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Health care reform discussion continues...

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Health care reform discussion continues...

Old 07-21-09, 11:46 AM
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Health care reform discussion continues...

continued from http://forum.dvdtalk.com/politics-wo...insurance.html
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Old 07-21-09, 11:59 AM
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Re: Health care reform discussion continues...

Originally Posted by Dr Mabuse
But it's the fact that most every other major nation on earth has wonderful health care systems going with the government playing a role. They curtail the profiteering of corrupt health care companies, and deliver excellent care.

The US system, left to corporations, spends magnitudes more money than any nation on earth to make corrupt billionaires richer, and has the worst care of any major nation.
1) The government does play a role in the US System already, perhaps much like the other nations (nearly every major one?) with "wonderful" health care. That isn't the root of this problem.

2) I think that most would agree with you that costs are out of control and that abuses are at times horrendous. Government oversight in specific areas seems like it could be much more workable. There is a big difference between oversight and anything being proposed.


After all this discussion, one thing I'm glad about in all this is that certain abuses and problems are being brought to light. The good thing about that is that it is highly likely that health care providers are not immune to this press. Companies in the past have been shown to address public concerns like "being green" in great ways. I look forward to our more people-friendly healthcare companies who go out of their way to prove that they are not guilty of the abuses being brought up. Of course, as long as the costs are so high, it could be hard to drive rates down too far. So maybe in the wake of this crisis, some good will (PR) will be extended in that department as well. The people need to demand it.

People will feel good about switching to a "clean" provider... even if it costs the same. Heck the good feelingness might even improve their health.
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Old 07-21-09, 12:15 PM
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Re: Health care reform discussion continues...

Originally Posted by Dr Mabuse
But it's the fact that most every other major nation on earth has wonderful health care systems going with the government playing a role. They curtail the profiteering of corrupt health care companies, and deliver excellent care.
The fact that most every other nation on earth has wonderful health care systems goin with government playing a role? Is that like the fact that when people in the US get really sick, they go to other countries to get the best medical care?
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Old 07-21-09, 12:19 PM
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Re: Health care reform discussion continues...

Originally Posted by Dr Mabuse
I remember they pulled Bush's strings during the whole 'order cheaper drugs form Canada' thing. Remember that? Bush himself, as well as many congressman and senators came out saying drugs from Canada were not like drugs form the US, they might be poisonous.

That's power.

We're past regulation.
So the mighty corporate machine can stop drugs from Canada, but they can't stop a complete takeover of the health industry? That makes sense to you? The all powerful "not government" can stop the little things but not the big?

That's power.
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Old 07-21-09, 12:31 PM
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Re: Health care reform discussion continues...

Originally Posted by kvrdave View Post
So the mighty corporate machine can stop drugs from Canada, but they can't stop a complete takeover of the health industry? That makes sense to you? The all powerful "not government" can stop the little things but not the big?

That's power.


They stopped Clinton's attempt in it's tracks. So again, simple facts show that they can stop a "takeover"(though you probably don't realize it, you are parroting one of the tenets of the propaganda there). If you somehow forget that about the Clinton plan, then I guess the hypothetical you pose above might make some sense. That was only ~15 years ago kvr... are you slipping?

They are stopping this current health reform bill with the "takeover", "government bureaucrat between you and your doctor", etc propaganda campaign. Polls are showing the stuff is working. Ignorant, weak minded Americans who really know almost nothing about the facts of US health care are easily swayed by the powerful putting out propaganda.

It's already hopeless this session. Obama is facing that fact and hoping for it by the end of the year now. I won't be surprised if the mostly ignorant American public yet again embraces the bullshit of billionaires and stays with the current corrupt system that kills so many for corrupt profiteering.
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Old 07-21-09, 12:37 PM
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I will embrace it.

I want to live as free as possible, making as many of my own decisions as possible. Government does not support that.
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Old 07-21-09, 12:45 PM
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Re: Health care reform discussion continues...

Is Canadian health coverage 100 percent free or how much does it cost?
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Old 07-21-09, 12:46 PM
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Originally Posted by kvrdave View Post
The fact that most every other nation on earth has wonderful health care systems goin with government playing a role? Is that like the fact that when people in the US get really sick, they go to other countries to get the best medical care?
You just hit every tenet of the health care propaganda. "They come HERE for treatment" now comes up.

People wealthy enough to do that, travel for care, don't need to, they can pay for healthcare out of pocket. Though Americans who can do travel for specialists, just like those who come here do, it's mostly for highly specialized care. The same kind of highly specialized care that many Americans are denied by either having NO insurance, or having that treatment denied by their insurance company. OOPS we're not supposed ot mention that. That millions are denied that care right here in America, the BEST health care in the world. Or they lose their life's savings and have to sell their house to pay for it themselves.

Healthy examples
Plenty of countries get healthcare right.


