I agree with your description of the problem. Solution? I still prefer the universal healthcare by expanding Medicare. Giving it to the insurers is just a waste of money. Ok, I know maybe in our crazy society, this will never work. But I'd prefer to advocate for what is really more sensible. Easier for providers to bill. Easier for patients to access. Trying to decide on an insurer may make sense for very bright people with access to info etc. But for the elderly, the disabled, the poor, the street people, the mentally ill ... no. Better one system that does not have policies. You get a card. You go for care. Medicare works!

We already have a fragmented number of social medical systems. Prisons.  Military. Veterans.  Public Health.  Medicare.  Medicaid.  Fold it all into one system:  Medicare.   

A single-payer, Medicare-for-all is my first choice, too, with the option to buy supplemental private coverage.   I hope I didn't give the impression that I was advocating for something else.  What I hoped to offer was an alternative way to buy off the biggest interests and get a real single-payer system.

There will still be premiums (taxes) under a single payer public system.  Going single-payer would just switch $1 trillon or so from private premiums to public taxes.  Personally I would rather that money be escrowed rather than put in the general fund to finance foreign adventures or build bridges to nowhere. 

My proposal is to let the insurance companies manage investment of the escrowed funds.  They will also offer Medicare supplement insurance but they will no longer be the primary insurer -- that would be Medicare.

France's healthcare system has often been held up as the model that we should emulate.  Did you know France had to buy off their insurance companies?  I don't know the details.  Maybe someone else here does. 

Anyway, if we have to buy them off and it seems like we do, there are better ways to do it than with mandates that help them more than us.

I am really, really disappointed and irritated with the Democratic candidates for suggesting the mandate schemes without even trying to explain why they would choose to promote such a complicated solution over a simple single-payer plan without a fight.  I wish Huey Long was still around to heap scorn and derision on them as well as on "the interests".

Thank you for this lovely post and your clarification here. I too am very distressed with the plans of the Dems.

I am intrigued by your idea of having the insurance companies "invest" the money. Hmmmmm. What would worry me is the high fees they might charge. Since this fiasco with the mortgages, I've been thanking our lucky stars that bush did not succeed in getting social security partly privatized, due to the way in which money would have been siphoned off for fees.

So, I get where you're coming from. And I did not know about France having to buy off the insurance companies. I do know that in Spain you can buy extra insurance so that you can go to special clinics and not just use the national healthcare. In Canada, they have a lovely system.

I am totally on board with your idea about Medicare. And sorry I misunderstood what you had in mind for the insurance companies. Do you think it can be done without tons of money being siphoned off by them? And if and when the repubs get back in again, what's to keep them from loosening controls over that... to allow for more of a money grab?

But if your plan would work, that would also solve Part D of Medicare, which is a travesty. Just yesterday i was looking at my husband's notification from Social Security. His Part D is literally half each month of the amount he pays for all of regular Medicare! (and likely that will keep creeping up)

Thank you, Emma, for your clear thinking and excellent posts here and at tpm Muckraker.

The purchase mandate on one hand, and the regulatory mandate that carriers take on all comers without regard to pre existing conditions at a community price, both appear to be obtrusive attempts by the government to force a "market based outcome" different from that produced by a free market.

In reality this is a (virtuous) scam, because, when coupled with the proviso that individuals of whatever age may fulfill their purchase mandate by buying into medicare , the resultant competition will crush for profit insurers into the dust.

Note that the present medicare premium deducted from individual social security checks is less than $100.00 per month (disclaimer:number pulled from ass, correction solicited.)

There's no question that any practical approach will require transition, and that things will be fought. While France's system has been mentioned tonight, and there are many references to Canada and Britain, I'm a little surprised the German system is not better known here. Japan's system is also quite close to Germany's.

Both are multi-payor with a government safety net. I'm more familiar with the German system, so I'll focus on that.

Germany passed its first medical insurance plan in 1883. Originally, it was 1/3 employer paid and 2/3 employee, administered by local committees elected by the employees (as the major contributors).

Over time, the employee contributions started to go into not-for-profit "sick funds", often administered by unions. Yes, there are employer contributions, but no "insurance companies" in our sense (there are some special cases, mostly for the wealthy). A government safety net handles the unemployed.

One of the interesting things is that they don't micromanage or preapprove, but still have a national quality control organization. Providers, in fact, are paid (I'm simplifying a bit) for the effort of collecting statistics.

Roughly quarterly, provider costs and outcomes are evaluated statistically by medical professionals and analysts. Good outcomes and low costs are investigated, as are bad ones.

When a provider is doing well, the investigators try to learn if it was statistically random, or if they are doing something especially well. If it does turn out they have improved techniques, this is disseminated to the medical community by the national quality organization. IIRC, if a provider stays above the norm for two years, they can list this in marketing materials.

For providers that do not do well, and again on a statistically significant sample, the investigators visit. In the journals I've seen, the term most often used for the flavor of the visit is "collegial". No threats to cut out of network, not reimburse, etc., to start, but an honest attempt to understand what happened.

Perhaps Dr. Schmidt had a practice of 85 year olds, whose bodies gave out at the same time. Perhaps there was an epidemic in Darmstadt. If there's a decent explanation for the outlier, there may be increased surveillance for a time, but nothing drastic.

If there is a problem with quality, the reviewers, again acting collegially to start, try to fix the problem. If the practitioner ignores the advice, there indeed may be consequences -- after reason has failed.

--

Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

"Note that the present medicare premium deducted from individual social security checks is less than $100.00 per month."

That is the premium only for Medicare Part B. It is a deceptive number because it along with the premium for Part A are subsidized with a 2.9% federal payroll tax and maybe from the general fund as well. According to Wikipedia:

Medicare-eligible persons who do not have 40 or more quarters of Medicare-covered employment may purchase Part A for a monthly premium of:

• $226.00 per month (2007) for those with 30-39 quarters of Medicare-covered employment, or
• $410.00 per month (in 2007) for those with less than 30 quarters of Medicare-covered employment and who are not otherwise eligible for premium-free Part A coverage.

There are additional premiums for Part D as well.  Medicare's financing is complicated. 

Premiums for a basic single payer plan should logically be less than what most people pay now for similar private coverage but they will most likely be more than $100 per month.

Maybe I am more comfortable with the idea because I spent most of my life working in the investment community -- most of it when it was more about investing than speculation.  Believe it or not, there are people in the industry who take their fiduciary responsibilities seriously.  Those who don't, the operators, are problematic but I think their glory days may be ending.  From David Ignatius's column today:

"What scares the central bankers now is the evaporation of trust from the system. Banks don't believe each other's numbers..."

""The basic problem is that banks don't trust each other. "

I imagine many in the finance industry will be shedding a lot of their hot shot creative accountants in favor of some duller but more trustworthy bean counters if for no other reason than to find out where they stand.  Maybe I should dust off my resume.

As for the fees, they are always negotiable.

Think about how much information on human health we could be gathering and analyzing with such a system. What we could be learning. We have three times their population and it is much more diverse.

With a combination of universal access to health care, and properly privacy-protected electronic medical records, perhaps we should justify this under the terrorism budget: finding early patterns in medical records is probably the mechanism best suited to detecting covert bioterrorism.

I am only guessing about the malpractice situation in France, but remember, they are Civil Law, not Common Law. Their judges and magistrates are not referees between opposing sides as we have here, but, even in criminal matters, charged with finding truth. An expert panel, then, would fit quite well into French legal culture.

--

Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]