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22 May 2014

How To Deal With The VA Talking Points and Socialised Medicine Arguments

 'cuz, like, um, ya know, we owe it to Bradley Chelsea Manning because he she disclosed hundreds of thousands of classified documents, which endangered his her fellow compatriots, who were on actual battlefields dealing with live ammo and IEDs.  Sure, her compatriots didn't betray their oaths and their country, but so what?  Chelsea is a special snowflake and she demands that her needs be met...even if actually wounded soldiers have to wait indefinitely.

If General Washington were Chelsea's CIC, she would be shot as Bradley.

Via NY Times (November 2011):

American health care is remarkably diverse. In terms of how care is paid for and delivered, many of us effectively live in Canada, some live in Switzerland, some live in Britain, and some live in the unregulated market of conservative dreams. One result of this diversity is that we have plenty of home-grown evidence about what works and what doesn’t.

Naturally, then, politicians — Republicans in particular — are determined to scrap what works and promote what doesn’t. And that brings me to Mitt Romney’s latest really bad idea, unveiled on Veterans Day: to partially privatize the Veterans Health Administration (V.H.A.). 

What Mr. Romney and everyone else should know is that the V.H.A. is a huge policy success story, which offers important lessons for future health reform. 

Many people still have an image of veterans’ health care based on the terrible state of the system two decades ago. Under the Clinton administration, however, the V.H.A. was overhauled, and achieved a remarkable combination of rising quality and successful cost control. Multiple surveys have found the V.H.A. providing better care than most Americans receive, even as the agency has held cost increases well below those facing Medicare and private insurers. Furthermore, the V.H.A. has led the way in cost-saving innovation, especially the use of electronic medical records.

What’s behind this success? Crucially, the V.H.A. is an integrated system, which provides health care as well as paying for it. So it’s free from the perverse incentives created when doctors and hospitals profit from expensive tests and procedures, whether or not those procedures actually make medical sense. And because V.H.A. patients are in it for the long term, the agency has a stronger incentive to invest in prevention than private insurers, many of whose customers move on after a few years. 

And yes, this is “socialized medicine” — although some private systems, like Kaiser Permanente, share many of the V.H.A.’s virtues. But it works — and suggests what it will take to solve the troubles of U.S. health care more broadly. 

Yet Mr. Romney believes that giving veterans vouchers to spend on private insurance would somehow yield better results. Why?

Well, Republicans have a thing about vouchers. Earlier this year Representative Paul Ryan famously introduced a plan to convert Medicare into a voucher system; Mr. Romney’s Medicare proposal follows similar lines. The claim, always, is the one Mr. Romney made last week, that “private sector competition” would lower costs. 

Since The Ferret is unavailable for comment today, we are pleased to have 'ThisIsYourBrainOnKoch', whom I am told spent last night at a Holiday Day Inn Express so that he could attempt to play a Nobel Laureate/economist/Professor of Economics and International Affairs at the Woodrow Wilson School of Public and International Affairs at Princeton University/Centenary Professor at the London School of Economics, and an op-ed columnist for The New York Times....

rightwingers blaming this va mess on socialism is as nonsensical as it is predictable. socialist countries have far and away the best health care in the world, an undeniable fact proved many times over.

what happened at the va has more to do with two pointless wars overburdening our resources and republicans being stingy and uncooperative when it comes to actually fulfilling promises.

ThisIsYourBrainOnKoch on May 22, 2014 at 3:24 PM

OK, let me first tackle this claim:

rightwingers blaming this va mess on socialism is as nonsensical as it is predictable. socialist countries have far and away the best health care in the world, an undeniable fact proved many times over.
- ThisIsYourBrainOnKoch on May 22, 2014 at 3:24 PM

Universal health care does not necessarily translate into better health and finances for a country and its subjects. 

Healthcare standards in the UK are worse than in many former communist states despite billions of pounds of extra funding being pumped into the NHS.  

The UK came in second from the bottom in bowel cancer survival, with only patients in the Czech Republic less likely to be alive five years after diagnosis. The survival rate in Britain was 51.6 per cent, compared with an OECD average of 57.4 per cent and 65.5 per cent in the US. 