By Jonathan Cohn
July 5, 2009

“I DON’T WANT America to begin rationing care to their citizens in the way these other countries do.”

That was Arizona Senator Jon Kyl, speaking last month about healthcare reform. But it could have been virtually any other Republican, not to mention any number of sympathetic interest groups, because that’s the party line for many who oppose healthcare reform. If President Obama and his supporters get their way, this argument goes, healthcare in America will start to look like healthcare overseas. Yes, maybe everybody will have insurance. But people will have to wait in long lines. And when they are done waiting in line, the care won’t be very good.

Typically the people making these arguments are basing their analysis on one of two countries, Canada and England, where such descriptions hold at least some truth. Although the people in both countries receive pretty good healthcare - their citizens do better than Americans in many important respects - they are also subjected to longer waits for specialty care and tighter limits on some advanced treatments.

But no serious politician is talking about recreating either the British or the Canadian system here. The British have truly “socialized medicine,” in which the government directly employs most doctors. The Canadians have one of the world’s most centralized “single-payer” systems, in which the government insures everybody directly and private insurance has virtually no role. A better understanding for how universal healthcare might work in America would come from other countries - countries whose insurance architecture and medical cultures more closely resemble the framework we’d likely create here.

Last year, I had the opportunity to spend time researching two of these countries: France and the Netherlands. Neither country gets the attention that Canada and England do. That might be because English isn’t their language. Or it might be because they don’t fit the negative stereotypes of life in countries where government is more directly involved in medical care.

Over the course of a month, I spoke to just about everybody I could find who might know something about these healthcare systems: Elected officials, industry leaders, scholars - plus, of course, doctors and patients. And sure enough, I heard some complaints. Dutch doctors, for example, thought they had too much paperwork. French public health experts thought patients with chronic disease weren’t getting the kind of sustained, coordinated medical care that they needed.

But in the course of a few dozen lengthy interviews, not once did I encounter an interview subject who wanted to trade places with an American. And it was easy enough to see why. People in these countries were getting precisely what most Americans say they want: Timely, quality care. Physicians felt free to practice medicine the way they wanted; companies got to concentrate on their lines of business, rather than develop expertise in managing health benefits. But, in contrast with the US, everybody had insurance. The papers weren’t filled with stories of people going bankrupt or skipping medical care because they couldn’t afford to pay their bills. And they did all this while paying substantially less, overall, than we do.


The Dutch and the French organize their healthcare differently. In the Netherlands, people buy health insurance from competing private carriers; in France, people get basic insurance from nonprofit sickness funds that effectively operate as extensions of the state, then have the option to purchase supplemental insurance on their own. (It’s as if everybody is enrolled in Medicare.) But in both countries virtually all people have insurance that covers virtually all legitimate medical services. In both countries, the government is heavily involved in regulating prices and setting national budgets. And, in both countries, people pay for health insurance through a combination of private payments and what are, by American standards, substantial taxes.

You could be forgiven for assuming, as Kyl and his allies suggest, that so much government control leads to Soviet-style rationing, with people waiting in long lines and clawing their way through mind-numbing bureaucracies every time they have a sore throat. But, in general, both the Dutch and French appear to have easy access to basic medical care - easier access, in fact, than is the American norm.

In both the Netherlands and France, most people have long-standing relationships with their primary care doctors. And when they need to see these doctors, they do so without delay or hassle. In a 2008 survey of adults with chronic disease conducted by the Commonwealth Fund - a foundation which financed my own research abroad - 60 percent of Dutch patients and 42 percent of French patients could get same-day appointments. The figure in the US was just 26 percent.

The contrast with after-hours care is even more striking. If you live in either Amsterdam or Paris, and get sick after your family physician has gone home, a phone call will typically get you an immediate medical consultation - or even, if necessary, a house call. And if you need the sort of attention available only at a formal medical facility, you can get that, too - without the long waits typical in US emergency rooms.

This is particularly true in the Netherlands, thanks to a nationwide network of urgent care centers the government and medical societies have put in place. Not only do these centers provide easily accessible care for people who use them; they leave hospital emergency rooms free to concentrate on the truly serious cases. Tellingly, a Dutch physician I met complained to me that waiting times in her emergency room had been getting “too long” lately. “Too long,” she went on to tell me, meant two or three hours. When I told her about documented cases of people waiting a day, or even days, for treatment in some American emergency rooms, she thought I was joking. (In a 2007 Commonwealth Fund survey, just 9 percent of Dutch patients reported waiting more than two hours for care in an ER, compared to 31 percent of Americans.)

Dutch and French patients do wait longer than Americans for specialty care; around a quarter of respondents to the Commonwealth Fund survey reported waiting more than two months to see a specialist, compared to virtually no Americans. But Dutch and French patients were far less likely to avoid seeing a specialist altogether - or forgoing other sorts of medical care - because they couldn’t afford it. And there’s precious little evidence that the waits for specialty care led to less effective care.

