Er, all three of the links point back to the original un-moderated discussion thread....

And a handful of further observations:

Medicare's only one of the three big federal gatekeeper bureaucracies, and the other two do have substantial wait/denial issues. The Oregonian just ran a big feature on the Social Security disability system, and then there's the VA, which is very good for some things and backlogged out the wazoo for others. Given the funding pressures on a prospective universal-coverage bureaucracy, I'd bet on such a bureaucracy bearing greater resemblance to the SS disability engine than to the Medicare engine.

Medicare also generates some interesting market-driven fallout: certain Medicare benefits (the most visible being powered wheelchairs & diabetes or asthma meds) generate enough payout that large for-profit businesses have sprung up purely because it pays them to sign as many people as they can up for that particular benefit, and then charge the government rather than the patients for the service. The issue of whether this is a Good Thing or not is open to disagreement, but it's definitely an artifact of the way Medicare has evolved.

The original "Oregon Health Plan" as developed by state Senator/later Governor John Kitzhaber -- an insurance-based system funded mostly by federal Medicaid money once a slew of waivers had been pushed (with great difficulty) through Congress -- was very much a rationed-care model, yet didn't get the socialized medicine stigma. It also actually worked, more or less, for a little while, but over time funding eroded and access became more complex, to the extent that it's not really what it was meant to be anymore.

Oops...fixed the link. Thanks.

As for the OHP, that was collapsing about the time I first moved to Oregon, apparently due to a conservative attack on its funding base.

I really don't understand why you don't think we can accomplish what dozens of other nations have done.

You don't think this profit-driven beast has a bureaucracy built in?

Well, the VA system is really only supposed to deal with "service-related" problems. So, although I am a veteran, the first part of any process for me to get VA benefits would be to prove that my illness is related to my service.

I think the Social Security disability system is similar, in that they don't want just anybody on the system, only those that truly can't work.

I’ve been reading most of the comments and I have yet to see anything about one part of health care that is universal and is socialized in many parts of the USA: pre-hospital emergency care brought to you by your friendly local EMTs. Whether it a fire district, fire department, or ambulance corps that is responding, our services are paid for by taxes. There are some fees for transportation in some places, but the initial response is free of charge. Even if you receive a bill, it is after the fact and not before. I do not know of any place in this country where emergency personnel would refuse services because someone did have any insurance, proper insurance, or otherwise were not able to pay.

What we have here, basically, is a niche in the country’s system of healthcare that is paid by taxes and that works just great. Rich or poor, a human being in this country gets the same care from us.

This begs the question: if we can make it work on this level, there should be no reason why it can’t work on any level. I say “should be” instead of “is” because the only roadblock I can fathom is simply the public will to put it in place. I suppose that there are conservatives who would say that this is a waste of their precious tax dollar. I cannot think of any call where we were told to go away because firefighters are a waste of tax funds. If anything, people would like to see us do more not less.

This does not mean that we do not have difficulties funding our activities. Fire levies are turned down every election. However, any time it becomes critical, the public becomes motivated at the thought of not having us around to respond and the community comes together to support us.

This same system could be used for healthcare. It is possible. It is a very good example of how government can and does work.

tillyjane makes the same point about government. People complain about waste and bureaucracies, but government is firemen and EMTs and bridges and public health nurses and school playgrounds and libraries and a whole lot of other things that even rabid libertarians and radical Movement Conservatives would have trouble living without. Government works well, every day, to everyone's benefit.

The "hate the government" meme, at least in its contemporary form, began with Ronald Reagan insofar as I can tell. It was wrong then, and it's wrong now.

The thing is, most of the government services people (and more specifically, voters) support most reliably are those services that are administered and provided by local governments -- libraries, schools, police & fire services. Voters also more reliably support state-funded services -- highways, education -- when those services are provided through earmarked and well-managed revenue streams.

For example, K-12 schools work well when they're governed by local school districts -- and certain specialized K-12 programs can work well when delivered by larger regional "education service districts". But the nature of bureaucracy imposes limits on how big a school district can get and still work well (the largest Oregon districts are beneath the ceiling; LA Unified, where my brother and his wife both teach, may be above it).

Government may well be able to do a good job of delivering health care -- but I'd bet on local/state government doing a better job at that function than the federal bureaucracy.