Britain also languishes near the bottom of the breast cancer league table, with a survival rate of 78.5 per cent. The OECD-wide average is 81.2 per cent. 

Heart attack victims in Britain are also more likely to die after entering hospital than in most other developed nations. 

Around 6.3 per cent of patients who have suffered a heart attack have passed away within 30 days of entering a British hospital – significantly higher than the 4.3 per cent average. 

The figures also show that British life expectancy is much lower than our nearest neighbours. Men in this country can expect to live to 79 years and six months, against 81 years in France. 

Labour invested billions in the NHS, but the system failed to improve even while it expanded in the size of employees.

A study by the NHS found that countries with comparable records on cancer and heart disease spend half as much money per person on health. The NHS and NICE were not necessarily interested in improving the cancer states. They were looking for ways to reduce costs. 

British health care is not 'free.' Most pay about 12.5% of the cheque to the insurance programme. Plus, you get to pay a 20% VAT and that is in addition to everything else.   For example, a senior level nurse in a London hospital earns approximately $49,000.  She will pay around $10,500 in income taxes, $6,039 in National Insurance  taxes, a 20% VAT, council taxes, and other assorted taxes…in an area where it is more expensive to live than in Manhattan or San Francisco.  

Britain has some of the worst cancer and coronary survival rates in the developed world. The Coalition recently unveiled its plan to move around £70 billion from the trusts to the GPs and opening up some areas of the system to competition from private firms.

According to the OECD, the United States has the most progressive individual tax system in the world.  While it is true that tax rates on the uber-wealthy are certainly higher in some countries, the tax base is much wider.  There isn’t a country in Europe where 47-52% of the working population avoids paying national income tax.

France has both a private and public system, but is closing public hospitals and clinics.

France Fights Universal Care's High Cost


Doctors, trade unions and others have called national protests against French health-care cutbacks this year. One petition signed by prominent physicians said they feared the intent of the reform was to turn health care into a 'lucrative business' rather than a public service. Agence France-Presse/Getty Images

Updated 7 August 2009

When Laure Cuccarolo went into early labor on a recent Sunday night in a village in southern France, her only choice was to ask the local fire brigade to whisk her to a hospital 30 miles away. A closer one had been shuttered by cost cuts in France's universal health system.

Ms. Cuccarolo's little girl was born in a firetruck.

France claims it long ago achieved much of what today's U.S. health-care overhaul is seeking: It covers everyone, and provides what supporters say is high-quality care. But soaring costs are pushing the system into crisis. The result: As Congress fights over whether America should be more like France, the French government is trying to borrow U.S. tactics.

In recent months, France imposed American-style "co-pays" on patients to try to throttle back prescription-drug costs and forced state hospitals to crack down on expenses. "A hospital doesn't need to be money-losing to provide good-quality treatment," President Nicolas Sarkozy thundered in a recent speech to doctors.

And service cuts -- such as the closure of a maternity ward near Ms. Cuccarolo's home -- are prompting complaints from patients, doctors and nurses that care is being rationed. That concern echos worries among some Americans that the U.S. changes could lead to rationing.

The French system's fragile solvency shows how tough it is to provide universal coverage while controlling costs, the professed twin goals of President Barack Obama's proposed overhaul.

French taxpayers fund a state health insurer, Assurance Maladie, proportionally to their income, and patients get treatment even if they can't pay for it. France spends 11% of national output on health services, compared with 17% in the U.S., and routinely outranks the U.S. in infant mortality and some other health measures.

The problem is that Assurance Maladie has been in the red since 1989. This year the annual shortfall is expected to reach €9.4 billion ($13.5 billion), and €15 billion in 2010, or roughly 10% of its budget.

France's woes provide grist to critics of Mr. Obama and the Democrats' vision of a new public health plan to compete with private health insurers. Republicans argue that tens of millions of Americans would leave their employer-provided coverage for the cheaper, public option, bankrupting the federal government.

