The puzzle is: Why does the president, who says that were America "starting from scratch" he would favor a "single-payer" -- government-run -- system, insist that health care reform include a government insurance plan that competes with private insurers? [...]Emphasis in original. Will's argument is apparently this: The government does not need to make a profit and will have greater leverage with providers; therefore it will deliver the same service for less money. That's unfair!
Assurances that the government plan would play by the rules that private insurers play by are implausible. Government is incapable of behaving like market-disciplined private insurers. Competition from the public option must be unfair because government does not need to make a profit and has enormous pricing and negotiating powers. Besides, unless the point of a government plan is to be cheaper, it is pointless: If the public option conforms to the imperatives that regulations and competition impose on private insurers, there is no reason for it.
Is this really the best argument that one of the most prominent intellectual conservatives can mount against the public option?
I'm a big believer in the profit motive in 99 percent of all cases. If the government decided to open a non-profit hamburger stand, I doubt that it would compete successfully against Five Guys. If it tried to open a non-profit airline, I doubt that it could offer the same value as JetBlue. Insert joke about General Motors and/or the Post Office here. The point is, I think the profit motive is generally well worth it in terms of the incentives it creates to cut costs, develop new products, improve customer service, and so forth.
But health insurance is not like those things.
Insurance exists because of the decreasing marginal utility of income: most people would rather have a 100% chance of paying $300 a month than a 1% chance of paying $30,000 a month. In fact, our hypothetical customer -- let's call him Frederick, after George F. Will's middle name -- might very well accept a 100% chance of paying $400 a month rather than take 1% chance of having to pay $30,000, which he might not be able to afford. This is true even though Frederick will lose $100 on this deal in an average month.
There's nothing wrong with this arrangement -- the customer has improved his marginal utility and the insurance company has made $100. It's a win-win.
The thing is, though, that the insurer hasn't had to work particularly hard for his $100. He hasn't had to figure out how to cook up tastier fries or save you a few bucks off the cost of your next flight to Orlando. All he has to do is to have a bunch of money pooled together, such that he has a different marginal utility curve than you do. He has the luxury to accept the risk of unlikely outcomes, particularly if he can hedge his position by making the same deal with other customers, most of whom won't wind up requiring an angioplasty or cataract surgery, even if Frederick does.
Now, what's supposed to happen in the free market is that another company will come in and offer Frederick a better deal: they'll offer him the same coverage for $350 a month, accepting a smaller profit, and Frederick will happily take the deal. There are at least a couple of reasons, however, why this may not be happening in the insurance industry. The first is that Frederick might not realize he's paying $400 every month for insurance. That's because if he's like the majority of Americans, he's getting his insurance through his work, and except when the HR lady gave him a shiny brochure on his first day at the office, he's probably never thought very much about what this insurance is costing him in terms of foregone salary. This is particularly so because health insurance benefits, unlike other types of income, aren't taxed, and so Fredrick is less cognizant of them if show up on his paycheck at all. Not only, then, is the free market maxim of perfect information violated, but it's violated in such a way that creates artificial profits for the insurance industry: the government is effectively subsidizing every dollar that Frederick's company is willing to spend on his insurance benefit.
The profits the insurance industry is making, of course -- profits artificially boosted by an enormous backdoor tax subsidy -- don't seem to be buying the customer much of anything in terms of improved service or cost savings. On the contrary, health care costs are rising by as much as 9-10 percent per year, without any concomitant increase in the level of service. If JetBlue were raising the cost of its fares by 10 percent per year, they'd be out of business.
The reason the insurers are staying in business, though, is because barriers to entry in the health insurance industry are in practice quite high. Insurers benefit from pooling risk. The larger the pool, the better in terms of the insurer's ability to hedge its risk and build negotiating leverage with its providers. That makes it very difficult for a Five Guys or a JetBlue type of start-up to compete: they'll have trouble getting together enough customers to pool their risk adequately, and even if they do, they won't have as much negotiating leverage as the big guys. Health care providers may demand a better deal or refuse to accept them. As such, they'll never get off the ground.
Insurance, in other words, is a volume business, the main requirements for which are that (1) you have a lot of money pooled together and that (2) you've been around for awhile.
CIGNA and Aetna have a lot of money pooled together and they've been around for awhile -- but they don't have as much money, nor have they been around as long, as the federal government. It's possible, certainly, that the profit motive in the insurance industry has driven more innovation than we're giving it credit for. But that isn't my bet, and it isn't George Will's: There's no obvious reason that the government couldn't provide more for less. And if we are wrong, we would find out soon enough: if the public option can't deliver more bang for the buck than private insurers, it wouldn't gain much market share from them, and Will will have nothing to worry about.
What Will's position reflects instead is ideology: who cares that the federal government could build a better mousetrap? They're the government and that's bad. His argument is really no more sophisticated than that. If a libertarian conservative wants to make this argument, more power to them, but they absolutely should not be turning around and suggesting that a public option would raise health care costs. They're saying, rather, that they're morally opposed to the cost savings that would ensue.
If you've been reading me for a while, you'll know that, as compared with most self-described liberals, I'm unusually sympathetic toward the notion of the profit motive and private industry; I've defended Wall Street bankers and the AIG bonuses at various points during the financial crisis, among other things. It's my belief that private industry is usually able to deliver more efficient outcomes to the consumer than the government could.
But usually isn't always. And health insurance, as Will seems to admit, is one of those exceptions.
244 comments
This is a relatively minor point, but you say that untaxed income doesn't show up on paychecks. All of mine does, and is itemized, including health insurance. And my company uses SAP, so I don't think it's that unusual...
For some reason, I think most ppl who support a public option do so because they think it will be cheaper, as well as being less capricious than their current policies. I think that most ppl who oppose a public option do so because they think it will not be cheaper, due to higher taxes outweighing whatever is already being taken out of their paychecks for their coverage, and that it will also be intolerably inefficient. This, I think, is probably so obvious I didn't even need to say it. What is not obvious is George Will's intended audience, since clearly neither of the above fit the bill. The only ppl he seems to be talking to are ppl who really like insurance companies. Which I guess means insurance companies, so they hardly need to be convinced of anything. Maybe predicting that they'll get trounced if a public option emerges is supposed to motivate them somehow?
... so this Will guy, is he the big time? Does he speak for/to a lot of conservatives? Will he get denounced for this, or will no one care but those of us who are just incredulous?
wv: tronsc
@Nate -- Typo "it will deliver the service same". Same service?
In his presser today, Obama did quite the smackdown in this line of argument. In response to a question about the claim that the public option would drive private insurers out of business, Obama stated: "Why would it drive private insurers out of business?... If they tell us they're offering a good deal, then why is it that the government, which they say can't run anything, suddenly is going to drive them out of business? That's not logical."
So is this really the best argument that one of the most prominent intellectual liberals can mount in favor of the public option?
To argue that the profit motive and free market does indeed work 99% of the time but simply won't do on this issue. This one issue - this 1% of the time - is an exception?
That's laughable.
Nate, you're cutting your nose off to spite your face. You are a leftwing hack.
A big reason our country is in dire straights is that so much of the critical infrastructure is run by people looking for a profit.
This includes power, banking and insurance, and health care. None of which should be operated on a for-profit basis. Yes, they need to make money to advance things and pay its employees, but that is not the same thing as maximizing profits for shareholders.
My power company runs as a not for profit, and delivers power at a fraction of the poor souls enslaved by a for profit company that continues to raise rates despite a nearly 8 figure profit each year.
Not coincidently, my power companies service is considerably better then the for profit. Hell, I even received a payback for cutting consumption that took care of my next 6 bills.
For some reason, I think most ppl who support a public option do so because they think it will be cheaper, as well as being less capricious than their current policies.
Medicare and medicaid are far more efficient and fair to its clients then any commercial health plan.
Why would this be different?
@NATE: another typ0 -- "and expect when the HR lady gave him...." You mean "except when," not "expect when."
Also I recommend you look at Obama's whole answer on the public option question.
"For some reason, I think most ppl who support a public option do so because they think it will be cheaper, as well as being less capricious than their current policies. I think that most ppl who oppose a public option do so because they think it will not be cheaper, due to higher taxes outweighing whatever is already being taken out of their paychecks for their coverage, and that it will also be intolerably inefficient. "
Agree 110% We will still go round and round as evidenced by the last week or so because each view is illogical to the other side.
The answer lies in the free market. Give consumers more choice and better access to that choice. Allow easier access into the medical field so we can have more doctors (nobody mentions the AMA has been intentionally manipulating - capping is a better word for it - the number of doctor available by restricting the number of medical school applications).
There is a free market and convervative answer to this problem. And, yes, we recognize that costs going up 9%-10% per year is a problem that is unsustainable. But hoping that the government stepping in and saving the day - when "99% of the time it isn't" - is just a pipe dream.
wv: obamses - what Obama's Pharaoh ancestors were called (Get it? Like Rameses?)
To argue that the profit motive and free market does indeed work 99% of the time but simply won't do on this issue. This one issue - this 1% of the time - is an exception?
That's laughable.
Nate, you're cutting your nose off to spite your face. You are a leftwing hack.
1. Nate didn't write that, but I doubt you noticed much since you froth at the mouth.
2. The free market is not the answer every time. Nothing laughable about that. Even a properly regulated free market isn't the answer all the time.
It is a fact that the free market has already failed in regards to health care.
Socialize capital! HA HA HA.
Well, seriously, yeah. In the financial and insurance sectors, since they have no actual product, market pressures cannot lead to improvement in the product. People will try to draw an analogy between an insurance policy and a Widget (and some consumers will spend money on a sleek white stylish iWidget) but there really isn't a parallel. The latest financial crash (in case the previous three didn't make this clear) has shown what "innovation" in the financial sector produces.
So rather than having banks borrow money from the treasury (however upteen fold leveraged) and then turn around and loan it to businesses, the treasury should just provide this service directly, and cut out the middleman.
Likewise, the government should be the insurer. When insurance companies can't make book, I'm sorry can't meet their obligations, it's the government that ends up holding the bag. So what were the insurance companies doing that entitled them to a profit in the meantime?
If there's a positive result of the financial crisis, it may be a populist/progressive streamlining of the current system, in which this kind of welfare for the rich is discontinued.
My God, I never thought I'd link to DailyKos, but somebody over there gets it in reference to what I was talking about with regards to the AMA limiting the number of doctors.
http://www.dailykos.com/story/2009/6/14/742513/-We-Need-MORE-DOCTORS-Single-Payer
Look Nate,
i'm a progressive, but I oppose a public option. if the gov't were too start offering health insurance it would use its huge monopsony power to drive down reimbursements to providers. It would lead to an exit from the market, leading to deadweight losses and other inefficiencies. Plus, you need high prices to encourage innovation. Sometimes you have to accept a little static inefficiency (eg. high patented drug prices because there is no monopsony of a single payer system) in order to achieve dynamic efficiency (eg. encouraging lots of innovation in the pharmaceutical sector, leading to technological progress, etc.)
If we were to adopt a single payer system (which a public plan will lead to), then we will lose a lot of dynamic efficiency. There will be wait times as well.
As a progressive, I'm supporting the Wyden Bennett Bill.
1. Nate didn't write that, but I doubt you noticed much since you froth at the mouth.
Here's Nate's direct quote, you imbecile.
I'm a big believer in the profit motive in 99 percent of all cases.
While I'm at it, you misspelled "straits" and companies should have been company's.
FTR, I support a public option, though I won't get into why, but my point is that GWill apparently does not, so he is neither talking to the ppl who already think it will be cheaper and want it nor is he talking to the ppl that don't think it will be cheaper since they already don't want it (if they were convinced it would be cheaper, as he's concluded, maybe they would want it after all). Since his argument boils down to what Nate wrote in bold, it seems like the only ppl he could be talking to are ppl who like insurance companies in a fairly unqualified way, which is... not very effective, if he's trying to convince his readers to oppose a public option.
wv: ivacked
@npunwani: Exactly how do you propose to hold down the rate of increase in costs of health care? How do you propose to assure 100% coverage, and keep insurers from cherry picking by dropping coverage of those who are at greatest risk?
Hmmm because the profit motive is working so well in the health insurance business at the moment!! The problem with the profit motive is that it works best for whoever is making the profit, and it doesn't necessarily follow that that works best for those receiving the service. Health coverage should not be about profit, it should be about providing the medical care that is necessary, when it is required.
It seems to me that author of the quoted article believes the government will run the entire endeavor at a loss that the people will then pay for through taxes. Given that no private concern can endure perpetual losses, the public option will crowd out all other competitors. That's Will's argument: "The government can run at a loss forever. that's unfair!" not "the government can deliver the same service for less money. that's unfair!"
The "profit motive" is not the problem in the health insurance business right now, nor is it the main problem with affordable health care.
The problems are that we have too few physicians available to practice medicine (artificially limited by the AMA, among others) and restricted choice when it comes to health care/insurance.
Increase the supply of doctors and increase choice, and I guarantee you that we have affordable health care for all...and what few we don't can still be picked up at a small cost under Medicare.
I am under the impression that a large part of the reason for high costs for medical care goes to malpractice insurance. So presumably (as someone mentioned previously) if a doctor screws up and causes a patient to require greater hospital care etc than he would otherwise, his government-administered insurance would cover all that, so it wouldn't be a factor in any litigation. Maybe there wouldn't be litigation, unless you really really really want to get back at that doctor for causing you pain and suffering (somewhere out there, someone owes you money~~). In any case, it seems like the cost of malpractice insurance should go down (or maybe the government should also be covering this). So the cost of healthcare would go down. Everyone wins except for the lawyers. Who's holding a pity party for them, anyway? Americans could stand to be less litigious.
The reason a public option will drive out private options is that the public option is funded differently. A private insurance company gets most of its income from customers (or their employers). From that income they pay healthcare providers and their administrative costs, and try to make a profit.
A government plan will also collect premiums from some customers or their employers. However, they have almost limitless ability to supplement this income by using revenue from the genral fund, i.e. or taxes. Thus they can price their "premiums" below private insurers and drive them out of business.
Before long the government plan will be the only plan. And rationing will be rampant. Just as it is in Canada and UK. God help you if you are over 65, or disabled,or have a chronic disease. You will not get timely help from the government plan.
Basically, Obama's argument is that private insurers should compete on quality -- on service offered per dollar.
Right now there's a great cooperative oligopoly among the private insurers, HMO's, and (weak) regulators (mainly in the states). And in this game they've priced 20% of the American population out of the market -- these folks have to beg and hope for a handout if they really get sick, and have little insurance against catastrophic damanges to health and their work careers. And those who aren't priced out are still paying excessive insurance costs -- far out of proportion to the health benefits that they might receive if there were true competition among insurers.
At the present time, I have a choice -- I could go onto Medicare, but I have a "better" plan with my employer. But a lot of employers have essentially been kicking their workers (younger than I am) off of having any plan at all.
There is a very confusing array of cherry-picking private insurers out there who you can find online -- but if you "sign on" to them you never know whether you're going to be covered for a particularly expensive treatment, until it's too late.
The whole system is just badly organized, chaotic, and oriented toward profit at the expense of social responsibility.
Dave McLain: Since I really have really no sympathy for insurance companies, that doesn't turn his argument into one that's particularly compelling, but it does make a great deal more sense, so thanks for that.
(After all, we just bailed out a bunch of insurance companies because they were "too big to fail", even if half of them were posing as financial institution and it was really a credit or liquidity or some other crisis rather than concern over ppl losing their health or whatever insurance.)
Doctor Who said...
So is this really the best argument that one of the most prominent intellectual liberals can mount in favor of the public option?
To argue that the profit motive and free market does indeed work 99% of the time but simply won't do on this issue. This one issue - this 1% of the time - is an exception?
________________________
No, no, not at all. We don't say that the "profit and free market does indeed work 99% of the time" at all. For emphasis--AT ALL. The free market screwed up our banking system--again--and has our entire health care system going broke. It is the most expensive health care system in the world, bar none--check the statistics--and we are ranked 37th, worldwide, for mortality. Our free market brought all the other nation's banking and financial systems to their knees.