How come Republicans crow so much about no free lunches but cannot put it into practice? What are they conserving anyway? If it is their own personal wealth then they are penny-wise and dollar-stupid. Why not pay expenses before they cost an arm and a leg?

Hate the government? They should read the constitution and find out whom they are foaming at the mouth about. I'll give them a clue: it's the first three words. Sigh. Pogo had it right.

PS: If you want some really good witnesses and paperwork for your case about The Child, check with the responding fire department. We are the ones who determine how a patient is transported. Leastwise, we make a determination and try our best to convince the parties involved agree to it. If they made a rule-out of decreased level of consciousness then that would automatically eliminate many modes of transportation, including POV (personally owned vehicle). The FD protocols come straight down from an MPD (medical program director) who is generally one of the leading ER physicians in the area.

Well, sure. There's bloat in any human institution. The Catholic Church. Publicly owned companies. Cub scout troops. That's not a problem specific to government, let alone unique to it. As a society, we don't deal with bloat at Citibank or Boeing by strangling the company in the bathtub.

As for the fire brigade, it's definitely in my interest to have my neighbor's house fire put out before it spreads to mine. Not to mention everyone else in the neighborhood. Conservatives love to pretend the commons doesn't matter, but they're either being idiots or disingenous when they do.

The most telling and poignant point, in my opinion, and in all the other cases I've read about regarding US healthcare, is that you, as someone with good insurance, are still out of pocket to a large degree. (sorry about all the commas. I like them. They are free!) Also, that is not due to a particularly long term illness. It's in this most simple form that I see the US system as failing. Many other points are valid, but I don't know why the argument has to go that far. People in America, to an extent, cannot afford to keep healthy. Now, whether this is because of advancements in technology that have made costs higher (and if so, where does the argument for drawing the line there come in...) or whether it's because pharmaceutical companies are jacking up the prices, I don't know... but it's wrong.

Meh, I'm not particularly dignified or smart in my discussions about the state of US healthcare, but that's because I don't feel the need to be. It isn't working for the people, unless they are at the top of the scale.

Actually, I should mention that that's in terms of the "is it broken or is it the best it can be" discussion, not the "how can we fix it" discussion, which obviously requires smart discussion.

There's one other observation about healthcare that nobody is making:

We pay substantial costs for not having universal access to healthcare; they're just not fully defined within GAAP, so nobody is quantifying them in the first place (let alone paying attention to them). Here are a few examples:

* Back when I was in-house counsel, we had a situation in which my secretary/personal assistant's "preexisting" pregnancy was not covered. In an effort to economize, she treated her "flu-like symptoms" that persisted for three weeks as "flu" instead of seeing a doctor, out of (justified) fear that a doctor visit would be "pregnancy-related" and therefore uncovered. This resulted in two distinct sets of losses: When it became unbearable to her and she had to quit, there was a distinct productivity loss. And then there's the medical costs for life of the disabled child that could have been prevented.

* An obvious one that nobody likes to talk about: Joe visits his grandmother in the hospital. A couple of days later, he develops a rash... but Joe has no coverage, so he doesn't seek attention, and can't afford to take a few unpaid sick days. Thus, Joe continues going to work at the meat-packing plant. You can fill in the blanks from here, right?

* And finally, consider this: Somebody is, somewhere, paying the costs of inadequate care. It results in lost productivity, complications, people losing jobs and educational opportunities, dogs and cats living together outside of wedlock... In short, it results in all of the ills that a single-payer system would allegedly result in, with the dubious advantage that there isn't one "villain" at whom we can point a Finger of Blame^tm.

In summary, a single-payer system just consolidates costs that already exist and makes them explicit. Gee, isn't that the first step in a coherent management review to determine how a company can reduce costs?

— CEP

American College of Physicians Endorse Single-Payer

(2nd largest group of Physicians in USA)

the best sum up of what I agree with I've read:

http://www.nybooks.com/articles/18802

I will be out well over $6K in copays alone this year, and that's without any catastrophic events. I have insurance that's mostly decent, but I hit a weak spot in the plan last year. I have enough income on paper that I don't qualify for any of the assistance programs, even though I have a SoCal mortgage eating a good chunk of my paychecks.

On the other hand, with the delays that are common in both the British and Canadian systems, I might have lost too much functionality to keep working by the time I was diagnosed and given the too-expensive drugs.