Despite the structural differences between the U.S. and French systems, both face similar root problems: rising drug costs, aging populations and growing unemployment, albeit for slightly different reasons. In the U.S., being unemployed means you might lose your coverage; in France, it means less tax money flowing into Assurance Maladie's coffers.

France faces a major obstacle to its reforms: French people consider access to health care a societal right, and any effort to cut coverage can lead to a big fight.

For instance, in France, people with long-term diseases get 100% coverage (similar to, say, Medicare for patients with end-stage kidney diseases). The government proposed trimming coverage not directly related to a patient's primary illness -- a sore throat for someone with diabetes, for example. The proposal created such public outcry that French Health Minister Roselyne Bachelot later said the 100% coverage rule was "set in stone."

Health Expenditures

Total expenditure on health in 2007, as a percentage of GDP.

Australia 8.7% +
Austria 10.1%
Belgium 10.2% *
Canada 10.1%
Czech Republic 6.8%
Denmark 9.8%
Finland 8.2%
France 11.0%
Germany 10.4%
Greece 9.6%
Hungary 7.4%
Iceland 9.3%
Ireland 7.6%
Italy 8.7%
Japan 8.1% +
Korea 6.8%
Luxembourg 7.3% +
Mexico 5.9%
Netherlands 9.8% *
New Zealand 9.2%
Norway 8.9%
Poland 6.4%
Portugal 9.9% +
Slovak Republic 7.7%
Spain 8.5%
Sweden 9.1%
Switzerland 10.8% *
Turkey 5.7%  #
United Kingdom 8.4%
United States 16.0%

Source: OECD Health Data 2009

"French people are so attached to their health-insurance system that they almost never support changes," says Frédéric Van Roekeghem, Assurance Maladie's director.

Both patients and doctors say they feel the effects of Mr. Sarkozy's cuts. They certainly had an impact on Ms. Cuccarolo of the firetruck birth.

She lives near the medieval town of Figeac, in southern France. The maternity ward of the public hospital there was closed in June as part of a nationwide effort to close smaller, less efficient units. In 2008, fewer than 270 babies were born at the Figeac maternity ward, below the annual minimum required of 300, says Fabien Chanabas, deputy director of the local public hospital.

"We were providing good-quality obstetric services," he says. "But at a very high cost." Since the maternity closed, he says, the hospital narrowed its deficit and began reallocating resources toward geriatric services, which are in high demand.

In the Figeac region, however, people feel short-changed. "Until the 1960s, many women delivered their babies at home," says Michel Delpech, mayor of the village where Ms. Cuccarolo lives. "The opening of the Figeac maternity was big progress. Its closure is perceived as a regression."

For Ms. Cuccarolo, it meant she would have to drive to Cahors, about 30 miles away. "That's fine when you can plan in advance," she says. "But my little girl came a month earlier than expected."

France launched its first national health-care system in 1945. World War II had left the country in ruins, and private insurers were weak. The idea: Create a single health insurer and make it compulsory for all companies and workers to pay premiums to it based on a percentage of salaries. Patients can choose their own doctors, and -- unlike the U.S., where private health insurers can have a say -- doctors can prescribe any therapy or drug without approval of the national health insurance.

Private insurers, both for-profit and not-for-profit, continued to exist, providing optional benefits such as prescription sunglasses, orthodontics care or individual hospital rooms.

At a time when the U.S. is considering ways of providing coverage for its entire population, France's blending of public and private medical structures offers important lessons, says Victor Rodwin, professor of health policy and management at New York University's Wagner School. The French managed to design a universal system incorporating physician choice and a mix of public and private service providers, without it being "a monolithic system of Soviet variety," he says.

It took decades before the pieces fell into place. Only in 1999 did legislation mandate that anyone with a regular residence permit is entitled to health benefits with no strings attached. Also that year, France clarified rules for illegal residents: Those who can justify more than three months of presence on French territory, and don't have financial resources, can receive full coverage.

That made the system universal.

In the U.S., health-overhaul bills don't attempt to cover illegal immigrants. Doing so would increase costs and is considered politically difficult.