No, no, the free market does not, in any way, work 99% of the time, Dr. Who. Get off your knees in adulation. At least a few of our systems are broken and it's precisely because of the free market system you apparently love so much.
Doctor Who - if you don't think the public option will be successful, is that a reason to not create one - because it would be an unnecessary and expensive bureaucracy, perhaps... or is it that you support the public option and hope that it works as advertised, but are pessimistic that it will? Also - is your statement that we need greater choice arguing for more industry regulation, or anti-trust action against monopolistic (by region) insurance companies? I don't exactly disagree with much of what you say, and your AMA comment is interesting, but I don't understand most of what you are proposing.
Leave_me_alone: you mention the UK and Canada (although I am not convinced about your assessment, but whatever); how about the German model?
"The profits the insurance industry is making, of course -- profits artificially boosted by an enormous backdoor tax subsidy -- don't seem to be buying the customer much of anything in terms of improved service or cost savings. On the contrary, health care costs are rising by as much as 9-10 percent per year, without any concomitant increase in the level of service. If JetBlue were raising the cost of its fares by 10 percent per year, they'd be out of business."
With all due respect to Nate, this is an extremely silly argument. If JetBlue's labor and fuel and other costs were increasing by 10% per year, as were the costs of every other airlinse, then JetBlue would NOT be out of business. Health insurers don't raise their prices by X% every year just for fun - they do it because their own costs of providing service are increasing.
The reason that health insurers stay in business isn't barriers to entry - it is that all health insurers are subject to the same cost increases.
This post is obviously wrong.
Most Americans have been so brainwashed into thinking our system and the "free market" and all the blah, blah, blah, is so crucial and important and completely irreplaceable yet Europe and nearly the entire world has health care systems that are equitable, fair, intelligent, reasonably-priced, working and available for all yet we don't think we can do it because God forbid we don't have "Capitalism" and a "free market". That explains the likes of "Dr. Who", above and his answers. It's so tiresome.
Americans really are stupid. Just zombies, spewing out the corporatespeak.
It's maddening.
Go ahead. Attack me, now, Dr. Who. Unless you're wealthy yourself, you're only supporting the corporations and wealthy people.
Nate,
There's a simple term for what you're describing: a natural monopoly, where entry barriers are too high. In traditional antitrust terms, natural monopolies were called "utilities" are were subject to regulation by the state.
So, because it's cost prohibitive to string new power lines to every home to have a competing power company, power companies are utilities. Sure, you can unbundle some of the services, but whoever owns the wires is a natural monopoly.
Even in High Gilded age jurisprudence this phenomenon was accepted and recognized.
Market forces only work where market failures like natural monopolies don't crop up.
Further, I think that Nate is not understanding Will's argument.
Nate writes: "But that isn't my bet, and it isn't George Will's: There's no obvious reason that the government couldn't provide more for less. And if we are wrong, we would find out soon enough: if the public option can't deliver more bang for the buck than private insurers, it wouldn't gain much market share from them, and Will will have nothing to worry about."
What Will is saying, I think, is that the Government will be able to provide health insurance on a basis that is cheaper *to policyholders* because the government can provide subsidies to the public option.
That is, the public option will be cheaper to insurance buyers because taxpayers are picking up part of the tab.
Nate doesn't wrestle with that issue at all. (Note that Obama discussed this in his press conference today.)
Dr.Who: interesting thing you say about choice of health care/insurance... if I have insurance through my employer, then obviously I can't choose my insurance. And if my insurance company then tells me I can only see the doctors on their roster, then I don't have my choice of doctors, either. So... how do you think this is supposed to work?
Also, I would like a little more detail about how you feel the AMA restricts the number of doctors... from what I know about the system (not much, but at least it's not knowledge I picked up from watching Scrubs or whatever), the number of doctors trained each year would be limited by positions for internships, residencies, etc. It seems that arranging things so that doctors can be trained in greater numbers inevitably would result in training that would be arguably inferior to what is currently provided. So how could that be resolved, or do you not think that could be the case? Malpractice fees are high enough, aren't they? (If I'm mistaken about the burden malpractice fees represent, someone please correct me....)
Austin, the itemized health insurance charge on your pay stub is actually only the portion that you pay. Your employer is also paying a portion, which may in fact be several times what you pay. This cost is hidden from you, but if you, say, get laid off and decide to continue your current coverage via CORBA, you'll see the full amount that your coverage costs.
Of course, as Nate points out, while you don't see the amount that your employer is paying, that doesn't mean that your employer isn't factoring it into your total compensation. Presumably if our health insurance weren't tied to our employers as it is for most of us, our take-home salary would see something of a boost.
Josh
@Alexander K: So the insurance companies aren't responsible for the 9-10% annual increase in costs of medical coverage? And the AMA doctors are complaining that they are getting squeezed so much that it's becoming less and less attractive to be a doctor. Why? And Americans pay a 50% premium for their health care (relative to the quality of care they receive). Why?
How can health care be organized to satisfy certain basic criteria (e.g., 100% of people covered) without the costs growing at such a high rate and our overall bill being 50% higher than comparable coverage is in other large countries?
I'm unclear on why we would expect a free market to work well in an industry that seems to present externalities, emotion, and time pressures.
Externalities: those without means are still treated in our hospitals, because we think it morally right to do. The free market can't price this in, because those who don't pay, don't pay. Or, more accurately and worse, people are asked to pay at all stages in the proces, making it so people don't pay to get information (another flaw in the free market, because those without insurance don't realize how sick they are and that they won't get better without care until it gets worse and ends up costing MUCH more to fix the problem). Thus, unless you want to divorce morality from medicine, we have a major problem for the market.
Emotion: Cost is, essentially, irrelevant in our health system. Two reasons: insurance "covers it" and the vast majority of people value life at infinity. Thus, they have no incentive to bargain shop.
Time pressure: if we were buying widgets, we could price various suppliers for the best value. However, when my appendix burst, I didn't have the option of finding a different surgeon: the guy who was there was the guy who was going to do it. In less dramatic fashion, when you are sick, OK care now is better than great care later. There is no time to find out competing prices; essentially, this is a form of limited information, but a very nasty one. Not only do consumers not have complete information, but they only have 1 piece of information.
Finally, while I'm on information failures of the health market, this is a case of very specialized knowledge. The consumer cannot evaluate whether a purchase was a good idea until after the fact, often MUCH later. And the only way of really doing that is consulting with another guardian of information (here, the point about not enough doctors might be appropriate, but we'd do well to remember that not everyone is cut out to BE a doctor, and the US already has one the highest rates of doctors per capita in the world). Even then, the guardians of information do not, in fact, know everything, and many people might have incurable or undiagnosable conditions, given current technology.
So, I gotta say I agree with Nate that I just don't expect free market logic to work here. The conditions just ain't there. I can compare airline prices and know what I get for my money. I can test drive as many cars as I want. I can look at a bookshelf at IKEA and figure out if it's stable. And, more than my parents, I can look at a computer and figure out if it's delivering what I want for a price I want. But I can't possibly know all the risks to my health, how much they would cost if untreated now, or any number of things.
*Let's not forget the known phenomenon of the young to think they are invulnerable. The whole pyramid scheme of insurance falls apart without 20-29 year olds paying for all the old people, and those 20-29 year olds might not buy insurance if you simply put it on them.
Thanks Nate. You have put a voice to what I have been saying about insurance for years. I am a "free-market liberal." But there are a substantial number of instances where the market breaks down; insurance being the penultimate (any number of public goods (e.g. parks, roads, etc.) being the ultimate). The bottom line is that insurance is an industry that works optimally without a profit motive and more successfully at scale. Likewise, we all subsidize the uninsured, in one way or another, so we are better off creating a public plan and requiring all to be a part of it. It is no different than requiring all drivers to have car insurance.
@Juris: "@Alexander K: So the insurance companies aren't responsible for the 9-10% annual increase in costs of medical coverage?"
I don't think so. Have health insurers' profit margins increased? Not that I'm aware of (feel free to correct me if I'm wrong). And I believe Medicare's costs have increased faster than private insurance's costs.
sorry guys I can't talk,so I just post some links.
“Health care is one of the most expensive items of both nations’ budgets. In the United States, the various levels of government spend more per capita on health care than levels of government do in Canada. In 2004, Canada government-spending was $2,120 (in US dollars) per person on health care, while the United States government-spending $2,724.
However, U.S. government-spending covers less than half of all health care costs. Private spending for health care is also far greater in the U.S. than in Canada. In Canada, an average of $917 was spent annually by individuals or private insurance companies for health care, including dental, eye care, and drugs. In the U.S., this sum is $3,372. In 2006, health care consumed 15.3% of U.S. annual GDP. In Canada, only 10% of GDP was spent on health care.”
http://en.wikipedia.org/wiki/Canadian_and_American_health_care_systems_compared
"The United States spends six times more per capita on the administration of the health care system than its peer Western European nations."
http://www.nchc.org/facts/cost.shtml
just for "fun" see also:
http://investing.curiouscatblog.net/2008/02/09/international-health-care-system-performance/
good night 538' addicted .
:)
@npunwani I don't think you would see wholesale exit; rather, you would see a helpful realignment from specialists to primary care physicians. Demand for primary care will increase dramatically as coverage increases, and so the government will likely have to induce med students into primary care with higher reimbursements for primary care visits and basic procedures, probably offset by reducing reimbursements for less effective specialist procedures. For people who still want access to those specialty procedures that are unjustifiable from a QALY point of view, there will very likely be plenty of private, supplemental insurance.
@Jarv. Perfectly said. As for the information issue, what's even worse than patients not knowing how effective various treatments are is that doctors THEMSELVES often don't know how effective treatments are, hence the government's creation of a vast dataset on effectiveness for doctors to draw from when settling on a course of treatment. The truth is, many doctors do things one way because that's how they were taught, not because that's the best way to do them, or the most effective course of treatment.
All in all, the debate between the "free market" and evil socialized medicine is a canard. There is no free market in health insurance, and for all the reasons Jarv listed, an effective free market can never exist. Given the choice between least worst cases, it's clearly better to have a government player disciplining the market and creating incentives that help supply the inputs that make the most difference in creating a health population at the least cost -- widespread primary care and preventive medicine. Our current system has decisively shown itself to be completely incapable of doing so.
Y buenas tardas to maricones too...
Choice. That's the big issue, right? Whether it's some private startup insurer who has somehow managed to accrue the volume and capital necessary to pool their risk and offer a competitive rate (somehow), or whether it's the government, people want choice.
Take me as an example. I'm a 23 year old unemployed non-smoking male living in Austin Texas. I just looked up what it would cost me to get health insurance coverage. I can cover myself and my unemployed non-smoking 24-year-old wife for about $200 a month. My previous job offered a health plan (one that, for whatever reason, they never allowed me to enroll in for the six months I was there) that would have covered us for significantly cheaper (sorry, don't know the exact amount, as I threw away the benefits package; it didn't come until after I'd already left the job, so it didn't seem relevant).
This is why most Americans are covered through their employer; it's their only option, fiscally. You either get insurance through your employer, get coverage elsewhere for significantly more, or you get buried in bills next time you need to go to the emergency room. That's not competition.
My wife's previous job actually had free health insurance. That was nice, but as soon as she got laid off, the benefits went away.
If all of the nation's employees were offered a program (either by the government, or by anyone else) that was competitively priced against their employers' programs, then the consumers would be able to weigh out the pros and cons. But of the ones who have any health care at all, most are simply paying for the only affordable option.
Hence: choice. Either the free market can do it, or the government can do it. I really don't care. But someone or something needs to stimulate competition in the insurance industry, so more Americans can have doctors again, ASAP.
By the same derivative logic as Nate's, Obama "admitted" today that the porkulus bill was a failure because unemployment will go above 10%.
With something as vital as healthcare (we all need it, many times in our lives) it seems sensible as an economy to pool resources.
In the UK the National Health Service has a budget of around £100bn. This works out to roughly $2700 per person. For this they get entirely free healthcare - GP appointments, dentists, all in/out patient hospital visits. They even get 2 rounds of free IVF treatment.
In the US medicare and medicaid budgets total around $700bn ($400bn + $300 bn). This works out as roughly $2350 per person. This doesn't include Federal Employees Health Benefits or the Military Health System.
The British system is clearly offering better value for money (and they live a year longer according to WHO). From what I hear other European countries offer even better.
For the record, George Will speaks for an army of one within the conservative movement. He is a shadow of his former self, a captive of the beltway doddering his way into irrelevancy.
Still Nate misses the point entirely.
Right now private healthcare has become so expensive because the government refuses to adequately reimburse for Medicaid and Medicare, forcing health care providers to demand more from insurance companies and private pay patients. If they don’t they will go out of business and then the health insurers will not have a network to refer their insureds to and they too will lose business.
The problem with a public option is that the government already has overwhelming bargaining power and can simply say take it or leave it to providers. It is expected that the public option will adopt Medicare reimbursement. This will lead to further pressure on providers to make up their losses with the private insurers and patients hence there will be need for more cost shifting to the private system, making it more and more expensive or unprofitable.
The increased cost that is forecast for the private system is the reason why it is believed that it will ultimately fail with all Americans being forced by cost issue to migrate to the government plan.
(This is precisely what many fear will happen with government owned banks and car companies – they will have an unfair advantage that will drive the private competition from the marketplace and one day all that will be left is the government owned competitor. Welcome to Commerce 101 – the DMV.)
Once the private insurers are driven from the market, at that point then the government will have to foot the whole cost of medical care and will need to raise taxes to make up for the short fall formerly made up by the private system and it will need to restrict care so people don't gorge themselves on free medicine. Rationing and higher taxes, much higher taxes are inevitable.
The dead-end here of course is rationing and a two-tiered system where the Upper Middle Class and the Rich pay premiums to get the care they need and 90% of the public is left with DMV-quality healthcare.
This is the debate we need to have.
petekent01 (on twitter)
@ Juris:
Easy, do what Germany, Switzerland, and the Netherlands have done. Ban cherrypicking. Adopt community rating, everyone in a certain area must be charged the same price for a given insurance plan. Also, we would need to mandate that everyone buy insurance to keep costs down. If everyone is purchasing insurance, you have a huge pool to disperse risk so community rated payments dont skyrocket. The Wyden-Bennett bill does all this (Healthy Americans Act).
As for holding down costs, ultimately we'll need market competition. the price and expenditures of Rx drugs were growing out of control. The Medicare Part D program changed all that. Costs have been dropping. I propose that our health care system follow that model. We're also going to need to do cost-benefit analyses in deciding whether to insure for new drugs and medical devices.
leave me alone said
'Before long the government plan will be the only plan. And rationing will be rampant. Just as it is in Canada and UK. God help you if you are over 65, or disabled,or have a chronic disease. You will not get timely help from the government plan.'
---------------------------
LMA, you are just plain wrong in your assessment of the UK healthcare system. I can't speak about the Canadian system, but the UK system works pretty much ok. My sister in law and mother in law have both had very serious operations within the National Health Service, both happened in a timely manner, and both are happily recovering. Without expensive health insurance in the US, I cannot be certain that either would have been able to receive as good care as simply as they did in the UK.
The saddest thing for me in this whole healthcare debate is that those opposing a government run option will be doing it for political and financial, rather than medical reasons.
@ hat,
Here's the problem. We've had a primary care shortage the last 20 years! Congress didn't do jack. You're assuming Congress will act but they haven't done so, and refuse to do so.
I'm in medical school right now. I wanted to do primary care, now I realize its just a disrespected profession with a future of declining reimbursements when I'm strapped with $250k in debt and will face rising malpractice insurance costs.
I'm a big believer in anyone claiming to be a big believer in the profit motive should know profit's origin, exactly, without any bullshit about opportunity cost.