On the contrary, the data suggests that while American healthcare is particularly good at treating some diseases, it’s not as good at treating others. (In some studies, the US did pretty well on cardiovascular care, not so well on diabetes, for example.) Overall, the US actually fares poorly on measures like “potential years of lives lost” - statistics compiled by specialists in an effort to measure how well healthcare systems perform. In a 2003 ranking of 20 advanced countries, the US finished 16th when it came to “mortality amenable to healthcare,” another statistic that strives to capture the impact of a health system. The Dutch were 11th and the French were fifth. These statistics are necessarily crude; diet, culture, and many other factors inevitably affect the results. But, taken together, they make it awfully hard to argue that care in these countries is somehow inferior. If anything, the opposite would seem to be true.

Critics of health reform frequently point to cancer as proof that American healthcare really is superior. And, it’s true, the US has, overall, the world’s highest five-year survival rate for cancer. But that’s partly a product of the unparalleled amount of government-funded research in the US - something healthcare reform would not diminish. Besides, it’s not as if the gap is as large or meaningful as reform critics frequently suggest. France (like a few other European countries) has survival rates that are generally close and, for some cancers, higher. Much of the remaining difference reflects differences in treatment patterns that have nothing to do with insurance arrangements and everything to do with idiosyncratic medical cultures. This is particularly true of prostate cancer, where a staggeringly high survival rate in the US seems to be largely a product of aggressive US treatment - treatment that physicians in other countries, and increasingly many specialists here, consider unnecessary and sometimes harmful.

None of this is to say that either the Dutch or French systems are perfect. Far from it. In both countries, healthcare costs are rising faster than either the public - or the country’s business interests - would like. And each country has undertaken reforms in an effort to address these problems. The French have started to introduce some of the managed care techniques familiar to Americans, like charging patients extra if they see specialists without a referral, while developing more evidence-based treatment guidelines in the hope that it will reduce the use of unnecessary but expensive treatments. The Dutch overhauled their insurance arrangements a few years ago, to introduce more market competition and reward healthcare providers - that is, doctors and hospitals - who get good results.

But cost is the one area in which France and the Netherlands are a lot like Canada and England: They all devote significantly less of their economy to healthcare than we do. The French spend around 11 percent of their gross domestic product on healthcare, the Dutch around 10. In the US, we spend around 16 percent. And, unlike in the US, the burden for paying this is distributed across society - to both individuals and businesses - in an even, predictable way.

Of course, reforming health insurance in the US isn’t going to turn this country into France or the Netherlands overnight, any more than it would turn the US into Britain and Canada. The truth is that the changes now under consideration in Washington are relatively modest, by international standards. But insofar as countries abroad give us an idea of what could happen, eventually, if we change our health insurance arrangements, the experience of people in Amsterdam and Paris surely matters as much as - if not more than - those in Montreal and London. In those countries, government intervention has created a health system in which people seem to have the best of all worlds: convenience, quality, and affordability. There’s no reason to think the same thing couldn’t happen here.

Jonathan Cohn is a senior editor of The New Republic, where he writes a blog called “The Treatment.” He is also the author of “Sick: The Untold Story of America’s Health Care Crisis - and the People Who Pay the Price (HarperCollins, 2007).
© Copyright 2009 Globe Newspaper Company.
Before you gobble up the "Britain and Canada" propaganda that's being spoon fed to Americans by the healthcare companies. You might look into what health care is actually like in all the other major nations.

None of them want to change places with Americans and lose everything they've worked for to pay to save their life.

You know Obama set this site up to give people a place to tell some of their stories. People who are insured, as several put forth in this thread that means they have the 'BEST damned health care in the WORLD!'.

Some of the stories are interesting to read. Kvr you put forth the 'hard work' thing as divine, you might read how thousands of those who worked hard lost everything, including their lives, here in the 'best health care in the world' system.

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Old 07-21-09, 01:00 PM
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Re: Health care reform discussion continues...

Fine, put in a Pakistan type program where the government offers nothing but catastrophic coverage. But NooOOOOoooo, that isn't what they want. They want it all. They have no interest in going for something good, they want to go for something that gives them the most power over everything.

Don't tell me that there is only one side of propaganda on this subject, because there isn't. And The Obama is not looking for an unobtrusive solution that is best for the most free nation on the planet. He has a bill so large and cumbersome he hasn't read all of it. At a press conference he didn't know about the provision that would fine people $2,500 per year if they don't get insurance "voluntarily."

So why not set up just catastrophic coverage, since that is the real issue that sends people to the poor house, destroys families, etc?
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Old 07-21-09, 01:01 PM
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Re: Health care reform discussion continues...

Originally Posted by kvrdave View Post
The fact that most every other nation on earth has wonderful health care systems goin with government playing a role? Is that like the fact that when people in the US get really sick, they go to other countries to get the best medical care?
Actually a lot of people are flying to India for expensive surgeries these days.
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Old 07-21-09, 01:01 PM
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Re: Health care reform discussion continues...

