came here, the US was having a "recession"...I obtained more from rummage sales that summer than in the entire 13 years of my marriage. There ARE no rummage sales there, nobody can afford to get rid of stuff the way people do here. I thought "If this is recession, bring it on!"
3. WAITING LISTS galore--people w-suspected cancer, for instance, may have to wait up to 2 years IN ORDER TO SEE A SPECIALIST, which would, of course, be prior to any treatment. In the meantime, they die. A few years ago, there were a million people on waiting lists, and more than 400,000 waiting over 3 months to see a specialist TO GET ON a waiting list. My husband was on a "short" waiting list for removal of a testicular cyst--"only" a year.
4. A callous approach to life--eg, their much-trumpeted "dismal American neonatal death rate". HAH! In the UK, many babies would not even be looked upon as neonates--they'd be called "miscarriages".
I was about 31 weeks pregnant when I had some bleeding, and the dr callously said "there wouldn't be anything they could do". 31 weeks is LATE. Here, the woman would be thoroughly checked out; hospitalised if necessary. Over there, they didn't even have me in for an appointment. I have a friend that just had a baby 15 months ago, at 27 or 28 weeks. He's very much alive, yet wouldn't be COUNTED AS A NEONATE in the UK.
Every once in a while there are horror stories of parents whose baby DIDN'T die right away, pleading for treatment (like a simple incubator) for their child. Sometimes they're lucky, sometimes not
Right now, we are concerned for my mother-in-law. Here, if an elderly person falls and/or doesn't want to eat, (like her) they are checked for possible urinary tract infection (UTI), pneumonia, heart trouble, and stroke (if symptoms warrant). UTIs are very commonly a cause of altered mental status and weakness, and the test is one of the cheapest. Yet the drs. there refused to do even as much as that...she's old so they don't care. They just want her to die. (This is not idle iamginings; one elderly friend wrote to us and said she was terrified because she knew she wouldn't get treatment if she got sick).
5. No technology. I do question whether we ought to have cutting-edge technology, but we do. THEY don't. How would you like it if you had a pulmoray embolism, or a brain aneurysm and there was no CT scanner? Or the dr. didn't feel like sending you for one? Read "When the Air Hits your Brain" tales of neurosurgery. Its author spent some time in the UK--what he says is TRUE.
6. ER--what can I say about ER? Casualty, as they call it. Ambulance patients brought into the lobby, to wait along with everyone else. Here, they go straight into ER thru the ambulance door.
What about the woman whose son had a testicular torsion about 5 years ago? This is an extremely painful medical EMERGENCY. She was sent to 3 different hospitals because the first 2 "didn't have the capability to do pediatric conscious sedation"--absolutely necessary, as reducing the torsion is excruciating without it. This boggles the mind!
At the 3rd hospital, where there were dirt and pubic hairs on the floor under the table, they just reduced it without any pain meds whatever. So all the running around (to get conscious sedation) was useless anyway. Can you imagine the torment the 4-year underwent?
Finally, you have to understand the mentality of the populace in Europe. Most people practically have to be dragged kicking and screaming to get them to go to the dr.--not so here. We're a lot more pro-active. I eblieve this mentality plays a large part in why their systems aren't more broke than they are--for, broke they surely are indeed.
Emily Matthews (Tue Jan 22 18:37:38 2008)
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