Well?
sam said
'In the UK the National Health Service has a budget of around £100bn. This works out to roughly $2700 per person. For this they get entirely free healthcare - GP appointments, dentists, all in/out patient hospital visits. They even get 2 rounds of free IVF treatment.'
---------------------------
For the sake of accuracy let me point out that dentist appointments are not free in the UK, unless you are on government benefits. (I believe the cost is about £20 for a check up at the Dentist.) Though the rest of what Sam said is I believe accurate.
Nate, you are the man.
Break this thing down for these suckaaaaz!
"Also, we would need to mandate that everyone buy insurance to keep costs down. If everyone is purchasing insurance, you have a huge pool to disperse risk so community rated payments don’t skyrocket."
There's truth in this - a lot of it.
Plenty of Americans don't want health insurance -- they simply don't need it. Most people between 18 and 40 never go to a doctor. That's the reason why we spend so much money on those last three months of life -- 90% of your healthcare spend -- for many before that they hardly spent a dime!
And why should they? They didn't need to.
It is curious to me how we have gotten so far away from first principles and we now must require people to buy things they don't want or need.
The healthy must be made to subsidize the sick. I say let the sick fend for themselves as they have done throughout human history and keep your hands off my wallet and pay check.
If your hearts bleed for the sick and uninsured, then please care for them, call it welfare or charity or whatever, but don't screw with my healthcare system to achieve these goals.
And don't bankrupt the nation in the process.
This scrutiny is very good. Exposed to the harsh light of day the American people are sure to revolt against this folly.
Obama's reform plans cost way too much and achieve too little while messing it up for the vast majority of us who are satisfied with what we got.
If anything we need a consumer-driven healthcare revolution not a government one. Read Regina Herzlinger.
petekent01 (on twitter)
Nate:
I've been reading your blog for a while, and I wanted to comment in the pro for universal health-care, and the public option.
Outside the "frothing at the mouth" responses, I see two major themes:
1) The public option allows the government to compete as one of the players in the field of health care. If it was impossible to do so, then the problem should take care of itself. If not, then it becomes part of the solution and a part of the conservatives answer, being, "Give the consumers more options."
2) Economies of scale work in favor for the government and in the case of the consumer, for the insurances and against the insured.
So what I see is three groups of insured Americans:
The basic insured, who have basic needs and emergencies covered in a minimal plan through work, put there by the race to marginal profit by employers and insurance companies.
The Luxury Insured who either have private insurance packages that cover all and any aliments or self insured due to personal wealth or position.
Finally there are the Uninsured, who, due to our medical system treating emergencies regardless of whether they pay, and end up being, I believe quoted at "a really large number with a dollar sign in front of it" every year from the federal budget.
Where this goes is back to what Obama talked about with his stimulus package philosophy. That we make big payments to save money later.
Because of the large bill we pay from the uninsured every year, due to that pesky thing we call empathy, we start to think of the time old philosophy, "It is best to have insurance, because it will be cheaper to pay $400 a month rather than $30,000 a month 1% of the time."
What this means is, if we borrow money to prime the public insurance engine, then the Federal Government Saves money by not providing emergency care. This amount may be more, but will definitely be similar to the cost of providing universal care.
If we have resolved to cover medical costs of the uninsured at the emergency level, then by wisdom alone, we should as a group conclude that it will save us money to give them public coverage for no other reason than it is cheaper for us to not pay their emergency bills.
By offering a public option, however, who's goal is simply to provide service we create the competition necessary to break the private sector race to the bottom with health-care, described earlier.
Nest to the public option, now the uninsured are insured with a basic coverage, and those with minimal insurance now have an option that may be better suited to their needs, which moves two of the insured groups into a better situation coverage wise. The final group, the luxury insured, have better insurance then the government can provide.
However, because some of the minimally insured will have had better coverage then the public option, their plans will migrate towards luxury insurance, equating to better coverage for them too (think of companies, like Google, who actually want to provide for their employees).
All in all, this becomes a win win for the consumer. But the insurance companies loose out on, what I'm paraphrasing from Silvers as Subsidized Profit. Touch someone's gravy train, and they'll kick and scream till their forced to work for a living like the rest of us.
npunwani said:
If we were to adopt a single payer system (which a public plan will lead to), then we will lose a lot of dynamic efficiency. There will be wait times as well.
How long do you think the wait time is for poor Americans who have no health insurance?
Will has two other objections, as I see it, that you haven't addressed.
First, if the public plan underestimates its costs (and that is likely- Medicare/ Medicaid grew to be 10 times more expensive in 1990 than they were projected to be in 1965), guess who makes up their losses? Yep, you and me, the taxpayers. So we don't actually save any money.
Second, if the government becomes the de facto (or de jure) monopoly supplier of health insurance, it then has the thin edge of the wedge to force people to do or to avoid certain activities (ie, require proof of exercise or banning tobacco) because it has the public interest of saving money on health care bills. This criticism also applies to Waxman-Markey, which seeks federal control of energy consumption.
In short, the savings that you claim are the reason to overrule the private market are unlikely, and hokey as you no doubt think it is, we'll lose some of our freedom in the process.
Doctor Who said:
The problems are that we have too few physicians available to practice medicine (artificially limited by the AMA, among others) and restricted choice when it comes to health care/insurance.
If we had more doctors, I suspect that most of them would still wind up in specialty practices, where they can make enough money to pay off their educational debts.
The high cost of med school is a big factor in our lack of GPs. I think we have enough doctors already, but they are in the wrong places. A GP in a poor rural area would most likely go broke, so we need some economic incentives to allow doctors who would like a GP practice to actually afford one.
Nate said:
On the contrary, health care costs are rising by as much as 9-10 percent per year, without any concomitant increase in the level of service.
Why do health care costs go up? Because there is no natural force to stop them from going up. Insurance companies aggregate risk, but they are a pass-through for the costs. Doctors write orders for tests and procedures that are excessive or unnecessary, in part to reduce the risk of litigation, but especially when they have also own the clinics and imaging facilities that perform the tests. Consumers don't have the power or the incentive to negotiate the cost of health care. After all, who wants to dicker on price with the person who is going to be cutting you open?
Proponents of free-market economics bleat that only a market-based system can contain costs. We have a market based system, and costs are rising without improved service. When you can raise prices without losing customers, that's called monopoly pricing power. Free-market economics don't apply here.
Insurance companies and doctors are not owed the right to make obscene profits by our society.
Public option? Yes! Single payer (someday)? Yes! Let's hope so.
@npunwani I guess I'd have more sympathy for your plight if my girlfriend weren't in the exact same financial boat (i.e. debt) and matching in family medicine. Your citing of financial reasons for your choice only strengthens the argument for shifting money from specialties to primary care in order to induce people like you to take the plunge. And I think there's absolutely no problem with being money motivated to an extent.
@ hat,
I'm not asking for your sympathy, I could care less for it. What I am trying to say is that we've had this primary care shortage for decades, Congress still didn't act. I'm studying for radiology, and I think they should get a a reimbursement cut, but every time there is talk of this politicians don't want to do this. This is why I want payment decisions to be out of the hands of politicians. This is why I do not support a public plan. As long as if we have a fee for service system, primary care will always be shortchanged just because they cant perform as many procedures. If Medicare and Medicaid dropped fee-for-service, private insurers will experiment with their own payment methods and the most efficient ones will prevail. Instead, Medicare payment rates dictate how other private insurers should respond.
Jarv said:
Finally, while I'm on information failures of the health market, this is a case of very specialized knowledge. The consumer cannot evaluate whether a purchase was a good idea until after the fact, often MUCH later. And the only way of really doing that is consulting with another guardian of information (here, the point about not enough doctors might be appropriate, but we'd do well to remember that not everyone is cut out to BE a doctor, and the US already has one the highest rates of doctors per capita in the world). Even then, the guardians of information do not, in fact, know everything, and many people might have incurable or undiagnosable conditions, given current technology.
Another big information failure is the lack of ratings of doctors. Given my choice of doctors A, B, and C for an operation, which one has the best success rate? Or a choice of hospitals? Just try to find out...
Also, I understand it is very hard to find a doctor who will testify against another doctor in a malpractice case. A classic case of information failure.
Alan,
You make a good point about wait times for poor people. But at least I want the public option side and single payer advocates to be honest and admit at some point there will have to be rationing, wait times, and queues. There is nothing wrong with that as long as if society consents to this. Instead I'm hearing such advocates say there wont be any sacrifice none at all.
I think such talk is an immature, asocial mentality and is the most disdainful expression of pie-in-the-sky thinking
@npunwani If health care reform is going to work, i.e. dramatically increase coverage, it's going to have to increase the supply of primary care. There's only one way to do that -- increase reimbursements for primary care visits and basic procedures, or provide debt relief to people thinking about primary care, or reimburse primary care physicians with a flat salary, as you imply. You can't achieve the improvements in coverage and cost effectiveness without drastically increasing the supply of primary care physicians delivering preventive medicine to more Americans. These changes will have to come alongside a public plan.
Maybe we're arguing less about whether or not a public plan should exist, and more about what should come with it, i.e. a significant change in how primary care physicians are reimbursed. Eh?
What Will (who has excellent health inaurance, thank you) is really saying is that the government will force private insurers to stop raping participants financially and cherry picking them. Since that violates the free market, Will is naturally against it.
Another gasbag with no moral compass except the one pointing to greed.
Odd, I think both gWills and Nate are missing the point here. It is not about price, it is about value. To my mind, a reasonable argument against a public option would be unfair market advantage that leads to lesser consumer value.
I tend to think the entire argument though is rather silly, because the private companies will simply dump their unprofitable patients on the public option, thereby subverting the entire insurance paradigm.
PeteKent said:
The dead-end here of course is rationing and a two-tiered system where the Upper Middle Class and the Rich pay premiums to get the care they need and 90% of the public is left with DMV-quality healthcare.
In case you haven't noticed, Pete, we already have rationing and a three-tiered system.
The rich, as in any system world-wide, get whatever they want.
The middle class with insurance gets your DMV-quality health care (if they want anything more, they have to pay for it themselves - see "rich", above.)
The poor and uninsured get virtually nothing - here is your "rationing".
Leave_me_alone said:
God help you if you are over 65, or disabled,or have a chronic disease. You will not get timely help from the government plan.
What universe do you live in? The above people are usually covered by Medicare or Medicaid, both government plans which usually (but not always) provide timely help.
"That's because if he's like the majority of Americans, he's getting his insurance through his work, and except when the HR lady gave him a shiny brochure on his first day at the office, he's probably never thought very much about what this insurance is costing him in terms of foregone salary."
I think this is true for Frederick, but what about Frederick's employer? Health insurance is a huge cost for Frederick's employer, and therefore should have every incentive to consider lower cost options such as a different insurance company or pooling with other employers to self-insure. Does anyone know if there is some barrier preventing this from happening?
Also, some mention should be made of cost shifting as one of the causes of high and increasing health insurance rates. Hospitals, for example, generally lose money on public programs such as Medicare and Medicaid. Some patients without insurance don't pay anything. The cost of treating the uninsured and public program patients is shifted to others. This is behind one of the major concerns with a public option, that it will pay Medicare rates which are much lower than what a private insurer could get. This would put not only private insurace companies out of business but possibly many hospitals as well. Does anyone know if this issue has been addressed?
Thanks, I enjoy the discussion.
Doctor Who:
There is a valid reason why health care is different from the other 99% of things in which the free market is better.
If you dine every night at the finest restauarant in town while I'm stuck with Mickey D's because you can afford it and I can't, nobody feels sorry for me, and rightly so. In point of fact, if I'm unable to afford ANY food and have to eat off charity at the local Salvation Army, nobody feels particularly sorry for me, either.
This principle cuts across almost every facet of American life -- housing, cars, vacations, you name it. If you can afford the best, God bless you, and if you can't, figure out some way to do something about it or shut up.
That's not how people feel about health care. Maybe YOU don't, but the overwhemling majority of Americans feel that any individual is entitled to whatever life-saving, certainly, and even "only" life-improving measures are available. Comfort is not part of that (think E-rooms and wards vs. private rooms and "boutique" medical plans), but the plain fact is that if you show up at an emergency room at 3 AM with a heart attack in progress, you WILL get all the help you need to survive it, including open heart surgery, stents, what have you, regardless of cost and regardless of insurance status. And with the exception of a handful of Ayn Rand hard-asses, everyone is OK with it.
But obviously the costs of "what have you" must be borne by somebody, and in fact they're borne in one of two ways -- by taxpayers who fund state and municipal hospital systems (which see a high percentage of the uninsured) and by people with insurance whose hospital costs, and thus their insurance premiums, are increased to cover those who do not have insurance and are unable to pay.
There is nothing else in our economics like this -- a situation in which everyone is "entitled" to product, even extremely expensive product, without regard to their ability to pay for it. So when Nate says that the free market can handle 99% of things but not health care, he has a valid point and you, who have said little to counter him other than that 99% yes, 1% no seems cuckoo to you, really ought to consider this before assuming blindly that health care is like apartments and cars and eating out.
It's hard enough to make a profit in any endeavor, but it's especially hard to do so when people are entitled, by common consent of the populace, to the benefits of your product even if they cannot afford to pay for it. This means that the health industry, taken as a whole, CAN'T make a profit unless it overcharges the majority of its customer base.
In point of fact, what the public option as expressed by Obama will do, even if it DOES drive the private sector out of the business, is to simply transfer some of the cost of the national medical care bill from where it is now, upon state and local taxpayers plus insured persons paying for those who cannot afford insurance, onto the federal taxpayer. Nothing else need change at all, necessarily. The only real reason to oppose this idea is that it will shift some (not all) of the cost of the national health bill onto the wealthy (who pay more progressive taxes at the federal level than they do at the state or local levels) from lower- and middle-income people. Does that seem unjust? Well, what is so fucking "just" about sticking a larger percentage of the bill (as at present) to those whose ability to bear the cost of the uninsured is far less than high-income earners?
Of course, the dramatically increased bargaining power of the national government would almost certainly drive down the profits of Big Pharma and alter the salaries of doctors downwards to some degree. As you yourself note, the REAL reason those salaries are so high is that the AMA acts as a monopoly in limiting the number of medical schools and thus the number of doctors, so a side benefit of the public option would be to reduce the profits from the chokehold of the monopolists. I'd think you would be happy about this.
Alan,
In the hospitals I have worked in, the poor and unemployed have free unfettered access to medical services; the working uninsured (or partially insured) get a *really* raw deal.
We are beating around the bush though. Escalating costs will NOT be controlled while the population is getting older, fatter, and sicker by the year.
@ Hat,
The problem with a public plan is that its not accompanied with anything about reimbursement reform. ALL OF THE PROPOSALS FROM KENNEDY-DODD TO ROCKEFELLER, argue for using Medicare's fee-for-service rates. This won't do jack for primary care.
Even if we increase primary care's reimbursement rates it will be a one time thing. As long as if technology advances, more health care services are introduced, the fee for service system will continue to grossly pay specialists. It is inherently discriminatory to primary care, yet Congress refuses to act. I will not support a public option until this is addressed, we're just building on the worst elements of our system.
Look at the Dutch,
They have a universal health care system thru private insurance only. What's happening, private insurers are discovering which ways of reimbursement work for them and providers in order to improve cost effectiveness and attract more enrollees. The secular trend of all this is better pay for primary care and dropping specialists who perform too many procedures from their networks.
The healthy Americans Act of Wyden Bennett does will move our country closer to the Netherlands.
PeteKent said:
Plenty of Americans don't want health insurance -- they simply don't need it. Most people between 18 and 40 never go to a doctor. That's the reason why we spend so much money on those last three months of life -- 90% of your healthcare spend -- for many before that they hardly spent a dime!
And why should they? They didn't need to.
As long as they don't expect any subsidized help at all during their life, either for medical emergencies or for end-of-life care, they shouldn't have to.
But it is amazing how many of these rugged individuals, when faced with death, demand treatment they can't afford.
