``I can't do political appointments since I've spent too much time hanging out with the likes of you...
...Other stuff worth pursuing, and to me at least as important, are social insurance and public investment, neither of which has much to do with organizer-bureaucrat/inside-outside connections. It's more straight-forward and top-down. I don't think there is any other way to do it, though as President Barack said in one of his speeches, it will depend on mobilization after the election...''
Max Sawicky
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I think Doug is more of a background check problem than me. I am just an old War on Poverty warrior has been. Doug, on the other hand is a currently active, shinning public figure of rather dubious reputation. Either way, I am sure President Obama's vetting team would understand.
(Also I never abstain. I vote religiously and often.)
Let's get to the social insurance and public investment. I interpret these to be economic speak for socialized medicine funded by income tax---possibly modeled on social security, unemployment, worker compensation models, some kind of matching contributions from employee, employers, with additional income tax supplements found by taxing the rich and their capital goodies. Please correct me if I am wrong here, and point me to links to clarify if need be. I am assuming the above because your expertise is tax reform.
Let's say the single payer plan SPP is a component of some larger social insurance package that includes Social Security, Medicare, Medicaid, unemployment insurance, worker's compensation and other allied programs (VA, US civil service plans, etc). I would argue from a top-down perspective many of these existing systems should be consolidated into modules under a uniform funding system.
SPPs are all what I call funding mechanisms for medical and other social services. Great, we are all for them. That is indeed a classic top-down solution.
However there are several components to the healthcare system that are left out of most funding designs, with (from my view) service delivery, claims adjudication and review, and cost control among the most important.
Uniform funding systems like a neutron bomb leave the existing healthcare and social service systems intact while hopefully killing off most of the private market parasitic colonies that have grown up like muscles, other bivalves and sea moss on the boat hull of the ship of state.
I say most but not all. For example claims processing and payment systems to such a sanitized funding system would still very likely be subcontracted to a consortium of private insurance industry giants to administer, since they have the infrastructure and the US government doesn't. I could see something like a public utilities monopoly system developed.
In fact this contracting out of claims processing and payments is the Medicare Medicaid model with CMS as the regulatory and oversight agency (ignoring for the moment Bush's coup d'etat take over under OMB).
Blue Shield is one of several private insurance giants who bid for this contract, which I think is opened for bidding every four or five years. I don't know who is the current contractor.
(Are we still on the same track here?)
Okay, I am still going to advocate something like a War on Poverty approach to the healthcare industry, even if a top-down social insurance system-public investment (and uniform) funding system was passed.
>From the economic pov, which always seem inescapable, I don't see any
built in system of cost control. And that problem is pivotal.
The way current cost control is handled in CMS is to limit re-imbursement through a very elaborate fee schedule. What this means is that a primary provider (doctor, hospital, or allied service provider) is constrained by the fee re-imbursement schedule with the overall effect that rising prices (for medical procedures, hospital fees, supplies, drugs, and equipment) are passed on to the patient or consumer base in the form of a systemic reduction of service or outright denial of service.
The list probably needs a couple of examples at this point to clarify the problem.
Let's say you have a serious tooth ache. The dentist finds the tooth is cracked and has become infected. The normal course of treatment is, stabilize the infection with anti-biotics, wait a few days, then begin a root canal, which starts with cleaning out the infected interior of the tooth, including the nerve, inserting a small rod of fiberglass or titanium, and grinding off the hard enamel exterior. The next step is to cast a mold of the tooth stub and get a dental lab cap of either precious metal (gold or silver) or an acrylic covered version over a precious metal base which looks like a normal tooth. The latter is the preferred treatment for any tooth that shows during talking, smiling, or eating, etc. In other words it is interpreted as cosmetic and therefore not a medical necessity.
That's the two to three thousand dollar version. The alternate version which completely fulfills the medical necessity guidelines with no cosmetic argument is to pull the tooth and construct a removable
bridge, for about five hundred dollars, a little more or less depending on the region and the dentist. If the tooth is a back molar, the bridge is skipped and the cost drops to something around one hundred dollars plus. Extraction is dirt cheap. Reconstruction of the mouth always costs more, often three to ten times more.
Now guess which procedure has a better re-imbursement schedule under CMS guidelines?
At this point in the Medicare Medicaid system, the medically necessary guideline requirement has been exploited by the rightwing econo-metric assholes of the universe, to become the sin que otra razon for all manner of denial of service. In the above example, this becomes something equivalent to George Washington's wooden false teeth. Good enough for government work. Do you want to be toothless?
It gets worse and worse.
Take an auto accident that shatters the tibia (below the knee main bone) into dozens to hundreds of fragments. This is a very common injury. There are two courses of treatment. The medically preferred course is to reconstruct the tibia.
The first part of the reconstruction is to clean out the shattered bone, and install a titanium mesh plate to join the top and bottom sections of the tibia along with bone graphs to encourage bone re-growth along the plate. The bone graphs are composed of a corpse bone matrix that has been specially processed for this kind of procedure. Over a six month to several year course the patient's living bone will grow along the corpse matrix, stabilized by the underlaying titanium mesh plate. While the ultimate results are often fragile, the lower leg is eventually restored. The patient somewhere along the course of treatment begins rehabilitation therapy to strengthen the leg muscles and simultaneously encourage the bone growth process. Rehabilitation lasts from six months to over a year. Other surgeries often accompany this injury to restore vascular, tendon, and muscle damage.
The above treatment schedule is costed out at tens (possibly hundreds) of thousands of dollars.
The alternate treatment is below the knee amputation, with post-surgery prosthetics and rehabilation counted in a few weeks. Cost ranges widely, but comes in tens of thousand dollars, but definitely under hundreds of thousands.
Guess which version the Medicare patient enjoys?
I could go on and on. But you get the idea. While SPPs are certainly the answer, we have to be very careful about the details of how that goal is accomplished and how it is sustained.
CG
Beyond lets say a vastly increased oversight and regulatory system created in Health and Human Services to negotiate
Note. The idea of a joint public and private system at the top, was how the Kennedy administration sold the NDEA student loan program. Student loans were real estate long term loan at about 3 percent interest, guaranteed by the NDEA who paid the entire interest while the student was in school, granted a year breathing period on re-payment while the NDEA continuted to pay the interest. If the student became a public school teacer or enrolled in Teacher Corps (another War on Poverty program) both the interest and principle were paid off by the government.