Originally Posted by kvrdave View Post

So why not set up just catastrophic coverage, since that is the real issue that sends people to the poor house, destroys families, etc?
That's why I mentioned the Singapore model last week. The problem is that it makes too much sense for Congress to consider.
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Old 07-21-09, 01:04 PM
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Originally Posted by Red Dog View Post
That's why I mentioned the Singapore model last week. The problem is that it makes too much sense for Congress to consider.
Singapore. Thanks. I said Pakistan by mistake.

So, followers of The Obama, why not do this? Depending on the particulars, I probably wouldn't oppose this.
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Old 07-21-09, 01:05 PM
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Originally Posted by orangecrush18 View Post
Actually a lot of people are flying to India for expensive surgeries these days.
They aren't doing it to get the best care, but the best value (in their minds). And I don't think that shows that the problems we do have here are one dimensional.
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Old 07-21-09, 01:06 PM
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I'll keep posting them because they are still a good example:
http://www.healthbeatblog.org/2008/0...h-care-in.html
spoilerized for size (I did some bolding though):
Spoiler:
Health Care in Singapore: What's the Secret?
It’s always worth exploring how health care works in other countries, if for no other reason than that models in other countries give us the chance to see how some of the approaches discussed by American reformers might pan out. What do the experiences of Germany and Netherlands tell us about the possibility of a better mixed public-private system in the United States? How is China’s health care system a cautionary tale of market forces gone wild? The answer to these questions can add to—or detract from—the appeal of certain health care strategies in the U.S.

It’s hard to imagine a country that could provide a more valuable example than Singapore. The Southeast Asian city-state is widely regarded as a health care superstar, especially when compared to the United States. Life expectancy at birth in the U.S. is 78 years; in Singapore, it’s 82 years. The Singaporean infant mortality rate is a mere 2.3 deaths per 1,000 live births, versus 6.4 in the U.S. As some have noted, these trends persist despite the fact that the U.S. has far more caregivers: 2.6 physicians per 1,000 people, compared with 1.4 physicians in Singapore. The United States has 9.4 nurses per 1,000 people; Singapore, just 4.2. Last—but certainly not least—is the issue of spending: the U.S. spends almost 16 percent of its GDP on health care, while Singapore spends a mere 3.7 percent.

For reformers eager to cite examples proving that their health care ideals are a formula for success, Singapore offers a powerful case study. Its population is healthy, its system isn’t overloaded by medical professionals, and health care spending doesn’t gobble up a huge chunk of its economy.

So how does Singapore do it?

A Consumerist Utopia?

At first glance, Singapore’s health care system seems to have all the trappings of consumer-driven medicine, which emphasizes the need to shift medical expenses directly onto patients through higher co-pays and deductibles. Eighty-five percent of Singaporeans have health coverage through Medisave, a national health savings account (HSA) program introduced in 1984. Like the HSAs found in the U.S., Medisave accounts are tax-free, earn interest, and become part of one’s estate after death. Accountholders can take money out of the account only to pay for approved categories of medical treatments like hospitalization, surgery, and radiotherapy.

In addition to Medisave, people can pay extra for optional catastrophic insurance called MediShield. MediShield helps to cover the care associated with prolonged illnesses, which can get very pricey in the context of Singapore’s high-deductible and high co-pay system of insurance.

An element of consumer choice is also evident in Singapore’s hospitalization practices—even though 80 percent of hospital care in the country is delivered by publicly-owned hospitals. In these public hospitals, patients can choose different classes of ward accommodation ranging from 1-bedded room to an open dormitory with 8 or more beds. Patients in the 1-2 bedded rooms pay the full cost for their stay, whereas patients in other ward classes enjoy subsidies from the government ranging from 20 percent of the cost for the 4-bedded rooms to 80 percent of the cost for the open dormitories. The Ministry of Health also has a web-page that lists the costs for a wide set of conditions and procedures to inform patients about likely medical expenses once hospitalized.


Paying for care through savings accounts and imbuing hospitalization and medical services with consumer choice—if we were to stop here, it would seem that Singapore represents a validation that efficient, sustainable health care depends on consumer-driven medicine. Or would it?

First, the sustainability of Medisave has a lot to do with some very distinct features of Singapore’s society. The country is relatively young: only around 8 percent of the population is over 65 years old, versus 13 percent in the U.S. Most European nations are even older.

A younger population that needs less care is more amenable to consumer-driven medicine. It’s the older people who suffer more when forced to pay medical costs out-of-pocket or out-of-savings, because they need more care. So more old people means more people needing care that exceeds their ability to pay, which results either in more government aid or more sick people—both of which drive up health care costs.