The healthy must be made to subsidize the sick. I say let the sick fend for themselves as they have done throughout human history and keep your hands off my wallet and pay check.
When your turn comes (as it must), then don't whine to me about needing any care. Go off and scream in a corner while you die.
slasher14: *very* incisive post. From my POV though, the current state of giving everybody whatever is untenable long term. Rationing is coming.
npunwani said:
As long as if we have a fee for service system, primary care will always be shortchanged just because they cant perform as many procedures.
Amen! This definitely calls for government intervention.
Good introduction, but isn't adverse selection the number one argument for a single payer? If you could explain that in the same readable terms, we'd really be getting somewhere.
npunwani said:
But at least I want the public option side and single payer advocates to be honest and admit at some point there will have to be rationing, wait times, and queues.
I agree completely. Any health care plan, no matter what kind it is, will have rationing, wait times, and queues.
My gripe is with those on the private side who will not admit that we already have rationing, wait times, and queues in our current private health care system, and then knock the public plan for having them.
Nate I agree with your assessment with Will's comments that it all just boils down to a simple philosophy of "government=bad." For the past thirty years we have seen the GOP make strives not only to get goverment out of big business but to get big business to take over government's roles. We've seen this political philosophy creep into schools, roads, and even social secuirty. Can you imagine the nightmare the country would be going through right now if George Bush had succeeded in privatizing Social Security.
Basic Republican thought is that every role which government performs can be done better if only big business and competition were let in (Funny how that only seems to be a one way door in this particular situation). That is except for one area - Defense. And by Defense I'm talking not only about the US Military but also area Police and Fire Departments.
Not that long ago in the world's history armies were staffed mainly with mercencaries. Police and Fire Fighters were operations owned by private individuals. We can still see leftovers of this line of thought in some areas where the ambulance service is not provided by the government but by private operators. A lot of places it is a mixture of both government and private ambulances.
Yet somewhere along the way we as a nation decided that having guns for hire with no alliegence to country was a bad thing. We also realized the potential pitfalls that having a police and fire fighters being owned by a for profit would entail.
If Republican political thought had some validity then taken to its logical end of "Government=Bad" then why are these areas of defense not run by corporations or do you hear any Republican voices crying out for Privatization of the armed services. One of the few areas where both Republicans and Democrats find common ground is that our Armed Forces, Police and Fire Departments do an excellent job. But the last I looked all were not-for-profit government run organizations. Yes there have been cases of program over-runs for the DoD and cases of corruption but those get weeded out fairly quickly due to the power of the vote. So if Big Government does a good job at defending our country and protecting our lives and property then isn't it possible that BG could also do a good job with our health care system.
One last point is all the Republican emphasis on 'market innovation' that would be lost with a government run Health Care System. I personally don't see a lot of market innovation when it comes to big corporations. In fact big corporations because they are looking at the bottom line tend to move slowly. I can remember a time when on the nightly news the Big Three Automakers were wailing and screaming that if they put air bags in vehicles it would drive them to brankruptcy (well they're there now but not due to air bags!). But how many people would buy a car today without a basic air bags - not many would be my guess. In fact now days carmakers have so totally embraced the air bags that they put them practically everywhere. Another example from a business sector not in finacial troubles would be the electric companies. Not even a hundred years ago most of what is today Red Rural America had no electricity or access to electricity despite the fact that cities and small towns had it. The electric companies' arguments went that it was too expensive and that there would be no demand for electricity if it was available. How did rural America get hooked up to the grid - thanks to FDR and Big Government manadating it. I haven't heard of an electrical company going out of business and I doubt I would find many Republican Rural voters willing to give up their electricity. Lastly, despite Big Pharma's insistence that the reason it charges such high prices for drugs is that money goes into research the truth of the matter is that most medical research into new drugs is conducted at state run universities and at the NIH, a government run organization. So where is the 'market innovation' that Republicans like to brag about? And I would argue back that having a cell phone in blue, pink or fuscia is not a choice of neccesity.
Eric said:
It is not about price, it is about value. To my mind, a reasonable argument against a public option would be unfair market advantage that leads to lesser consumer value.
And how do you think that the poor and uninsured, who currently have no access to health care, would complain about a "lesser consumer value"?
Eric said:
In the hospitals I have worked in, the poor and unemployed have free unfettered access to medical services; the working uninsured (or partially insured) get a *really* raw deal.
I suspect you really mean: the poor and unemployed have free unfettered access to emergency medical services.
I don't know much about hospitals, but from what I have read, they will not provide free access to long-term treatments like chemotherapy. Or to non-emergency treatments that may prevent a subsequent medical emergency. As an insider, what is your view on this?
Just one comment on the "insert GM or Post Office joke here" thing --
-- actually the post office strikes me as an argument in favor of the public option.
Sure, when I was a kid in the 70s the USPS was the butt of a lot of jokes (and those dusty jokes still get trotted out), but over the last couple decades the USPS has been great. I've never had any significant problem with it -- using priority and express mail is both convenient and affordable -- hell, I get a 2 day turnaround via NetFlix and that's mailing both ways!
I think part of the reason it's improved so significantly and is overall so excellent nowadays is that it's got private competition via UPS, DHL, and FedEx -- and the result of this public/private competition has been a variety of excellent shipping services -- services so excellent that they've helped drive a major new part of the economy: internet sales and things like E*Bay businesses.
And I think this kind of public/private competition can wind up working well for health insurance too.
@PeteKent: Plenty of Americans don't want health insurance -- they simply don't need it. Most people between 18 and 40 never go to a doctor. That's the reason why we spend so much money on those last three months of life -- 90% of your healthcare spend -- for many before that they hardly spent a dime!
And why should they? They didn't need to.
Although I don't believe that most people would rather not go to a doctor at all for 22 years of their life, you clearly state one of the main reasons EVERYONE should be receiving healthcare. If people didn't rot away without the option of going to a doctor and instead were EDUCATED and took care of themselves we would have less cost as they age and better national health and productivity. This is an indisputable win win for everyone involved. How can you not see this?
@ Alan:
"Amen! This definitely calls for government intervention."
Where is that gov't intervention. Its been sorely lacking for the last 20 years, primary care has been butchered because of Medicare and Medicaid.
Isn't insurance simply a pass-through for the costs? In other words NOT the place that innovation is supposed to happen?
E.g., if we decompose the events:
(1.) Patient visits doctor, maybe pays co-pay
(2.) Provider prepares bill or claim
(3.) Administrator checks eligibility, benefits, etc (adjudication) and then approves payment of none, some, or all of the claim.
(4.) Insurance entity pays bill
(5.) Provider cashes the check
Many large companies are self-insured thus the "insurance company" is actually the employer and they can design their own benefits plans.
Thus the costs in the events above appear at 2 places:
(2.) The provider's services and admin costs (practice management systems and staff), and
(3.) The administration of the actual claim: was the patient eligible for their service? Did they pay the co-pay? Did the provider charge correctly?
In other words, NOT insurance.
So that would mean the innovation that is speculated to lower costs in a "public option" must occur at the claims administration level.
Is the government really an expert at administration? Don't they already contact that out for Medicaid?
And wouldn't that encourage a single plan if only to eliminate the rules and costs choice would bring?
Thus we could lower costs by having only a few plans even if we didn't innovate on claims admin, but then we'd be left with little choice.
A. I agree that the number of physicians is restricted, BUT the data show that the more doctors per person in an area, the higher the cost of health care.
B. Myth - "It will be very expensive to get good health to everyone."
Fact - Actually there's a way we can have better universal health care at no more than we are now paying (see 5. below). Here are the facts (cf. www.pnhp.org):
1. We waste $100 - $200 Billion a year on the high overhead of insurance companies.
2. We waste $200 - $300 Billion a year on doctors filling out forms for insurance companies.
3. I don't know the compliance cost of patients fighting with insurance companies, but it must also be in the 100's of Billions.
4. We pay the highest drug cost in the world to drug companies that spend twice as much on profit and three times as much on "marketing" as they spend on research. This is about another $100 Billion each year.
5. Because of the above, we could give Super Medicare (few limitations, no co-pays, no deductibles and complete drug, dental & mental coverage) to everyone at no more cost per person than we are now paying.
Other countries with single payer systems get better health care as measured by all the basic public health statistics and they do it at less than half the cost per person. If we build on our rotten system, we will get a health care system with rotten foundations.
C. The President says we have to take incremental steps. Medicare for All IS an incremental step. Step one was Medicare for the highest risk pool, old fogies like me. Step 2 is Medicare for everybody else which is actually easier because it does not cost any more (see below). Step 3 would be more efficient medical practice.
The main reason that it is far better to extend Medicare to everyone is cost. Private insurance companies waste about $400 Billion each year in high overhead and physician and patient compliance costs. There is another $100 Billion wasted on high drug prices to companies that spend 3 times as much on "marketing" as on R & D. This $500 Billion each year can be used to pay for the extension of Medicare to everyone.If you simply add a public plan, you are leaving the $500 Billion on the table. You are simply adding cost. This is just stupid.
In addition, there are technical reasons just adding a public plan is foolish. If it has to take everyone while private companies can pick and choose , it will wind up with another high risk pool--the sick and the poor. While the idea of creating another pool is bad enough, if it is a high risk pool, it will be very expensive. The Republicans will seize on this and progress will halt. Also if it covers preexisting conditions, then it will greatly expand the pool of the self insured which is terrible from an efficiency point of view. After all, why pay premiums when you are well?
Finally as to the attitudes of the public, Representative Anthony Weiner recently held a telephonic town meeting with 4,700 members of the public. He asked who preferred the public plan option and who preferred Medicare for All. Two thirds preferred Medicare for All. Then the Representative said the private insurance industry would never permit that option.
Who is running this country?
D. 1. The total of all malpractice insurance premiums amounts to 0.56% of health care costs.
2. The CBO has examined the idea of defensive medicine. They found no difference in practice between states with limits on tort settlements and those with no limits.
3. There is no correlation between the price of malpractice premiums and the amount given out in malpractice settlements.
4. The price of premiums does (anti) correlate with interests rates.
5. If you take all the money given out in malpractice settlements over $250,000 in NJ ( a state without caps) in a year and give it to physicians, each doctor would get $15.
The first four come from the book The Malpractice Myth by Peter Baker (U of Chicago Press) while I believe the last is from Uwe Reinhardt (sounds like him).
Thus the doctors are wrong on almost every count. Malpractice premiums are not a significant factor in health costs. Physicians order unnecessary tests and treatments even when there are draconian limits on lawsuits as in Texas. Caps would save us nothing. The price they pay for insurance has nothing to do with the large settlements given out, and the total amount of money involved in these settlements is trivial.
What they believe is a fantasy.
npunwani said:
Where is that gov't intervention. Its been sorely lacking for the last 20 years, primary care has been butchered because of Medicare and Medicaid.
Note that during the past 20 years, we have had mostly Republican administrations. Even under Clinton, Republicans controlled congress for 6 years. (And surely you haven't forgotten what happened to Clinton's health care plan?)
I think that Republicans bear most of the responsibility for our current (private) health care system, as they do for our current financial crisis.
In defense of Big Pharma (gasp! on this blog?) it is not exactly research that drives up the prices of new drugs. It's clinical trials, and satisfying the myriad requirements of the FDA-equivalents in all the countries they hope to sell their drugs to. A new drug costs about $.8bil to develop, and that's actually a figure that's a few years old. Also, if it's a biological, it will cost much more. This is R&D and clinical trials, by the way, not marketing. Marketing is a separate thing entirely. Although I think this figure averages in the failures, but there you are. To recoup the cost of development, pharma companies want to be able to have a monopoly on their product, at least for a while. The problem is that competition is fierce, such that even if you are the first to market it is likely that a competitor will have a similar product out within a few months (since they are all aware of what's going on in the field and pursue things they hope will be profitable). It seems to me that the innovation is in the universities, because of gov't funding, and some academic will come up with something interesting; when there's proof of concept pharma will step in and try to make it profitable (or they'll have been collaborating already).
Now the interesting thing about DTC advertising... in most countries it's not allowed, so pharma companies don't have that kind of marketing expense; they only have to market to the government (assuming they have a socialized insurance scheme, as is likely in wealthy developed countries). But it's also true that Americans pay obscene prices for drugs that the rest of the world won't tolerate; if we have the government to negotiate the prices of our drugs, I do wonder what would happen to the cost of medications in other countries.
Doctor Who…
You said, “The answer lies in the free market.”
Where’ve you been? The free market is responsible for the health care system we currently have, which everybody (but you) understands is an unworkable mess.
Then you go on to say “Give consumers more choice, and better access to that choice.” Who’s going to be doing this “giving”? If you mean the insurance companies they would long ago have given us “more choice”, provided there was a nickel in it for them. But “more choice” to them means more costs, so they aren’t interested, as proven by their behavior. If you mean the government should be “giving [us] more choice”, you’re kinda puncturing your own anti-government argument, aren’t you?
You’re chasing your own tail here.
Could someone please tell me What the hell could possibly be innovated in a finance-based industry like health insurance? What are they going to do, buy supercomputers? "We'll process your insurance 10% faster than before!"
@lensch
I'm afraid I can't quite parse what you wrote... w/r/t D, do you mean doctors pay a lot of malpractice insurance but in reality shouldn't need it? If doctors weren't so paranoid about getting sued, they wouldn't order too many unneccessary tests, and costs would go down and everything would still be ok (for both patients and doctors)?
So is it really the malpractice insurers that are making like bandits?
@juvanya
I want to say something about tranches and credit default swaps--I guess they can make bets on which subsets of their collective customer base will develop cancer or some other disease?
@ Alan:
"Note that during the past 20 years, we have had mostly Republican administrations. Even under Clinton, Republicans controlled congress for 6 years. (And surely you haven't forgotten what happened to Clinton's health care plan?)
I think that Republicans bear most of the responsibility for our current (private) health care system, as they do for our current financial crisis."
We've had this reimbursement system since 1965. We've hadmany revisions of it, the most drastic 1983 the Hospitals Payment law and in the Resource-Based RVS Physician Pay Scale in the late 80s and early 90s. These have been bipartisan reforms, both parties are responsible. Yet in spite of so many payment revisions politicians relentlessly butchered primary care.
Your partisan rhetoric doesnt hold in this situation. You are dead wrong.
@Jenya
For starters, real-time adjudication.
The innovation possibility is NOT in insurance, it's in adminstration: both at the provider office and to adjudicate the claim.
Claims adjudication would not disappear with a public option unless you eliminate choice which even with Medicare the government has decided to keep thus far.
Most of the waste in the medical care system is needless insurance company overhead. Yep, those tens of thousands of people who do nothing but shuffle claims and referrals and authorizations around, and the office buildings that house them, and yes even their health insurance benefits.
By trying to ration care, operating on the theory that less care equals fewer payments to providers, insurers came up with the Managed Care farce, which is really nothing more than a merry-go-round designed to befuddle patients and hamstring the delivery of medical care. The Congressional Budget Office did a study of Managed Care about 6-8 years ago, and excoriated it as wasteful and harmful to both patients and healthcare providers.
Booya, 538 gets schooled bitches!
Well, not really.
Health care is a trillion dollar industry with fat margins. Dollars will drive the legislation the same way it's driving this debate. It's not really a debate so much as name-calling, but I'm too tired to dig into my ass-hat bag to bring my A-Game in the ad hom-tacular.
Facts:
- Millions are uninsured through no choice of their own.
- US costs are far higher than anywhere else, for less service.
- UHC nations also spawn medical breakthroughs.
- Insurance CEOs average $6.476 million a year, and they will do anything in their power to keep it that way (scroll down and click "Insurance Health & Disability" to see each CEOs pay.
So if you've got a better plan, I'd like to hear it. I think the public option is toothless and a half-measure that fails to address the majority of the problems.
We need a solution. If you have one, let's hear it, otherwise you're just making noise for the hell of it. My neighbors dog does that, it isn't very persuasive then either.