A protest in April in Caen, France. Agence France-Presse/Getty Images

Today, Assurance Maladie covers about 88% of France's population of 65 million. The remaining 12%, mainly farmers and shop owners, get coverage through other mandatory insurance plans, some of which are heavily government-subsidized. About 90% of the population subscribes to supplemental private health-care plans.

Proponents of the private-based U.S. health system argue that competition between insurers helps provide patients with the best possible service. In France, however, Assurance Maladie says its dominant position is its best asset to manage risks and keep doctors in check.

"Here, we spread health risks on a very large base," says Mr. Van Roekeghem of Assurance Maladie.

The quasi-monopoly of Assurance Maladie makes it the country's largest buyer of medical services. That gives it clout to keep the fees charged by doctors low. About 90% of general practitioners in France have an agreement with Assurance Maladie specifying that they can't charge more than 22 (about $32) for a consultation. For house calls they can add 3.50 to the bill.

By comparison, under Medicare, doctors are paid $91.97 for a first visit and $124.97 for a moderately complex consultation, according to the American College of Physicians.

In France, "If you are in medical care for the money, you'd better change jobs," says Marc Lanfranchi, a general practitioner from Nancy, an eastern town. On the other hand, medical school is paid for by the government, and malpractice insurance is much cheaper.

In 2000, the World Health Organization ranked France first in a one-time study of the health-care services of 191 countries. The U.S. placed 37th.

Financial pain has long dogged the French plan. As in the U.S., demand for care is growing faster than the economy as people take better care of themselves and new treatments become available.

Tilting the Balance

Since France began building up its universal health-care system, in 1945, successive governments have been faced with the challenge of balancing the national health insurance budget without going back on the original promise of taking good care of the entire population. For the past three decades, small reductions in health care coverage and incremental increases in health-care taxes have been the main recipe.

1976 -- Coverage of ambulance costs is reduced.

1977 -- Coverage of some medications is reduced. Some hospital beds are closed.

1982 -- Patients must pay a "moderating fee" of 20 francs (3 euros) out of pocket when they are hospitalized.

1985 -- Coverage of some paramedical procedures is reduced.

1986 -- Increase in health-care payroll taxes.

1987 -- Letters sent to the national health insurance must be stamped.

1988 -- Creation of a special tax on medication advertising to help fund health care.

1990 -- Introduction of the CSG, a new tax levied on all types of income to help fund health care.

1991 -- Increase in health-care taxes levied on payroll.

1993 -- Increase in CSG rate. Coverage of doctor consultation is reduced.

1996 -- Increase in health-care taxes. A new health-care tax is levied on private health-care plans.

1999 -- New tax levied on drug makers when their revenue exceeds a pre-defined level.

2000 -- Doctors are required to explain to the national health insurance why they granted a worker sick leave.

2003 -- The "moderating fee," which was increased over time, is raised to 15 euros.

2004 -- Patients must register with a "preferred" general practitioner who will reroute them toward specialists when necessary, or face lower reimbursement for care.

2005 -- The national health insurance deducts 1 euro off doctor consultation fees before it starts calculating how much it must reimburse patients.

2008 -- The national health insurance deducts 50 cents off every pack of medicine before it starts calculating how much it must reimburse patients.
Source: WSJ research.
Since the 1970s, almost all successive French health ministers have tried to reduce expenses, but mostly managed to push through only minor cost cuts. For instance, in 1987, patients were required to put a stamp on letters they mailed to the national health insurer. Previously, postage was government-subsidized.

In 2004, France introduced a system under which patients must select a "preferred" general practitioner who then sends them onward to specialists when necessary. Under that policy -- similar to one used by many private U.S. health-care plans -- France's national health insurance reimburses only 30% of the bill, instead of the standard 70%, if patients consult a doctor other than the one they chose.

At the start, patients balked, saying it infringed on their right to consult the doctors of their choice. But the system is now credited for helping improve the coordination between primary and specialty care, which remains one of the main weakness in the U.S. health-care system.