Second, Singapore’s economy has been something of a juggernaut. The country’s GDP is growing at a rate of 7-8 percent per year—almost as fast as the Indian economy. By contrast, in the U.S. GDP is growing by only about 2-3 percent annually. When an economy grows this rapidly, it generally means that many people have more money. Thus many can afford higher co-pays and deductibles. Perhaps more importantly, the growth of the Singapore’s economy has actually outpaced increases in health care inflation, something that is definitively not the case in the U.S.

So even if the Medisave model of HSAs was to be carried over into the U.S., its success is far from guaranteed, since its ability to function is part and parcel of Singapore itself. But that’s not the whole story. More important than saying Medisave wouldn’t work in the U.S. is noting that health savings accounts are not the key to Singapore’s high-performance health care. Far from it: Singapore’s health care success isn’t due to consumer-driven medicine, but rather to government intervention.

The Role of Government

Even Medisave isn’t entirely consistent with the vision of American consumer-driven reformers: savings are compulsory. Every citizen gets 40 percent of his or her income deducted by Singapore’s Central Provident fund, which distributes the money for programs like retirement funds and Medisave. When all is said and done, the government deducts between 6.5 and 8.5 percent of workers’ pre-tax income to be re-directed to their Medisave account, with the percentage varying according to age.

In other words, the Singaporean government mandates savings and funds those savings by re-distributing compulsory contributions. This helps to maintain a relatively stable level of savings that you wouldn’t get in a save-only-what-you-want HSA system like the one advocates push for in the U.S.

Yet the real kicker here is that, when it comes to accounting for Singapore’s efficient health care system, Medisave is beside the point. In fact, according to William Hsiao, a Professor of Economics at the Harvard School of Public Health, Medisave has failed to contain health care costs in Singapore: since Medisave was introduced in 1984, the rate health care spending per capita increased from 11 percent to 13 percent a year after the program’s introduction.

By 1993, Singapore’s government was starting to feel the fiscal pinch and began to notice that, even with Medisave, many citizens were unable to afford the care they needed. That year the government formed Medifund, an endowment fund to help poor, indigent patients pay their medical bills. According to Singapore’s Ministry of Health, the Medifund endowment was S$1.6 billion this year and 98 percent of patients who apply for Medifund aid are approved.

1993 also saw a paradigm shift that became the real engine behind Singapore’s health care system: regulation of supply-side medicine. Consumer-driven strategies like HSAs are all about adjusting the demand of care. In theory, when you pay for more of your care directly, the amount of care you desire and consume changes, because people are more frugal with their own money. In contrast, supply-side interventions look to regulate the amount and kind of medical resources that are available.

Singapore’s government introduced a number of these reforms in the 1990s, all of which have gone a long way toward controlling health care costs. One such change has been a restriction on how fast new, unproven technology can be introduced into government hospitals Before this reform, notes Hsiao, “hospitals competed…by offering the latest technology and expensive equipment, which appeared to be demanded by physicians and accepted by the public as an indicator of quality.” Unfortunately, “once the new technology was put to use, it produced a higher cost inflation rate in medical services.” Sound familiar?

The government also put price caps on all services and procedures delivered in public hospitals, which provide 80 percent of hospital care in Singapore. These caps apply not only to procedures like surgery, but also to ward stays. So while patients are in fact able to choose between types of accommodations for a price, those prices are fixed by the government (except in the case of private hospitals, which can charge whatever they want). Further, beginning in 2009, subsidization for hospital stays will no longer be a universal privilege. The government will introduce a means-testing program to make sure that only poorer citizens who need subsidization actually receive it.

Singapore’s government also put hospitals on a budget, setting a predetermined amount to be given to hospitals each year, so that they would not have a blank check to provide an open-ended number of treatments and hospital stays. Similarly, the government set a limit on the number of beds a hospital could have, to make sure that patient volume was managed efficiently.

One of the most noteworthy changes that the government instituted was a set of reforms aimed at streamlining Singapore’s mostly-private physician workforce. In the late 1990s, the Ministry of Health noticed that “countries with more doctors tend to spend more on health care” and took steps to make sure that Singapore was not supporting more physicians than it needed.

According to Michael Barr, an Australian historian who specializes in Singapore, the government instituted controls on the number of medical graduates produced by local universities and reduced the number of overseas medical schools whose degrees were recognized in Singapore from 176 to 28. . It also set a limit on the proportion of the physician workforce that could be specialists at any given time (40 percent).

Over-Treatment Is the Key

All of these supply-side measures are aimed at reducing the risk of over-treatment. Singapore has made it a point to guard against a glut of expensive technology, high-volume care, too-long hospital stays, and an excess of physicians and specialists. These reforms helped Singapore reduce its per capita health care spending from 1997 to 2001 by 13 percent—even as the United States increased its per capita health spending by 24 percent over this same period. Today Singapore spends one-seventh what the U.S. does per capita on health care.