Come on .kali, read what I wrote. The cost of malpractice insurance is a tiny part of health care cost. Physicians say they order extra tests because of fear of being sued, but even when that fear is abated, they still order extra tests.
The whole thing is a classic red herring.
npunwani said:
We've had this reimbursement system since 1965. We've hadmany revisions of it, the most drastic 1983 the Hospitals Payment law and in the RVS Pay Scale in the lates 80s and early 90s. These have been bipartisan reforms, both parties are responsible. Yet in spite of so many payment revisions politicians relentlessly butchered primary care.
I agree that a lot of Democratic congress members are part of the health care problem. The AMA, insurance industry, and pharmaceutical industry lobbies have been major contributors to people in congress and, for all practical purposes, own many of them in both parties.
That said, I still believe that Republicans (free market, more profits for for the rich, etc.) have had more of an adverse impact on health care than Democrats.
@ Alan,
"I agree that a lot of Democratic congress members are part of the health care problem. The AMA, insurance industry, and pharmaceutical industry lobbies have been major contributors to people in congress and, for all practical purposes, own many of them in both parties.
That said, I still believe that Republicans (free market, more profits for for the rich, etc.) have had more of an adverse impact on health care than Democrats."
See here's your problem you blame this on lobbyists. There was no insurance or pharmaceutical industry lobbying Congress over the 1983 Hospital Payments Act and the later Physician Resource Based RVS Pay Scale for Physicians. These were Medicare reforms so those interest groups didnt care because they had nothing to do with them.
As for the AMA, they've fought against primary care cuts every time.
Those two laws are what caused hospitals and primary care specialties to suffer. It was because Congress wanted to save money, but in doing so they compromised seriously on quality.
@ Alan:
It's not really lobbyists causing this mess, its that many politicians didn't understand what they were doing when they passed those laws. They were just interested in trying to save money. The Resource-based RVS made sense in theory (pay more for services that require more resources), but that alone is what seriously devastated primary care over the decades. Once something has been set in motion, its hard to recall it and fix it. That's political economy for you.
I liked your discussion a lot. Free markets make a lot of sense in commerce, etc., but when it comes to societal needs such as health care, education, and imprisonment, there is a strong incentive to maximize profit and executive pay by providing the cheapest service that can be gotten away with. If employees who actually interact with the clientel can be hired at minimum wage, for few enough hours that they need not be paid benefits, this can surely increase the bottom line for the executives and stockholders, but the societal cost is appalling.
Two questions about Nate's post. First, why don't the companies who are paying for workers insurance use the market to their advantage? Workers may not know what they are paying, but the companies do - and they can drive a market deal more effectively than individual workers, no?
Secondly, is it really just entry costs that stifle competition in the insurance industry? Not collusion? Not government regulation of health plans? I'm dubious.
By the way, liberals never consider the possibility that government health care might be not more efficient at controlling costs (i.e., by rationing health care), but less. The government might prove more susceptible (rather than less) to public pressure to cover various health treatments, etc. Liberals are willing to excoriate private health care both coming and going: for depriving people of care, and also for inefficiently paying too much for health care. By contrast, they always assume the best of government. Such a faith in government "efficiency" is touching but not convincing.
Let us not loose sight of the fact that the US does not really have a functioning "Health Care" industry. True health care includes prevention and education which have been undercut for decades. It is way less expensive to maintain a healthy person with education and preventative care than to treat someone who, for whatever reason, becomes ill and delays treatment until it becomes a severe and possibly chronic condition.
HMO's were invented to provide a better perspective to care but they were perverted shortly after inception.
when it comes to societal needs such as health care, education, and imprisonment, there is a strong incentive to maximize profit and executive pay by providing the cheapest service that can be gotten away with. If employees who actually interact with the clientel can be hired at minimum wage, for few enough hours that they need not be paid benefits, this can surely increase the bottom line for the executives and stockholders, but the societal cost is appalling.
This was the same argument used for airline de-regulation and now we have as safe a system as ever.
The key is this: government regulates the market, the market provides the products and services.
Government can also use policy to guide the market and consumer behavior.
But when government starts providing the goods and services, you abstract the person that pays for and consumes the products - the taxpayer - from the person that provides them.
And that abstracted 3rd party - Congress - is more open than ever to lobbyists because they control more.
Replacing one payer with another won't solve anything except to give a false confidence while the real forces of corruption muster themselves for the new buffet.
npunwani said:
It's not really lobbyists causing this mess, its that many politicians didn't understand what they were doing when they passed those laws.
Check out Senator Ben Nelson, one of the key figures in the health care reform. His background is in insurance industry, and there's no doubt that he's a friend to it. As a blue dog Democrat, Nelson's entire record after more than two decades in public service says that he's against any government competition to or in substitution for private health insurers.
I think I can safely say that Senator Nelson knows what he is doing, and who is contributing to his re-election campaign. He is far from the only one like this in congress.
Jeff said:
By the way, liberals never consider the possibility that government health care might be not more efficient at controlling costs (i.e., by rationing health care), but less. The government might prove more susceptible (rather than less) to public pressure to cover various health treatments, etc.
I have considered this, and I suspect that many other liberals have also.
If people want better health care and are willing to pay for it, I see no reason why a government program should not provide it. Isn't this what democracy is all about?
And with a government program, there is at least the possibility of throwing the rascals out of office if we don't like the program. With insurance companies, we have much less leverage.
Alan said:
I think I can safely say that Senator Nelson knows what he is doing
Or maybe he understands the insurance industry, understands what would be required by the government, and knows it's the wrong move based on his experience.
And maybe philosophically he thinks government's role should be making great regulation and great policy, and that production of goods and services should be left to private industry.
Take Medicare. Parts A, B, and D are government run, Part C isn't.
Why not simply extend eligibility to all Americans and be done with it?
Nate, as a mailman, here's a joke you can insert. Go screw yourself Nate. Just so you know, it was about 95 out today and I delievered every piece to each stop and chatted up people that only get one visitor a day. I like your stuff, and generally you are pithy, but there is no joke about the post office, look where we stand every year on most trusted agencies, and proffessions. Sometimes you can be too big for your britches, like when you wrote that line.
Thanks for the excellent clear presentation. And for sharing your religious inclinations: "I'm a big believer in the profit motive in 99 percent of all cases."
I would suggest that there are more than a few areas where "profit spoils the product." One is my old line of work, broadcasting, where the public option has been a withering fig leaf for using a limited public resource to sell the audience's attention--with concomitant irresistible pressure to put out "programs" that are skewed to maximal fears and desires and minimum mindfulness and so make a less-than-zero contribution to the empowerment of the viewer. Less than zero due to the inherently narcotic quality of the old phosphor box.
Yeah, we're past all that with the internet, right? Except that the same model will be imposed if it can be--and except that we have 50-60 years' worth of operating-system-level cognitive damage to the average American. How else could we have a nation in which the people's representatives in government have been sold to the highest bidders--and the vast majority of the public doesn't actually get it? Not to notice that your government is no longer your own is, well, an induced mental deficiency.
Alan Said:
And with a government program, there is at least the possibility of throwing the rascals out of office if we don't like the program. With insurance companies, we have much less leverage.
Well let's compare:
If you don't like your plan today you just switch.
With a government plan, you'd have to convince more than 50% of people to make the plan the top political issue and vote on it. Then the new guy would have to introduce legislation, get it passed by the whole of Congress AND convince the President to sign it.
And you'd get that chance every 6 years.
And when you think about it we've been talking about this for 16 years across 2 administrations and getting anything passed right now seems far from clear.
That doesn't feel like leverage.
@TINAandRON - I don't think Nate was being negative, I think he was diffusing a common point of debate.
Jon Stewart showed a clip montage of Republican congressman tearing down health care reform with bogus arguments like "do you really want a health care system run like the DMV or post office?"
To which Jon Stewart said like 'For 44-cents they come to my house, pick up something I wrote, and deliver it to the other side of the country on an airplane."
I live in Washington state. The DMV runs just fine here, as does the post office.
I trust no offense was intended, I believe he just wanted to throw out that invalid argument before it was raised.
@ Alan:
You still have no way to explain how lobbyists got those reimbursement reform bills passed. There is no explanation. Lobbyists had nothing to do with killing primary care. It was elected politicians who did it when they passed Medicare's Resource based RVS physician fee schedule.
@Gruss - Your argument only makes sense in the context of a single-payer system. That is not what's proposed. You would retain the option to choose another company at any time.
It's like a weird half-attempt at a straw man argument. Be careful taking pointers from Frank Luntz's memo. He's a smart man and did very well before the masses used the internet, but times have indeed changed.
In other words, debate the plan as it exists, not as you wish it existed.
Gruss said:
Or maybe he [Senator Ben Nelson] understands the insurance industry, understands what would be required by the government, and knows it's the wrong move based on his experience.
Sort of like Dick Cheney understands Halliburton and the oil industry?
Color me cynical. I suspect that Nelson's campaign contributions mean more than anything else when it comes to the health care issue.
Spot on, Nate.
A public option will be a (literally) life saver for small business and freelancers who can't compete in an market where large pools are needed.
npunwani,
So you say you're in med school.
So you say unless you go into a specialty or sub-specialty, but remain in GP, you say you won't be able to repay your med school loans.
Have you, and others in your situation, done anything to influence Congress to pass any of the various bills that would pay for med school for those who, after graduating from med school, practice for a period of time in underserved communities, Indian reservations, etc.?
No?
Why not?
Maybe it's you and your cohorts don't want to go to 'a poor area', without being paid a salary that is commensurate with your training?
Don't bitch here about your 'plight'.
Oh, and and all your comment that 'private insurers will experiment with their own payment methods and the most efficient ones will prevail' says is that private insurers will tinker with how to make the lowest payments to increase the company's bottom line, dress it up in a lot of PR, and sell it to the American public as "Look what private enterprise improved on!"
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
Gruss said:
Alan Said:
"And with a government program, there is at least the possibility of throwing the rascals out of office if we don't like the program. With insurance companies, we have much less leverage."
Well let's compare:
If you don't like your plan today you just switch.
You mean you are going to tell your employer to change carriers? Good luck! So you don't have that much leverage at work. No sweat - switch jobs. (You can find a new job these days, can't you? No pre-existing medical condition, I hope.)
Even people who pay for their own insurance may not be able to easily switch. Better insurance may be unaffordable, or they may have medical conditions that make them uninsurable by any other company.
npunwani said:
You still have no way to explain how lobbyists got those reimbursement reform bills passed.
Get serious. He who pays the piper calls the tune.
Companies do not contribute to campaigns out the goodness of their hearts, without expecting anything in return.
I cannot give you any quid pro quo proof, but I have no reason to believe that politicians (like former Illinois governor Rod Blagojevich) are any less corrupt than business people (Bernie Madoff, for example).
npunwani said...
You make a good point about wait times for poor people. But at least I want the public option side and single payer advocates to be honest and admit at some point there will have to be rationing, wait times, and queues.
Excuse me, but an honest person will not 'admit' to something that is not yet proven, and there is nothing that I've seen that leads even to an indication that "there will have to be rationing, wait times, and queues". So no, I will NOT admit to your fantasy scenario above.
Prove your assertion (impossible to prove something will happen when the events haven't yet happened), or admit that it's conjecture on your part (or some right-wing, Lush Rimbaugh-type hyperventilator), and tell us on what 'facts' you base that conjecture upon.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
Alan,
But Obama isn't promising "better" health care for most of us. He's promising cheaper health care for more of us. And I doubt very much he can deliver the cheaper part. This is where Obama's "false choices" rhetoric falls apart. His plans will NOT save us money. They will NOT even break even. It even looks as though they won't cover most of the uninsured. Obama could peddle this snake oil that universal health care would cure our fiscal woes only so long.
My sister pays 14,000 dollars a year for her family's health plan (she's self-employed). I am well aware of the shortcomings of the system. But I happen to live in Canada, and I know with a moral certainty that INSURED Americans would not trade what they have for what we've got. Why? Because of wait times, which can be outrageously long (and dangerously so). And while Canada, Europe etc. enjoy lower per capita health care costs, let's not forget that they are - in a sense - free riders. The US health consumer pays the premiums to the doctors and drug companies that these countries won't pay. Unfair? Yes. But it provides the profit margins that fuel innovation. Where will the free riders go when we cease to pay? Nate should have considered this point. One of the reasons that the health care market doesn't work is that it's only a market in the US. Elsewhere, health care is government run, regulated to death, and doom fro private enterprise. It has been a very long time since there has been a "free market" in health care. What has failed over the past thirty years is not a free market in health care.
leave me alone said
Before long the government plan will be the only plan. And rationing will be rampant. Just as it is in Canada and UK. God help you if you are over 65, or disabled,or have a chronic disease. You will not get timely help from the government plan.
Go ask David Letterman how the UK system treated his mother when she suffered a medical emergency when on vacation in the UK.
Since Letterman is more than 60, and his mother's trip to the UK in which she suffered the medical emergency was within the past 15 years, Mrs. Letterman was MORE than 65 years old, AND a non-resident and non-citizen of the UK.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
Mike in Maryland said:
npunwani said...
"You make a good point about wait times for poor people. But at least I want the public option side and single payer advocates to be honest and admit at some point there will have to be rationing, wait times, and queues."
Excuse me, but an honest person will not 'admit' to something that is not yet proven, and there is nothing that I've seen that leads even to an indication that "there will have to be rationing, wait times, and queues". So no, I will NOT admit to your fantasy scenario above.
I'm sorry Mike, but even a liberal, pro-single-payer person like me has to say that npunwani is right. These things may happen regardless of what health care plan is in effect.
For example, suppose swine flu mutates and becomes highly contagious. Suddenly we have 10 million sick Americans. With our health care system overwhelmed, I would expect rationing (triage), wait times, and queues.
Granted, under normal conditions, rationing, wait times, and queues under a public plan will not be nearly as severe as our opponents would like us to believe.
What you and I and other public health plan proponents must stress is that our current private health care system already has rationing, wait times, and queues.
Jeff an others say wait times in other countries are longer than those in the US, but that only looks at the patients who actually received the surgery. Since everyone is covered in the other countries, that does not effect the result, but in the US where millions have no insurance, there are many people who need surgery who never get it. These statistics ignores these people whose wait time is infinite. Obviously if you only give a benefit to some of the people you can do it faster.
Actually the waits are nowhere near what the lying conservatives say. For Canada go to http://canadaonline.about.com/od/healthcarewaittimes/Wait_Times_for_Health_Care_in_Canada.htm
Furthermore the reason the wait time are longer for these benefits has nothing to do with the fact that other countries have more efficient systems, but because they spend less than half per patient than we do. I invite the reader to try to imagine the wait times in our system if we cut health care payments by over 50%.
Finally, the bottom line is that if you look at all the basic public health statistics (life expectancy, infant mortality, etc.) or the WHO rankings, these other countries provide much better health care and they do it at much less cost.
@ Gruss
Take Medicare. Parts A, B, and D are government run, Part C isn't.
Why not simply extend eligibility to all Americans and be done with it?
You finally posted something intelligent.
dre7861 said...
. . . Police and Fire Fighters were operations owned by private individuals. We can still see leftovers of this line of thought in some areas where the ambulance service is not provided by the government but by private operators.
In colonial times, Philadelphia had many 'private' fire companies (they usually were called 'fire guilds'). People bought into the guild to protect their home from fire. If a fire broke out, the proper guild had to be informed, and that guild would show up at the scene. However, if the property owner didn't have the proper guild shield appearing on their property, the 'fire department' didn't feel they had the responsibility to fight the fire.
The problem was, if one house (not covered by a guild, or covered by a different guild) burned, the neighbor's house might also burn, even if that house had the proper guild shield appearing on the property.
Benjamin Franklin saw the problem with the system as it then existed, and helped to organize fire departments in Philadelphia whose duties were to protect ALL properties in a geographic area, and to assist, when needed, other departments in fighting fires. Franklin's concept was the beginning of volunteer fire departments, which then evolved into professional fire departments.