In recent years, Assurance Maladie has focused on reducing high medicine bills. Just like U.S. insurers and pharmacy-benefit managers, France's national health insurer is promoting the use of cheaper generic drugs, penalizing patients when they don't use them by basing reimbursements on generic-drug prices.

The most important aspect of Mr. Sarkozy's latest health-care legislation, passed this summer, focuses on reducing costs at state hospitals. About two-thirds of France's hospitals are state-run, and they are seen as ripe for efficiency savings. Among other things, Mr. Sarkozy has asked them to hire more business managers and behave more like private companies, for instance, by balancing their budgets.

The proposals didn't go down well.

In April, some of France's most famous doctors signed a petition saying they feared Mr. Sarkozy would turn health care into a "lucrative business" rather than a public service.

In the U.S., hospitals are paid for each individual procedure. This system, called fee-for-service, is suspected of contributing to runaway costs because it doesn't give hospitals an incentive to limit the number of tests or procedures.

Ironically, France is actually in the midst of shifting to a fee-for-service system for its state-run hospitals. The hope is that it will be easier for the government to track if the money is being spent efficiently, compared with the old system of simply giving hospitals an annual lump-sum payment.

France's private hospitals are more cost-efficient. But state hospitals say it is unfair to compare the two, because state hospitals often handle complex cases that private hospitals can't.

"When a private hospital has trouble with a newborn baby, we are here to help, night and day," says Pascal Le Roux, a pediatrician at the state hospital in Le Havre, an industrial city in northern France. "Having people standing by costs money."

In theory, Assurance Maladie should be able to contain hospital costs the same way it does with doctors: by harnessing its position as the dominant payer in the health-care system. In practice, it doesn't work that way.

The state hospital of Le Havre, called Groupement Hospitalier du Havre, or GHH, has nearly 2,000 beds and is one of the most financially strapped in France. A 2002 report by France's health-inspection authority found that the hospital had a track record of falsifying accounts in order to obtain more state funds.

Philippe Paris was hired about two years ago to help fix the hospital's spiraling costs. He is cutting 173 jobs out of the staff of 3,543.

And he is trying to enforce working hours. "People don't work enough," he said. "If consultations are scheduled to begin at 8 a.m., that means 8 a.m. and not 11 a.m."

Yet even the smallest budget moves are proving controversial. Local residents are up in arms over a cost-cutting measure that makes patients pay1.10 an hour to park at the hospital. "It's a scandal," says retired local Communist politician Gérard Eude. "It goes against the very idea of universal health care."

Canada is also moving to privatise more of its system and see the decision from the Supreme Court in Chaoulli v Quebec (Attorney General) 1 S.C.R. 791, 2005 SCC 35 [2005]:

For many years, the government has failed to act; the situation continues to deteriorate. This is not a case in which missing scientific data would allow for a more informed decision to be made. The principle of prudence that is so popular in matters relating to the environment and to medical research cannot be transposed to this case. Under the Quebec plan, the government can control its human resources in various ways, whether by using the time of professionals who have already reached the maximum for payment by the state, by applying the provision that authorizes it to compel even nonparticipating physicians to provide services (s. 30 HEIA) or by implementing less restrictive measures, like those adopted in the four Canadian provinces that do not prohibit private insurance or in the other OECD countries. While the government has the power to decide what measures to adopt, it cannot choose to do nothing in the face of the violation of Quebecers’ right to security. The government has not given reasons for its failure to act. Inertia cannot be used as an argument to justify deference.

Holding in Chaoulli:

Section 15 of the Health Insurance Act and section 11 of the Hospital Insurance Act, which outlaw private medical insurance, violate the right to personal inviolability as guaranteed by the Quebec Charter of Human Rights and Freedoms

Via the New York Times:

The Canadian Supreme Court struck down a Quebec law banning private medical insurance (in 2005), dealing an acute blow to the publicly financed national health care system.  

The court stopped short of striking down the constitutionality of the country’s vaunted nationwide coverage, but legal experts said the ruling would open the door to a wave of lawsuits challenging the health care system in other provinces. 