These numbers owe little to HSAs. As the Canadian Medical Association Journal has put it, “Singapore's MSA program itself has contributed less to cost control than the more recently introduced supply-side tactics” Hsiao also notes that “the well-executed Medisave scheme in Singapore could not contain costs, so it is unlikely that such a scheme could do so here.” And Barr eloquently concludes that while HSAs are an institutionally distinctive feature of Singaporean health care, “the practical and spiritual heart of the system lies in control and parsimony.”

In the end, Singapore’s health care experience isn’t an argument for consumer-driven medicine, but for targeted government interventions and smart, timely, regulation of over-treatment. One of the world’s most successful health care systems is built on the principle that personal responsibility is good, but it has practical limits—and the understanding that when it comes to health care, more can easily become too much.

Posted by Niko Karvounis on July 30, 2008
There are some very good points about the ages of population and growth of GDP, but overall they provide a very good example of what works.
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Old 07-21-09, 01:07 PM
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Re: Health care reform discussion continues...

I'll keep posting them because they are still a good example:
http://www.healthbeatblog.org/2008/0...h-care-in.html
spoilerized for size (I did some bolding though):
Spoiler:
Health Care in Singapore: What's the Secret?
It’s always worth exploring how health care works in other countries, if for no other reason than that models in other countries give us the chance to see how some of the approaches discussed by American reformers might pan out. What do the experiences of Germany and Netherlands tell us about the possibility of a better mixed public-private system in the United States? How is China’s health care system a cautionary tale of market forces gone wild? The answer to these questions can add to—or detract from—the appeal of certain health care strategies in the U.S.

It’s hard to imagine a country that could provide a more valuable example than Singapore. The Southeast Asian city-state is widely regarded as a health care superstar, especially when compared to the United States. Life expectancy at birth in the U.S. is 78 years; in Singapore, it’s 82 years. The Singaporean infant mortality rate is a mere 2.3 deaths per 1,000 live births, versus 6.4 in the U.S. As some have noted, these trends persist despite the fact that the U.S. has far more caregivers: 2.6 physicians per 1,000 people, compared with 1.4 physicians in Singapore. The United States has 9.4 nurses per 1,000 people; Singapore, just 4.2. Last—but certainly not least—is the issue of spending: the U.S. spends almost 16 percent of its GDP on health care, while Singapore spends a mere 3.7 percent.

For reformers eager to cite examples proving that their health care ideals are a formula for success, Singapore offers a powerful case study. Its population is healthy, its system isn’t overloaded by medical professionals, and health care spending doesn’t gobble up a huge chunk of its economy.

So how does Singapore do it?

A Consumerist Utopia?

At first glance, Singapore’s health care system seems to have all the trappings of consumer-driven medicine, which emphasizes the need to shift medical expenses directly onto patients through higher co-pays and deductibles. Eighty-five percent of Singaporeans have health coverage through Medisave, a national health savings account (HSA) program introduced in 1984. Like the HSAs found in the U.S., Medisave accounts are tax-free, earn interest, and become part of one’s estate after death. Accountholders can take money out of the account only to pay for approved categories of medical treatments like hospitalization, surgery, and radiotherapy.

In addition to Medisave, people can pay extra for optional catastrophic insurance called MediShield. MediShield helps to cover the care associated with prolonged illnesses, which can get very pricey in the context of Singapore’s high-deductible and high co-pay system of insurance.

An element of consumer choice is also evident in Singapore’s hospitalization practices—even though 80 percent of hospital care in the country is delivered by publicly-owned hospitals. In these public hospitals, patients can choose different classes of ward accommodation ranging from 1-bedded room to an open dormitory with 8 or more beds. Patients in the 1-2 bedded rooms pay the full cost for their stay, whereas patients in other ward classes enjoy subsidies from the government ranging from 20 percent of the cost for the 4-bedded rooms to 80 percent of the cost for the open dormitories. The Ministry of Health also has a web-page that lists the costs for a wide set of conditions and procedures to inform patients about likely medical expenses once hospitalized.


Paying for care through savings accounts and imbuing hospitalization and medical services with consumer choice—if we were to stop here, it would seem that Singapore represents a validation that efficient, sustainable health care depends on consumer-driven medicine. Or would it?

First, the sustainability of Medisave has a lot to do with some very distinct features of Singapore’s society. The country is relatively young: only around 8 percent of the population is over 65 years old, versus 13 percent in the U.S. Most European nations are even older.

A younger population that needs less care is more amenable to consumer-driven medicine. It’s the older people who suffer more when forced to pay medical costs out-of-pocket or out-of-savings, because they need more care. So more old people means more people needing care that exceeds their ability to pay, which results either in more government aid or more sick people—both of which drive up health care costs.

Second, Singapore’s economy has been something of a juggernaut. The country’s GDP is growing at a rate of 7-8 percent per year—almost as fast as the Indian economy. By contrast, in the U.S. GDP is growing by only about 2-3 percent annually. When an economy grows this rapidly, it generally means that many people have more money. Thus many can afford higher co-pays and deductibles. Perhaps more importantly, the growth of the Singapore’s economy has actually outpaced increases in health care inflation, something that is definitively not the case in the U.S.