Travel through certain sections of some cities on the US East coast, and you can still see the shields that people placed on their property to show that they were a member of a fire guild, and thus 'were protected'.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
Jeff said:
But I happen to live in Canada, and I know with a moral certainty that INSURED Americans would not trade what they have for what we've got. Why? Because of wait times, which can be outrageously long (and dangerously so).
In a number of threads on this blog, Canadians have contradicted your assertion. They have said that while elective procedures can have very long wait times, emergency procedures go to the head of the queue (preempting elective procedures). I see nothing unfair about this practice (which is standard for U.S. emergency rooms), and I would be willing to trade for your system. (I'm insured, by the way.)
Three questions for the economists:
One, I think Nate's argument about competition needs work? Its true that most workers do not make a choice about insurance, but surely their companies do, and wont they choose the cheapest option?
Two, don't the insurance companies save themselves and their customers money by setting lower rates that the doctors can charge?
Three, would a public option require doctors to enroll? ould it not then set arbitrarily low rates, forcing dotors to cut corners? You will have a scalpel wielding mob on your hands, unless you also do tort reform!
@ Alan:
The point is that lobbyists had nothing to do with those bills. There were no interest groups that had a stake in those bills except for doctors and hospitals, both of which got screwed in a way that is hampering quality and devastating primary care.
Your inability to name any the groups that would have had a stake in and cause the decline of primary care means you don't have a good explanation at all for this. You just have no clue whatsoever.
Well thought out and well written articles like this make it more sensible to be a liberal. While the politicians you root for as a liberal don't deliver often, the bloggers do:). And there is no way a Michelle Malkin or a Sean Hannity presents their case like this.
Thanks Nate!
@ Mike in Maryland:
"Have you, and others in your situation, done anything to influence Congress to pass any of the various bills that would pay for med school for those who, after graduating from med school, practice for a period of time in underserved communities, Indian reservations, etc.?"
Actually, yes we are lobbying Congress to give us debt relief if we worked in unpriviliged areas. I think its a great idea, and Israel has something like this which is working quite nicely I must add.
I'm quite insulted that you would think I would say "No." Perhaps you shouldn't be so stupid as to speak for other people next time.
"Oh, and and all your comment that 'private insurers will experiment with their own payment methods and the most efficient ones will prevail' says is that private insurers will tinker with how to make the lowest payments to increase the company's bottom line, dress it up in a lot of PR, and sell it to the American public as "Look what private enterprise improved on!"'
Well thats whats happening in places like the Netherlands, Germany, and Switzerland. It works quite well there, maybe it can work here. These are countries that had systems very similar to ours before they got universal health care. I think we can learn from them. Perhaps you should actually read actual legitimate health policy research like the New England Journal of Medicine. It might actually give you some original ideas.
Excellent analysis in a very informative post. I do wish, however, that you hadn't chosen the unnecessary "feud with Will" angle.
I would love to recommend this post to a conservative friend, but the Will bashing is off-putting, and I don't think he'll read it.
@ Mike in Maryland,
I support universal health care, Mike! What do you mean by Rush Limbaugh talking points. I think everyone should be entitled to some kind of health care. I support the Wyden Bennet health care bill so everyone gets universal health care. I'm just saying that we'll have to ration whether it be through people paying more for care or thru wait times.
Why is Medicare going broke... because there is nothing to control for utilization. Canada has global budgeting and actually explicitly regulates the number of operating rooms, scanners, etc. Medicare is too scared to do that, so costs soar.
I have a feeling most Americans won't like that either, we've already had that experience with certificate of need laws in different states. So thats why I think we should adopt a health care system like Germany, Japan, or Switzerland, or the Netherlands.
. kali,
In your 'defense' of big pharma (post of June 23, 2009 8:16 PM), how do you explain the cost of medicines that were 'patented' by big pharma, but most or all the costs of development and clinical trials were done at medical schools and/or at government expense and/or were done decades earlier?
Example: azidothymidine, aka AZT.
Originally developed in 1964 as an anticancer drug, but never approved or used for that purpose.
In 1984, Burroughs-Wellcome Company, which owned the rights to the drug (although that is disputed by many), reexamined it as part of a search for any antiviral drug that might be effective against the virus that causes AIDS.
And yet, when Burroughs-Wellcome put AZT on the market for treatment of AIDS, the original price per patient was $10,000 per YEAR!
Development costs? Already accounted for (or should have been) in the previous 20+ years.
Marketing costs? None, as it was for a disease that had no other treatment to that point, and there was no other disease AZT could be used for.
Costs to produce? Today, AZT can be purchased for pennies per pill, the same as the cost of production was when the FDA approved it in the late 1980s, when it was approved for treatment of AIDS.
How could Burroughs-Wellcome charge so much? Because there was no one in a position to say, "Burroughs-Wellcome, you rat bastard thieves!" and publicaly embarrass Burroughs-Wellcome into lowering the price, or be able to force Burroughs-Wellcome into lowering the price.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
npunwani,
You are touching on several different issues that all seem to have the same basic problem. The cost of medical school (and graduate school generally) has grossly outpaced the ability of people to attend, graduate and serve in general practice. The law is suffering the same problem (although there are a lot more law schools than medical schools) with fewer and fewer top graduates being able to afford to enter public service because of debt. These same students don't even think about going into teaching because the compensation and respect is seen as so poor.
Many doctors also assert their med mal claims/insurance impacts their choice of profession and behavior. These costs, like education, have grown steadily with almost no regard for claims conditions - in fact, there was a good expose a few years back showing stock prices had more impact than med mal claims on rates. These rates also keep going up even in states where the exposure is capped through various "tort reform" measures.
Finally, insurance premiums go up every year, with seeming indifference to market conditions. With the pool of people with jobs who either get plans through work or can afford it shrinking, logic would suggest insurers would want to reduce premiums to keep customers or recruit new ones to make up for lost business. But it doesn't happen.
In all three cases, the problem seems to be that the payor simply lacks the degree of market power to avoid the increase. Students (and their parents in many cases)generally aren't going to give up on education because of marginal yearly increases - they'll just take out another loan, until eventually their job choices are driven by the loans. Nothing quite so much fun as paying more in student loans than a mortgage on a nice house in the Midwest for 10 years. Doctors can't forego malpractice insurance, and they aren't in a position to waste too much time and energy comparing coverages. Ditto most individuals and employers. I watched my firm try to get better coverage several times, and typically what you got instead was something that was about the same as what you had before, but with different prescription benefits or co-pays that could really be detrimental for some people.
That's really why I support not only a strong public option, but one in which the public plan includes an emphasis on wellness, payment for outcomes and the like. You are right that until we fix how doctors and hospitals are reimbursed we can't contain costs, no matter how much coverage is offered. I just think that unless someone as big as the government starts pushing a new model of reimbursement (and the Netherlands and Switzerland do come up a lot when knowledgable Dems start getting into the details) private industry will lack the incentive to do so.
Even though it could impact the pay of academics like me, I'd also like to see the government try to get a handle on education costs. I can't say with a straight face that my law school is worth the 10k more a year than when I went there a decade ago (and private schools are orders of magnitude worse), but that's the situation. Why we can't come to a consensus that the best qualified, best trained lawyers, doctors and teachers should have every incentive to do critical, basic work that benefits all of society is beyond me, but it doesn't seem to exist just yet.
A couple thoughts for conservatives:
Do those who have a problem with the idea of government managed health insurance also have a problem with the idea/practice of government managed banking insurance such as the FDIC? If not, why not?
---------------------
Do those who have a problem with the idea of government managed health insurance also have a problem with the idea of government managed national defense?
We spend trillions of dollars for the purpose of safeguarding Americans as part of our national defense budget, why not just think of funding for health insurance as part of that effort.
Austin said...
This is a relatively minor point, but you say that untaxed income doesn't show up on paychecks. All of mine does, and is itemized, including health insurance.
Even though 'jfruh' addressed this earlier, I'm still going to post my comment on your blatherings:
First, your paycheck shows NET income, not gross income with a listing of deductions from that gross leading to the net income. The listing of gross income minus deductions is called an 'earnings statement' or similar title.
Second, does your "paycheck" (in actuality the earnings statement) include a listing for the portion of the health insurance paid by the employer?
That's also part of your compensation, but not taxed.
Does the "paycheck" (in actuality the earnings statement) include the portion of FISA tax paid by the employer?
That's also part of your compensation, but not taxed.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
Mike,
I generally agree that big Pharma oversstates its costs of development (Viagra is actually a better example than AZT, in my opinion, though, because B-W did in fact do more efficacy work before commercial release and at least it was a life-prolonging drug). The reason they can state these huge numbers with a straight face is because the final product is generally charged with all the costs of a range of processes the company would have done even if nothing ever came from it (like basic investigatory work that gets shut down once someone else patents a biologic compound and your company turns in a different direction). In a perverse way, though, the market almost demands companies overcharge. When Lilly introduced the first effective drug for sepsis (which took almost 20 years and started as something almost entirely different) the company priced it near prior treatment cost for fear of sticker shock. Doctors were skeptical of using it, though, because the perception was that if it was really any good the company would have priced it much higher.
I will note, though, that FDA clinical trials are almost never done by anyone but big pharma companies. Universities and startups typically do some basic work, get a patent application on file and maybe do some basic cellular level efficacy testing before looking for someone to take the process over and get FDA approval for the compound. Its just beyond the means of most entities to do this work.
Berkeley Bear in IL:
"That's really why I support not only a strong public option, but one in which the public plan includes an emphasis on wellness, payment for outcomes and the like."
Unfortunately, all of the public plan proposals right now build on the broken fee-for-service systems. Also, I want to add that the Dutch and the Swiss arent having gov't dictate to private insurers what reimbrusements should be like, the private insurers are doing it by themselves (in fact, they want to do it) because thats the only way to reduce costs without impairing outcomes. They can no longer compete by playing "Who can avoid the most sick people." Instead, insurers in those countries have to focus on paying for outcomes because thats the only way of saving money without impairing quality.
I'm glad reasonable people like you can find areas of common agreement. I think we can all learn something from this (I'm not too sure if Mike from Maryland can however).
npunwani said...
I'm quite insulted that you would think I would say "No." Perhaps you shouldn't be so stupid as to speak for other people next time.
Actually, I've heard interns at Johns Hopkins Hospital publicly told by doctors that they are being selfish and money-grubbing because they WON'T support such a concept.
Perhaps YOU shouldn't presume that I'm speaking for others, when I've heard, and discussed, the issue with doctors and other health providers.
And if you ARE in support of a public option, why are all your 'arguments' couched in terms that are so favorable to the anti-public option side?
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
From Pete Kent,
"The healthy must be made to subsidize the sick. I say let the sick fend for themselves as they have done throughout human history and keep your hands off my wallet and pay check.
If your hearts bleed for the sick and uninsured, then please care for them, call it welfare or charity or whatever, but don't screw with my healthcare system to achieve these goals."
Unfortunately, health care can't do much for someone with a small, dysfunctional soul.
I've worked in US health care for 32 years (RN) and followed the health insurance debate, through jobs where I had to deal with the payer system we have, and a lot of reading on the problems and solutions might be. Plus I've had my own experiences with insurance companies and health care.
Several people have given the numbers on what we spend per capita compared to other countries and our ROI. 59% of our doctors support single payer. The primary care physicians support it the most, while specialists (the highly paid ones, lead by radiologists) want to keep the mess we have.
An excellent review is Dr.Arnold Relman's "A Second Opinion". Having been a practicing physician, professor and editor of NEJM, he has an extensive perspective on the problems. Two that have been alluded to:
Too many physicians are becoming more focused on business than patient care. The over use of tests and procedures is linked the most to physician ownership of the testing and procedural equipment or facilities.
Consumer Driven Health Care is not an answer. He goes into many explanations, specifically addressing Herzlinger's arguments. One that needs more attention is the idea that breaking health care delivery into very specialized groups will be more efficient and effective. This is the WORST way to provide health care. Instead of treating the person as a complex sum of many interdependent parts, this concept tries to separate all of the parts and expects the patient to figure out how to coordinate their care.
We alos need to get mental health care on a par with cardioloy and neuro. The degree to which we isolate and underfund the treatment of the most important function of our most important organ is baffling.
Very successful programs have been developed to cut the hospitalization rate of the 'frequent fliers'. Much more can be done to address the 70% of expenses going to 10% of the users, especially at end of life. This is not rationing, it is making more informed decisions.
For most health care professionals, the problem is not the money (although it sure could be better for nurses and a lot of therapies), as much as stress, long hours and spending too much time on redundant paperwork while actual patient care suffers.
Our health care plan must reflect some American values - not all. Unrealistic expectations of some Americans to have service NOW, no waiting. Maybe for your car repair or business services. Health care, to alway supply that kind of speed requires more (expensive) facilities and equipment.
We are obsessed with making hospitals like 5 star hotels. Comfort and aesthetics are important, up to a point. Then it becomes an issue of whether you can deal with moderate amenities to get higher quality in the real service you need.
I see a misperception by people who think health care and innovation will suffer if the financial incentives are lowered. I find the best and brightest in this service are more motivated by contributing to their profession and to the care of humans - whose dignity and inherent worth we respect. I see a strong correlation in the difference between ministers who are into 'Prosperity theology' and those who think Jesus meant what he said about poverty and wealth.
What about not-for-profit insurers?
I'm late to this conversation, but I hope Nate will see this and respond to it. This conversation, and most conversations on this topic, posit government-run vs. for-profit and forget that there are many non-profits out there, like Kaiser, Pacific Source, and others. When I have a choice, I always chose the non-for-profit provider, and I've always been served well. The great example is Kaiser, which is vertically integrated and covers things most for-profit insurers don't, at least not in their basic plans: hearing aids, eye-glasses, fertility treatment, etc.
I'm in favor of a public choice, but I also support non-profits staying in the mix. I used to work at a non-profit (NOT a health care provider) and I appreciated how any income we earned was plowed back into our mission -- serving more people or serving them better -- instead of going into an anonymous investor's pocket. If non-profit health insurers do the same -- use income to improve service -- it seems logical to me that they would provide better value than and organization that's just siphoning all that cash right out of the system. I'm not against profit, and I'm very in favor or competition, but the U.S. health system is textbook example of market failure, for all the reasons people have explained so well above, and it's not something the market is going to get right on its own.
Would love to hear your thoughts on not-for-profit, Nate.
Melissa
@ Mike in Maryland:
"Actually, I've heard interns at Johns Hopkins Hospital publicly told by doctors that they are being selfish and money-grubbing because they WON'T support such a concept."
Well, the last time I checked you weren't talking to those people, you were talking to me. If you want to talk to them why don't you go on the Johns Hopkins Blog or something. I think you can find it at this link or something.
http://www.hopkinsmedicine.org/
"And if you ARE in support of a public option, why are all your 'arguments' couched in terms that are so favorable to the anti-public option side?"
I favor universal health care like they have in the Netherlands, Switzerland, and Germany. They have universal health care and no public option. I think its a better approach based on health outcomes and cost data. Those systems are also easily adaptable to ours.
npunwani said:
So thats why I think we should adopt a health care system like Germany, Japan, or Switzerland, or the Netherlands.
I agree that any of these would be better than what we have now. Keep up the good work!
@ Ginny in CO
I greatly appreciate your insightful comments. I hope to see more of your contributions on this and other threads here.
@ Alan,
Keep in mind those countries (Germany, Switzerland, and the Netherlands) do not have a public plan. But they make my point, we don't need a public plan to get universal health care. We just need smart regulation.
npunwani said:
Keep in mind those countries (Germany, Switzerland, and the Netherlands) do not have a public plan. But they make my point, we don't need a public plan to get universal health care. We just need smart regulation.
I understand that. While I prefer a public plan, I will settle for strong government regulations and consumer-friendly incentives for insurance companies. Not perfect, but a lot better than what we have now.
npunwani said...