The system, providing Canadians with free doctor’s services that are paid for by taxes, has generally been supported by the public, and is broadly identified with the Canadian national character. 

But in recent years, patients have been forced to wait longer for diagnostic tests and elective surgery, while the wealthy and well connected either seek care in the United States or use influence to jump ahead on waiting lists.  

The court ruled that the waiting lists had become so long that they violated patients’ “liberty, safety and security” under the Quebec charter, which covers about one-quarter of Canada’s population. 

“The evidence in this case shows that delays in the public health care system are widespread and that in some serious cases, patients die as a result of waiting lists for public health care,” the Supreme Court ruled. “In sum, the prohibition on obtaining private health insurance is not constitutional where the public system fails to deliver reasonable services.”

Sweden has privatised parts of its formally fully-socialised medical system.  (See:  The Non-Existent Stairway To Socialist Heaven In Sweden)

While the rest of the world is waking up to the disaster that is nationalised health care, the US is moving in that direction.

Don’t you love Lefties? They claim that the US should slash defence so that all of the fabulous domestic programmes can be implemented. What they seem to forget is that the US has been paying for Europe’s defence for more than 6 decades and the EU members, with the exception of Germany and a couple of others, ARE FISCAL BASKETCASES.  They can’t pay for their defence OR their lavish social safety net.

Second erroneous talking point:

what happened at the va has more to do with two pointless wars overburdening our resources and republicans being stingy and uncooperative when it comes to actually fulfilling promises.
- ThisIsYourBrainOnKoch on May 22, 2014 at 3:24 PM

Two ‘pointless’ wars which were voted for by every elected Federal official with the sole exception of Barbara Lee (Communist-CA) [Afghanistan] and 374 members of Congress [House For: R-215, D-82 (Against: R-6, D-126, I-1) Senate For: R-48, D-29 (Against: R-1, D-21, I-1)]

House breakdown:

* 82 (40%) of 209 Democratic Representatives voted for the resolution.

* 6 (<3%) of 223 Republican Representatives voted against the resolution: Reps. Duncan (R-TN), Hostettler (R-IN), Houghton (R-NY), Leach (R-IA), Morella (R-MD), Paul (R-TX).

* The only Independent Representative voted against the resolution: Rep. Sanders (I-VT)

* Reps. Ortiz (D-TX), Roukema (R-NJ), and Stump (R-AZ) did not vote on the resolution.

Senate breakdown:

* 58% of Democratic senators (29 of 50) voted for the resolution. Those voting against the Democratic majority include: Sens. Akaka (D-HI), Bingaman (D-NM), Boxer (D-CA), Byrd (D-WV), Conrad (D-ND), Corzine (D-NJ), Dayton (D-MN), Durbin (D-IL), Feingold (D-WI), Graham (D-FL), Inouye (D-HI), Kennedy (D-MA), Leahy (D-VT), Levin (D-MI), Mikulski (D-MD), Murray (D-WA), Reed (D-RI), Sarbanes (D-MD), Stabenow (D-MI), Wellstone (D-MN), and Wyden (D-OR). 

[Note: Clinton, Kerry, Reid, and Biden, amongst others, voted FOR the resolution].

* 1 (2%) of 49 Republican senators voted against the resolution: Sen. Chafee (R-RI).

* The only Independent senator voted against the resolution: Sen. Jeffords (I-VT)

From earlier:

Since 9/11, the VA budget has increased by 235%, from FY2001′s $45 billion annual budget to FY2014′s $150.7 billion. On a percentage basis, the only Cabinet agencies that had larger budget increases over that arc have been State (271%) and Homeland Security (245%), the latter of which barely existed at the start of that period. In the Bush era, comparing the final budget with his signature (FY08) to the final Clinton budget (FY01), VA spending rose 88.3% to $84.7 billion. Defense spending rose 104% in the same period.

In the last 13 years, funding for the VA has nearly tripled while the number of veterans has declined by 4.3 million.

It is not a funding issue. It is a managerial and systemic corruption problem.

Related Reading:

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