So even if the Medisave model of HSAs was to be carried over into the U.S., its success is far from guaranteed, since its ability to function is part and parcel of Singapore itself. But that’s not the whole story. More important than saying Medisave wouldn’t work in the U.S. is noting that health savings accounts are not the key to Singapore’s high-performance health care. Far from it: Singapore’s health care success isn’t due to consumer-driven medicine, but rather to government intervention.

The Role of Government

Even Medisave isn’t entirely consistent with the vision of American consumer-driven reformers: savings are compulsory. Every citizen gets 40 percent of his or her income deducted by Singapore’s Central Provident fund, which distributes the money for programs like retirement funds and Medisave. When all is said and done, the government deducts between 6.5 and 8.5 percent of workers’ pre-tax income to be re-directed to their Medisave account, with the percentage varying according to age.

In other words, the Singaporean government mandates savings and funds those savings by re-distributing compulsory contributions. This helps to maintain a relatively stable level of savings that you wouldn’t get in a save-only-what-you-want HSA system like the one advocates push for in the U.S.

Yet the real kicker here is that, when it comes to accounting for Singapore’s efficient health care system, Medisave is beside the point. In fact, according to William Hsiao, a Professor of Economics at the Harvard School of Public Health, Medisave has failed to contain health care costs in Singapore: since Medisave was introduced in 1984, the rate health care spending per capita increased from 11 percent to 13 percent a year after the program’s introduction.

By 1993, Singapore’s government was starting to feel the fiscal pinch and began to notice that, even with Medisave, many citizens were unable to afford the care they needed. That year the government formed Medifund, an endowment fund to help poor, indigent patients pay their medical bills. According to Singapore’s Ministry of Health, the Medifund endowment was S$1.6 billion this year and 98 percent of patients who apply for Medifund aid are approved.

1993 also saw a paradigm shift that became the real engine behind Singapore’s health care system: regulation of supply-side medicine. Consumer-driven strategies like HSAs are all about adjusting the demand of care. In theory, when you pay for more of your care directly, the amount of care you desire and consume changes, because people are more frugal with their own money. In contrast, supply-side interventions look to regulate the amount and kind of medical resources that are available.

Singapore’s government introduced a number of these reforms in the 1990s, all of which have gone a long way toward controlling health care costs. One such change has been a restriction on how fast new, unproven technology can be introduced into government hospitals Before this reform, notes Hsiao, “hospitals competed…by offering the latest technology and expensive equipment, which appeared to be demanded by physicians and accepted by the public as an indicator of quality.” Unfortunately, “once the new technology was put to use, it produced a higher cost inflation rate in medical services.” Sound familiar?

The government also put price caps on all services and procedures delivered in public hospitals, which provide 80 percent of hospital care in Singapore. These caps apply not only to procedures like surgery, but also to ward stays. So while patients are in fact able to choose between types of accommodations for a price, those prices are fixed by the government (except in the case of private hospitals, which can charge whatever they want). Further, beginning in 2009, subsidization for hospital stays will no longer be a universal privilege. The government will introduce a means-testing program to make sure that only poorer citizens who need subsidization actually receive it.

Singapore’s government also put hospitals on a budget, setting a predetermined amount to be given to hospitals each year, so that they would not have a blank check to provide an open-ended number of treatments and hospital stays. Similarly, the government set a limit on the number of beds a hospital could have, to make sure that patient volume was managed efficiently.

One of the most noteworthy changes that the government instituted was a set of reforms aimed at streamlining Singapore’s mostly-private physician workforce. In the late 1990s, the Ministry of Health noticed that “countries with more doctors tend to spend more on health care” and took steps to make sure that Singapore was not supporting more physicians than it needed.

According to Michael Barr, an Australian historian who specializes in Singapore, the government instituted controls on the number of medical graduates produced by local universities and reduced the number of overseas medical schools whose degrees were recognized in Singapore from 176 to 28. . It also set a limit on the proportion of the physician workforce that could be specialists at any given time (40 percent).

Over-Treatment Is the Key

All of these supply-side measures are aimed at reducing the risk of over-treatment. Singapore has made it a point to guard against a glut of expensive technology, high-volume care, too-long hospital stays, and an excess of physicians and specialists. These reforms helped Singapore reduce its per capita health care spending from 1997 to 2001 by 13 percent—even as the United States increased its per capita health spending by 24 percent over this same period. Today Singapore spends one-seventh what the U.S. does per capita on health care.

These numbers owe little to HSAs. As the Canadian Medical Association Journal has put it, “Singapore's MSA program itself has contributed less to cost control than the more recently introduced supply-side tactics” Hsiao also notes that “the well-executed Medisave scheme in Singapore could not contain costs, so it is unlikely that such a scheme could do so here.” And Barr eloquently concludes that while HSAs are an institutionally distinctive feature of Singaporean health care, “the practical and spiritual heart of the system lies in control and parsimony.”