Well, the last time I checked you weren't talking to those people, you were talking to me.
Sweetie, dear,
I LIVE in Baltimore where Johns Hopkins Hospital is located.
My health care needs are almost exclusively met THROUGH Johns Hopkins Hospital.
I didn't state WHEN I heard and discussed this with doctors at Johns Hopkins Hospital. You just made an assumption that it was recent and/or only once and/or ????????
For your information, the discussions (do you notice? That word is plural) have taken place over a period of years from the early-1990s to the present.
BTW - if you are so brazen as to come on here and make unfounded accusations about something you know nothing about (my discussions with personnel at JHH), be honest and upstanding enough to show your Blogger profile. Otherwise, you are just following the path that most of the TROOLs follow - Blogger profiles that give no information, and/or show a "Profile Not Available" when accessed.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
"I understand that. While I prefer a public plan, I will settle for strong government regulations and consumer-friendly incentives for insurance companies. Not perfect, but a lot better than what we have now."
Exactly, thats why I'm worried we're too busy debating this public plan idea, unless we first figure out how to regulate these insurers they will figure out ways to leave only sick people for the public plan. They'll just have taxpayers pick up the tab (sounds familiar?).
@ Mike in Maryland:
You told me that I shouldn't come here and bitch about my plight. Well, it sounds like from your previous post that somebody doesn't heed his own advice.
Look, instead of arguing and playing this nonsensical game of whos plight is worse, we need to put all of these problems together so we get a proper context for reform. Only then can we design a uniquely American health care system that meets our needs and our expectations. We need a serious, incisive look into the different policy options and we really need to delve into the minutiae of these arcane, but important, policy proposals.
npunwani said...
You told me that I shouldn't come here and bitch about my plight. Well, it sounds like from your previous post that somebody doesn't heed his own advice.
What? My Blogger profile has been visible for ages. YOURS however, still reads:
Profile Not Available
The Blogger Profile you requested cannot be displayed. Many Blogger users have not yet elected to publicly share their Profile.
If you're a Blogger user, we encourage you to enable access to your Profile.
If you have nothing to hide, why hide even the minimal information of your Blogger profile? Otherwise, your actions are EXACTLY the same as many of the TROLLs.
As the old saying goes, "If it quacks like a duck, walks like a duck, . . . ."
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
@Jinny in CO
June 24, 2009 12:55 AM
********
I think your post deserves my standing ovation.
@Doc,
I have been in CO:
May I say I like CO ?
@Mike in MD,
Probably also my profile is not available and I don't care much much about it.
Don't start a tempest in a cup of tea.
stay on topic,it will be fine .
bye.
:)
@Mike in Maryland
re: my supposed defense of big pharma
It is true that AZT was repurposed for HIV, but there is no way that they did not have to redo the part 3 clinical trials, which test for efficacy. They may have had safety data from part 1 and 2 clinical trials, but you can't take data you acquired for anti-cancer and just apply it to anti-HIV; so they must have had to redo all the part 3 clinical trials, which are, not incidentally, the most expensive and costly. Truthfully, the initial R&D is a small part of the final cost of producing a drug. Also, I think Berkeley Bear might have said it, but drug candidates fail all the time, so for each successful drug you are paying for the investment the company made toward a bunch of failures (although they try to have the attrition come earlier than later).
Not to say that big pharma aren't in it for the money. Well, they have shareholders to answer to, don't they. Nor that they aren't guilty of some fairly heinous things. But insisting that you're paying solely for marketing costs and to add extra lining to their pockets is not entirely true. Not that I wouldn't be pleased to see DTC go away, but on the other hand Americans like to feel they know better than their doctors, who've had close to 10 years of very expensive training, so I wonder if the American public would agree.
@Mike
One last thing: the intial price was at $10,000 a year, even though it was the only drug available at the time - well, even if they had no competition then, they could be certain something would be developed sooner or later, so as far as business goes they had to milk that monopoly as long as they had it. (It's more true now than then, but still.) (Where they screwed up is not giving Africa the drugs on the cheap....)
Bah, maybe it's sort of "blaming the victim", but we're the ones stupid enough to have put up with this system for so long; pharma can't get away with these kinds of prices in other countries.
Hmmm I notice the right wingers are out on the blogs on healthcare like no issue since the election. I am fascinated by this defense of an industry that clearly doesn't work, and as I said before it saddens me that the right opposes healthcare reform for political, sometimes financial, but never medical reasons.
Let me put it this way. The free market works best, as far as I can see, in industries that we choose to use. (Thats a sloppy way of putting it but hear me out on this). We choose to buy bananas, or buy a car or buy a house. Those are choices. But the problem with healthcare is that you aren't choosing to use it. You have a broken leg, you NEED healthcare.
PK cotinues to attempt to make the point that many people between 18 and 40 chose not to have health insurance (without providing numbers to back this up mind.) I think perhaps that shows that PK does not understand the nature of most health insurance across America. Most healthcare is provided by employers. Younger people can tend to be under covered or not covered at all for a number of reasons. PK may want to read this
http://www.nchc.org/facts/coverage.shtml
in order to educate himself some more.
The problem of poor health insurance coverage will only get worse if unemployment continues to rise. Yet another reason why this issue needs to be dealt with now, and not put off any longer.
One point that I have yet to see called out anywhere (to my surprise) when the idea of taxing employer health benefits is proposed is that this increases government revenue, and reduces the real income of the middle class, but does nothing to address health care cost inflation.
This is because the employee is not able to "move the money" that the employer is spending on health care. Employers do not give you the option of taking the money in cash to buy your own health care.
And the employer does not give you meaningful shopping choice. You may be given a few choices of health plan (if you are lucky) but usually from only a single provider (or two, again if you are lucky).
Now, if you couple a tax on health benefits with a legal requirement that the employee be able to take the money and buy health care elsewhere then that might create market pressure, but even then it is the ability to move the money, not the tax, that is causing this improvement.
BTW, it occurs to me that businesses themselves shop for insurance coverage for their employees. If they can insure their employees more cheaply they have a competitive edge. If this profit incentive does not bring about market pressure on medical prices, why should it when a weaker bargaining party, an individual, is involved?
Alan,
I'm happy that "several" Canadians have told you that only elective surgeries have long wait times in Canada. They happen to be wrong. I direct you to this recent article:
http://www.canada.com/Health+wait+times+require+action+docs/1712025/story.html
You will note that the Canadian Medical Association is very concerned about wait times for heart surgery, cancer treatments, and the like. Elective? Hardly.
Really, what is this obsession we all have with innovation in medicine? I don't get it.
At this point, we're pretty damn good at medicine. If it comes to a choice between 1)slow down pace of innovation in medicine & insure that everyone receives adequate medical care and 2)maintain (or improve) the pace of innovation in medicine & not(make sure that everyone receives adequate medical coverage), it is clearly (1) that will save more lives than (2).
Just to follow up my last post, so people get the picture. The study in Canada found that cancer patients wait 7 weeks for radiation, fully 4 weeks beyond the outside recommended limit.
Wake up folks. I'm very happy for David Letterman's mom, but facts are facts.
@markymark
18-40 is a bit of a stretch
18-29 is a bit more like it
I posted some info on another thread
Some Things Should NOT Be Done For Profit.
I am a fan of competition as well, but there are certain functions that cost money that we do not want done with a profit motive.
Police protection, the military, health inspections, access to the court system, trials, safety inspections, licensing of all types (from driving to medical practice), and so on.
These are the functions of government, because if these things are done for a profit motive they are more likely to be corrupted and ineffective. Why are roads built and maintained by the government? Because if every road was a toll road in a free market with no limit on the toll, the "tax" on our transportation would cripple the economy.
No free market economist has ever proposed even a plausible plan for all roads and highways to be privately owned that does not in essence reproduce the current system of taxes supporting publicly owned roads. There is just no other system. The free market had plenty of time to work on it before Eisenhower subsidized the Interstate Highway System, and never got even close: That is why Eisenhower subsidized it!
It is the government's job to do some jobs that the majority of us do not WANT done for a profit motive. The post office sends three pages cross country for 44 cents; FedEx sends three pages cross country for $9.95, minimum (and all the money the post office gets from the government beyond that don't add up to a penny per letter delivered).
The medical industry has proven, as Nate's article says, that it cannot be trusted to let competitive market forces work to constrain costs. Otherwise it would rise at the general rate of inflation, not at three or four times that. Why? Because when you are having a heart attack or trying to breathe with a collapsed lung or facing death by cancer, you don't have the time or will to shop around or argue about the prices.
This is precisely what makes it the type of industry we want done without a profit motive. Forty years ago, non-profit hospitals kept the for-profit hospitals in check. Since then, the non-profits have been largely absorbed by the for-profits, thanks to giant corporations like HCA, and that has eliminated the threat of the non-profit sector.
If charitable organizations will not keep the for-profits in check (either by selling out or matching the prices to generate income for themselves) it is time for the government to provide that non-profit restraint on prices.
Nate, competition holds down prices only when customers have a choice. I was an IT consultant for a large for-profit hospital chain for three years; and basically all of their "customers" (patients) are captives with zero leverage to negotiate or shop around. Agree to pay us every dime you have or die (or your child dies) is not really a choice.
Neither, typically, is your insurance company: People take what their company offers. Tax subsidy or not, it has become part of our compensation and turning it down is throwing away money, choosing a better alternative is going to cost 20% of the average American's pay.
Competition is for burgers, clothes, cars, washer/dryers and A/C systems and apartments. Things where we have the time and the vendors that let us make real choices. It is not for things where our lives are on the line. I don't want for-profit driving license companies competing for customers by making their driving test easier to pass. I don't want for-profit health inspectors examining restaurant kitchens.
And I don't want a for-profit insurance company deciding I have to die if they are going to make their quarterly numbers (which statistically they do), and I don't want a for-profit hospital deciding they can boost their bottom line by cutting preventive maintenance on medical equipment in half (which I have seen them do). So maybe a defibrillator or respiration monitor fails once in a while, if the chances of a lawsuit are small enough...
@Tony C.
your post should be written on the wall.
wouldn't the whole co-op idea basically give us the baby without the bathwater of it technically being the government
So instead lets cover everyone at the same rate regardless of personal decisions or consequences and lets tax other people to pay for it.
It should be like auto insurance. You pay based on how much of a health risk you are.
We already have safety nets in place. for kids poor people and seniors.
We need to focus on making Medicaid and Medicare more efficient.
The only solids number we have so far are 1+ trillion for 20 million covered. Thats not worth it.
On transportation I would love a user pays policy. Heck I would love user pays on everything. Imagine you pay based on your personal choices. Finally some consequences for your actions instead of mommy and daddy government.
@Anthony Burns:
A co-op works when it is small, and fails when it is large. As a small thing (studies put it at 175 members or so) people can find consensus and feel their voices are heard, when you exceed some critical mass of members, factions form and create friction and disagreement.
Gore-Tex keeps its factories to no more than 200 people for exactly this reason; they say that around 180 workers or so, they see the shift from "we decided" to "they decided" (referring to management). So when business gets better, they start a new factory instead of expanding the existing one.
This works sociologically as well; when what are supposed to be cooperative groups grow to hundreds of people, people feel the leadership is taking advantage of them, enriching themselves at the member's expense, etc. And this can be true; just look at the large unions of the past. Money corrupts.
In the government run alternative, there is less chance of corrupt leadership and more transparency, and it can be controlled by law and elected officials in ways that a co-op cannot, so it can theoretically respond to citizens concerns. Also, it isn't going to go out of business, like a co-op might, and it isn't going to be selective about where it forms, like a co-op might. The government can ensure everybody gets served, voluntary co-ops cannot ensure that, and in fact I think there is a high probability they will not come even close to achieving that.
In contract law, particularly sales of goods law, there is an assumption that if one source of a product fails to provide, the purchaser can "cover" by purchasing goods from an alternate source and then maybe suing the defaulting supplier for the difference.
That's pretty much how the competitive market for most of the things we buy and sell works, and for things where the outlay is relatively small, it works fairly well. If Burger King fails to give me a good burger, I take my business elsewhere. If my new Samsung TV explodes when I plug it, I return it and go buy an LG or Sony.
That kind of substitution is impossible in healthcare. If Blue Cross refuses to fulfill its obligations under our contract to pay for treatment, I can't just go to Cigna and get them to cover it. Whatever I'm asking to have treated is now a "pre-existing condition" and therefore not eligible for coverage. I could sue Blue Cross to force them to pay, but that's time-consuming and uncertain.
Whatever health insurance operates in right now, it's only a market insofar as the sale of policies is concerned. The issue is honoring those policies, and the market provides positive incentives to NOT honor those policies.
If you support the public option, let your voice be heard. Sign your name here, and it might appear in PCCC's commercial! www.WeWantThePublicOption.com
@ Opus1332
Why not simply extend eligibility to all Americans and be done with it?
You finally posted something intelligent.
But the question remains. If government provided services are the way to go for healthcare why even have a debate? Especially about insurance since the patient will just go to a provider and the taxpayer will pay the bill.
That type of government service, much like Social Security, requires a trust fund and not insurance.
So if Medicare-for-all is the answer why doesn't someone just put the bill out for a vote right now?
I'm guessing it something to do with the fact that the Medicare book shows -$30,000,000,000.
But if tax payer funded medical services for all are the answer, can someone answer why the Congress or President doesn't just put out Medicare-for-all to a vote?
I appreciate that physicians incur debt in medical school. However, a PhD in physics who needs post-doctoral work to land a good job at half the salary, doesn't spend substantially less on education. U.S. Physicans earn $100-300K in their first years, and average almost double that in latter years. This is wildly different than any other developed country. Surely, this is a factor in the cost analysis.
Salary information from:
http://www.allied-physicians.com/salary_surveys/physician-salaries.htm
@ MarkyMark
You have a broken leg, you NEED healthcare.
But try a mental exercise: of your entire family, and all the people you know, how many of them have health care costs that were truly not foreseeable?
For my wife and I, never once have we in our entire lives incurred health care costs that we couldn't foresee.
As for choice to use your example: yes we have the choice of bananas, but we don't have the choice of food.
We NEED food. So by your logic the government should take over the food industry.
That's not to say the health care industry isn't broken and doesn't need fixing, but the answer is not throwing it over the wall to the government.
If we agree that philosophically that government is for regulation not the means of goods and services, then I fail to see what's different about healthcare.
If you can't afford food, you need a safety net.
If you can't afford housing, you need a safety net.
If you can't afford healthcare, you need a safety net.
The only difference is that the government has failed in healthcare at regulation.
@ myself
We NEED food. So by your logic the government should take over the food industry.
Which, frankly, it has and it's why we have a problem in healthcare.
We need socialized medicine to solve the problem created by socialized agriculture:
http://www.foodincmovie.com/
I could not agree more with Nate's post. Now all we need is for a moderate Democrat to step up to the microphone and say exactly that. I personally would go one step further and think that Democratic leaders ought to as well. What are we afraid of?
Why are Democrats afraid of saying, "You're damn right a public insurance plan will destroy the private health insurance industry; that's the point! Health insurance should not be a for-profit industry where insurance companies have an incentive to deny claims. The billions of dollars that private health insurance sucks out of the health care industry could be used to improve care, cut costs, or even pay doctors more."?
A respected moderate Democrat should stand up on the steps of the Capitol, hold a press conference in prime-time, and say exactly that. And if they really had some cajones they would conclude with, "I'm sorry but the corporate executives of the insurance industry will just have to find another company to pay them millions of dollars a year to steal from the American people." Maybe the Republicans will hold their own press conference the next day defending the beloved health insurance industry. They may very well be that out of touch with Americans right now to think that a winning strategy.
-Josh Sear
the main problem with single payer is that it is a monopoly.
If you happen to dislike it, you can't realistically choose another one.
Liberals should be very concerned about a plan controlled by govt. What if 20 yrs from now uber-conservatism has a strong resurgence and things like abortion, birth control, IVF, drug rehab and abuse counseling get deemed "consequences of lifestyle choices" and get routinely denied.
I have to take issue with this blanket statement:
"This is particularly so because health insurance benefits, unlike other types of income, aren't taxed, and so Fredrick is less cognizant of them if show up on his paycheck at all."
Employees whose same-sex partner or spouse are covered under their health insurance do pay taxes on the additional premiums for their partner or spouse - it's treated as additional taxable income.
No wonder the 20% of same-sex couples currently raising children in the United Stated have a median household income 23% lower than opposite-sex couples raising children.
Regardless of what types of options become available, I hope any reform treats all couples and families fairly and equally.
Nate, this is a pretty decent analysis, but there is much more to the health care market than is dreamed of in your philosophy.
First off, most large employers self-insure to a large degree, or are even completely self-insured. The insurance companies provide administrative services only (ASO) contracts for them, and their pitch is that they will "manage" care to reduce costs. The advantage the large insurance companies have in this case is that they often have networks of health care providers in HMO or HMO-type constructs -- plus, they may have staff services designed to control costs.
The reason they can't actually control costs has to do with the blank check written for expensive technology and drugs for people of any age, any prognosis, etc.
Also, large private insurance companies benefit from a large team of actuaries to select low risk customers. Startups would have difficulty matching this at a similar cost per customer.
Another point of having a government plan is that customers probably could keep their insurance even if they finish college, change jobs, move, etc.
America doesn't have a public option because we know better than all the other industrialized countries. That is why we have a for profit health insurance sector and that is why we don't have the metric system..
America knows best!!
@Gruss But try a mental exercise: of your entire family, and all the people you know, how many of them have health care costs that were truly not foreseeable?
For my wife and I, never once have we in our entire lives incurred health care costs that we couldn't foresee.
Perhaps your definition of "foreseeable" is drastically different than mine but I don't understand where you are possibly coming from. I'm 25 and I've needed stitches in the emergency room a few times. This cost a friend without health insurance $1400 and it cost me $100. That is no small sum and I would not call that foreseeable. My mother had cancer, that was not foreseeable. My uncle fell off a roof and shattered his leg...you see where I'm going?
You compare shopping for food which is needed to healthcare which is needed. Are you really claiming that shattering all the bones in your legs and having probably less than an hour to live without medical attention is equivalent to shopping for bananas? That is insanity. There is zero choice when it comes to healthcare in most situations. It is not comparable to a product like bananas or human hunger. As I can predict how much food I will need for the rest of my life but honestly couldn't predict my healthcare needs for even the next few hours with certainty.
@ Josh
Your'e absolutely right.
There should be a massive education campaign,led by Obama personally,explaining to the American public (currently brainwashed by the insurance industry and its bought-and-paid-for members of Congress) the virtues of single payer.Medicare for all!
Conservatives seem to believe that private health insurers have a constituitonal right to screw its customers by refusing coverage to those who need it, refusing to pay valid claims to those who have it, and paying its CEO multi-million dollar salaries for thinking up new ways to screw the public.
Health care for all is a basic human right. Take the private insurers out of our health care system altogether and we will have access for all at an affordable cost.
So... ppl here who are on the left but oppose the public option do so b/c (ignoring the questionable bits about waiting times etc and how it's not faaaaaair that private insurers can't compete by being perpetually in the red and having taxpayers pick up the bill, which I think recent events have proven untrue anyway):
1) private insurers will offload their undesirables on the public option
2) it will not resolve the shortage of primary care physicians, which is the result of fee-for-service, which is due to Medicare and which a public option will probably be modeled after
Is that correct?
So do you feel the solution could lie in no public option but compulsory universal insurance wherein insurers are not allowed to not cover whoever wants to be covered by them, nor deny coverage for necessary treatment, (and the government would subsidize those with a disproportionate number of low-income, chronically ill patients, etc through risk equalization pools or something?) which leaves insurers to compete to generate profit by determining which doctors are good bets?
Since npunwani is so prominent in these discussions I am trying to understand what s/he means in particular, but wiki sez Germany's public system (how is this distinguished from a public option?) is based on fee-for-service reimbursement... or is it just that the German standards aren't weighed so heavily against primary care physicians? Also, it seems to me that the Japanese system (which you also seem to approve of?) also has the government calling the shots--consider this article.
(I'm unperturbed that both Germany and Japan are worried about their health care systems--they have universal coverage and still spend much less than us, so it's far from an argument against the USA implementing a more social system....)
@ Gruss
"We NEED food. So by your logic the government should take over the food industry.
Which, frankly, it has and it's why we have a problem in healthcare.
We need socialized medicine to solve the problem created by socialized agriculture:"
I have no idea what you are saying.Can you elucidate?
[quote]The only solids number we have so far are 1+ trillion for 20 million covered. Thats not worth it.[/quote]
It's 1+ trillion OVER TEN YEARS for 20 million covered. Five thousand per person per year.
That's a lot less than what I pay.
@gruss
I assume he's saying that agriculture is subsidized (corn in particular? Being a staple) and then we wind up with corn and HFCS in everything (all of the carbon in your body can probably be traced to corn!) and wind up with all kind of health problems like obesity (not to say it's not linked to personal choice and genetics, but if you're poor then you're limited as far as what kind of quality food you can get--don't some food stamp progams prohibit you from buying organic food with them? Or something.)
. kali said...
re: my supposed defense of big pharma
It is true that AZT was repurposed for HIV, but there is no way that they did not have to redo the part 3 clinical trials, which test for efficacy.
The part 3 clinical trials for AZT use for AIDS patients involved 147 patients, not the usual thousands for most drugs. And it was cleared by the FDA for use in 18 months instead of the years that most drugs go through.
So why the $10,000 per year per patient cost?
To recover the R&D (that was not borne by Burroughs-Wellcome)?
To recover the costs of the shortened and small number of participants in the part 3 clinical trials?
Or just big pharma greed?
My bet is on the latter.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
@ .kali:
"So do you feel the solution could lie in no public option but compulsory universal insurance wherein insurers are not allowed to not cover whoever wants to be covered by them, nor deny coverage for necessary treatment, (and the government would subsidize those with a disproportionate number of low-income, chronically ill patients, etc through risk equalization pools or something?) which leaves insurers to compete to generate profit by determining which doctors are good bets?"
You got it, dude!
In Germany and the Netherlands, taxes are collected in a national, government-run central fund that effectively performs the risk-pooling function for the entire system. This fund redistributes the collected premiums to hundreds of independent, nongovernmental, competing, insurers among which citizens can choose.
For example, in Germany and similarly in the Holland, if individual A chooses insurer X, then the central fund will give to insurer X a capitation payment that uses over 80 variables to identify individual A’s actuarial risk. The same payment would be made for this individual to any other insurer.
These insurers, in effect, act as purchasing agents on behalf of the central fund and patients.
"I am trying to understand what s/he means in particular, but wiki sez Germany's public system (how is this distinguished from a public option?) is based on fee-for-service reimbursement... or is it just that the German standards aren't weighed so heavily against primary care physicians"
Germany and the Netherlands pays capitation payments to insurers. They basically get a lump sum payment for the year that is risk adjusted for each patient they enroll. The more sick or old the patient is the more money the insurer gets from the gov't. As a result, the insurer has to be as efficient as possible (they have to encourage prevention and avoid unnecessary procedures or they lose a lot of this capitation payment). At the same time, if they try to reduce costs by impeding quality, people will switch to better benefit plans. Insurers get this capitation payment and they have to figure out how best to allocate it when the patient sees different providers. As a result, insurers in these countries are developing their own reimbursement systems to figure out which ones get the best quality for the dollar (or in this case the euro).
The net effect of this, is that insurers in these countries are establishing pay for performance guidelines, they've boosted reimbursements to primary care, and they are scaling back payments to specialists if they do too many procedures. Also, if physicians buy their own scanners and start referring all their patients to get these expensive but unnecessary scans, the European private insurers drop them from the network. Doctors in these countries have to weigh the benefits and the costs more when providing unnecessary services.
For more info on health care in Germany, Switzerland, and Holland:
http://economix.blogs.nytimes.com/2009/04/17/health-reform-without-a-public-plan-the-german-model/
@ Gruss
So if Medicare-for-all is the answer why doesn't someone just put the bill out for a vote right now?
I'm guessing it something to do with the fact that the Medicare book shows -$30,000,000,000.
But if tax payer funded medical services for all are the answer, can someone answer why the Congress or President doesn't just put out Medicare-for-all to a vote?
Because,as I stated above in my post above to Josh,the American public has been brainwashed by the very powerful insurance industry (remember the "Harry and Louise commercials?) to believe all the lies about Medicare.Lies like it will lead to rationing,it's too expensive,ypu'll have to wait for medical procedures,etc.
And also,at this point in time the insurance industry has,not to put too fine a point on it,bought members of Congress to fight its battle.
So,to counteract this,Obama is pushing The Public Option,which over time,will drive out the insurance companies and evolve into Medicare For All.
His opponents correctly see this truth and that's why they are fighting tooth-and-nail against an unalloyed public option.
Carey said...
One point that I have yet to see called out anywhere (to my surprise) when the idea of taxing employer health benefits is proposed is that this increases government revenue, and reduces the real income of the middle class, but does nothing to address health care cost inflation.
Carey,
Almost all the proposals (all that I've heard about, but there may be one or two different) propose taxing those health benefits of more than $X dollars per year - mostly those of $15,000 or more in employer cost.
Not many 'middle class' employees have an employer who pays that much for their health care.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
@ .kali:
Don't read wikipedia for health care policy. I've found a ton of accurate, but misleading comments. For example, it talks about how in the Netherlands health care spending is over 70% public. That statement makes people think that the gov't directly insurers people like a single payer system. BUT THATS NOT HOW IT WORKS. The gov't uses money collected from taxes to make payments to insurers, that's what wiki means by public spending on health care. Similar, in the german scenario you gave me.
Wiki is accurate but if divorced from the proper context, a lot of it is misleading. So I get health care policy info from the New England Journal of Medicine, Health Affairs, etc.
Why are people like Will allowed to have it both ways: They say that there is no way the the government can run a plan as efficiently as the private sector, and yet they whine that it will unfairly compete and drive private insurers out of business.
Nova middle man said
'It should be like auto insurance. You pay based on how much of a health risk you are.'
-------------------------
The only problem with that idea is that the poorest people, and the oldest people would be scored as at most risk, and therefore those least able to pay would be made to pay the highest premiums.
My problem with George Will is that he increasingly seems to comment in order to create a wave rather than to add reason to the debate. A lot of what he writes, a lot of what he says on This Week simply makes no sense. I don't get where he gets his reputation from. There are those on the right (David Brooks for instance) who can make intelligent comment, without seeming to be in the pocket of the Republican Party. George Will seems to have lost the plot somewhat.
Doctor Who, you are guilty of of misstatement and intellectual dishonesty. Nate did not write that the free market works "99% of the time". He wrote that it works in "99% of all cases". The difference between the two is huge. Health care is only one case, but it accounts for a huge amount of "time" -- e.g. per cent of GDP, basic human survival needs, etc. Other cases that account for the other 99% include hamburger stands, home theater stores, scented candles, house painting, etc. Neither one of these cases has as great an impact on our nation as health care.
Secondly, please explain how the "marketplace" works in health care. I've never known of a case of a doctor advertising in an open market what he or she will charge to treat a patient for lymphoma, or a hospital to advertise room rates (perhaps with a AAA member discount?). Do insurance companies provide people with a clear list of what treatments they will authorize for what illnesses. I've never had a car salesperson refuse to sell me a new auto because I've wrecked a car, but try getting health insurance if you've had cancer in the past 10 years.
Perhaps we should turn our police forces over to the private sector, and let you bargain for your safety on the streets?
Tony said:
the main problem with single payer is that it is a monopoly.
If you happen to dislike it, you can't realistically choose another one.
Well guess what, Tony. For most people, their private insurance is a monopoly too, since they have employer-provided insurance. They have no realistic chance of changing their insurance unless they change jobs, which is a real challenge these days. And people with pre-existing medical conditions don't even have the option of changing jobs.
Why not have some respect for individual freedom of action?
Do you all want to live in a nanny state where the government tells you what to buy and how to behave?
You are all a bunch of craven sheep!
Please have some humility and do not think your judgment is superior to everybody else's.
If you don't want health insurance you should not have to buy it. You should not be made to subsidize the sick if you are healthy and don’t need it. 95% of Americans between the ages of 18 and 40 never really need to see a doctor in their lives.
If you want insurance, get some, but don't ask the government to get it for you.
They are going to ruin healthcare for the vast majority of us who are satisfied.
Let's not impose Canadian style misery on us here. They flow across the border writing checks to have their breast surgeries. It is a scandal what socialized medicine does to the many in order to help a few.
This is the Obama way: drag down many to elevate a few.
And let’s not forget about how many jobs this will cost us. Millions are unemployed and starving – have some real pity on them and stop your social experimenting.
petekent01 (on twitter)
Gruss said:
For my wife and I, never once have we in our entire lives incurred health care costs that we couldn't foresee.
May your good fortune continue. As you have seen, others on this thread have not been so lucky.
But even you are only one serious accident or sickness away from bankruptcy (unless, of course, you are a millionaire). What would you do if you had an automobile accident and became paralyzed from the neck down, requiring millions of dollars of treatment and care for the rest of your life?
Doctor Who writes, "The answer lies in the free market. Give consumers more choice and better access to that choice. Allow easier access into the medical field so we can have more doctors."
But creating a public option would give consumers more choice! It might even create demand for more doctors and thus easier access into the medical field: a public option might make health care accessible to those who have no insurance now, which would create demand for more health care. Your desire for more choice is actually an argument for a public option.
As usual, when conservatives promote an action and/or inaction, what is almost never included are the three most important words for liberals...... Justice, equality fairness fairness.
Will's comments went to the heart of the matter.
When Joe Blows hardware store can't compete with the big box stores too bad....close your doors and find another way to support your family. But let this happen to a giant corporation and or industry and the whining, fabrications and untold millions of $$$$$$$ blanket the country like the plague.
Conservatism without hypocrisy means never to hold power again!
Dr. Who's laissez faire fundamentalism obscures some facts... The US spends about twice per capita on health care as do other Western nations (looking at %GDP). Quality of product is harder to measure, but most estimates are that it's pretty comparable. Life-span arguments suggest US is worse, but I think those are pretty flimsy.
I doubt that free market approaches will effectively account for externalities and risks. Don't want gov't to run it, but we are spending a boatload on paper-pushers who are not adding any value to overall societal productivity.
What we are doing is clearly suboptimal.
Moving towards universal care of the euro/canadian variety will be better, since we can see that every country doing so is delivering care more efficiently. I'm certainly of the belief that that is not optimal.
More "choice" is bs - plenty of evidence that the invisible hand is invisible because it isn't really there...
@Markymark
Thats why we have medicaid and medicare respectively already
Part of the problem is that many people who qualify for medicaid don't sign up for it. Depending on what source you use that takes anywhere from 10-30 million people.
After that you are really talking about around 20 milllion people or so without health insurance. I say stick them on medicaid and be done with this whole issue.
I hate to keep harping back but no matter what plans we have or don't have. The real problem is in the IT structure and efficiency.
If the guys who said Medicaid is in debt by that much we have some serious problems. I don't doubt him entitlement spending is taknig larger and larger shares of the totatl spending available
It just goes back to the fundamental issue. The Ds like to spend the Rs like to cut taxes. Nobody likes to cut spending or raise taxes and we are going to have to do both in the very near future.
@markymark
I think George is pretty good on most issues with some excpetions. His one flaw I think is that he lives in the past. He loves to bring up historical ponits (to make him look smarter???) but sometimes he fails to realize how much the U.S. has chaaged. Thats common with conservatives. They dont like change. Heck thats a large chunk of the whole healtcare debate from the R side change is bad.
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