In the end, Singapore’s health care experience isn’t an argument for consumer-driven medicine, but for targeted government interventions and smart, timely, regulation of over-treatment. One of the world’s most successful health care systems is built on the principle that personal responsibility is good, but it has practical limits—and the understanding that when it comes to health care, more can easily become too much.

Posted by Niko Karvounis on July 30, 2008
There are some very good points about the ages of population and growth of GDP, but overall they provide a very good example of what works.

Last edited by orangecrush; 07-21-09 at 01:12 PM.
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Old 07-21-09, 01:12 PM
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Re: Health care reform discussion continues...

Well, clearly that doesn't give the government enough control to satisfy some around here.
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Old 07-21-09, 01:16 PM
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Originally Posted by kvrdave View Post
They aren't doing it to get the best care, but the best value (in their minds). And I don't think that shows that the problems we do have here are one dimensional.
I agree. But I also think "best care" is a bit of a misnomer. Plenty of people get so-so care in this country and think it is the best. A lot of us think that other countries level of care is crap. I think for the most part if you get a run of the mill disease or common aliment, you get just as good of care in many other countries. If you get the rare crap, you are generally better off here.
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Old 07-21-09, 01:18 PM
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Originally Posted by kvrdave View Post
Well, clearly that doesn't give the government enough control to satisfy some around here.
It is sad really. Their system operates so much more effenciently than ours, but because it isn't Canada or Europe, we don't care.
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Old 07-21-09, 01:18 PM
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I still haven't seen anyone put forth why they have such a quasi-religious faith in greedy billionaires who are bilking the US into ruin.

It'll be funny for someone to actually try to put that into words. Someone give it a shot.

The model we have now is a 100% failure. No doubt, no question, no possibility of any other outcome. Under this system the US goes broke in 2-3 decades.

That's not very far off.
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Old 07-21-09, 01:21 PM
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Originally Posted by Dr Mabuse View Post
I still haven't seen anyone put forth why they have such a quasi-religious faith in greedy billionaires who are bilking the US into ruin.

It'll be funny for someone to actually try to put that into words. Someone give it a shot.

The model we have now is a 100% failure. No doubt, no question, no possibility of any other outcome. Under this system the US goes broke in 2-3 decades.

That's not very far off.
Some might argue that the government shouldn't be spending money on health care in the first place.
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Old 07-21-09, 01:22 PM
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Originally Posted by Dr Mabuse View Post
I still haven't seen anyone put forth why they have such a quasi-religious faith in greedy billionaires who are bilking the US into ruin.
As oppose to the quasi-religious faith some have in the government? It isn't my love of corporations that shapes my opinion, but my mistrust of government.

It'll be funny for someone to actually try to put that into words. Someone give it a shot.
I just did, and your assumption is off base. Now put into words your quasi-religious faith in the government.

The model we have now is a 100% failure. No doubt, no question, no possibility of any other outcome. Under this system the US goes broke in 2-3 decades.

That's not very far off.
So we need a system that speeds up how quickly we go broke? That's not going to convince me.
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Old 07-21-09, 01:24 PM
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Originally Posted by orangecrush18 View Post
Some might argue that the government shouldn't be spending money on health care in the first place.
Okay so do nothing.

The nation goes bankrupt, literally.

That's a good plan?
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Old 07-21-09, 01:24 PM
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Re: Health care reform discussion continues...

Originally Posted by Dr Mabuse View Post
I still haven't seen anyone put forth why they have such a quasi-religious faith in greedy billionaires who are bilking the US into ruin.

It'll be funny for someone to actually try to put that into words. Someone give it a shot.

The model we have now is a 100% failure. No doubt, no question, no possibility of any other outcome. Under this system the US goes broke in 2-3 decades.

That's not very far off.

"Quasi-religious faith in greedy billionaires." That's some interesting spin. I don't see it as faith in greedy billionaires. I see it as distrust of government controlling more facets of life. I've seen this distrust from you in numerous areas.

I don't know if the current system is 100% failure. I'm doubtful - I happen to like my insurance plan. Even if it is 100% failure, some of us happen to believe that you put government in control and you'll get 110% failure.
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Old 07-21-09, 01:25 PM
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Originally Posted by Dr Mabuse View Post
Okay so do nothing.

The nation goes bankrupt, literally.

That's a good plan?
Where did he say 'do nothing?" Did you not read his posts further up in this thread?
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Old 07-21-09, 01:26 PM
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Originally Posted by Dr Mabuse View Post
Okay so do nothing.

The nation goes bankrupt, literally.

That's a good plan?
What's wrong with the global catastrophic coverage? Keeps people out of the poor house, etc. Solves the problems the propaganda you prefer seems to yell about. Just not enough government involvement? Doesn't cost enough?
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