Comments on FiveThirtyEight: Politics Done Right: Blue Dog Districts Need Health Care More than Most...

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2009-10-12T04:04:34.078-04:00

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2009-09-06T03:35:55.227-04:00

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I recently came accross your blog and have been re...

2009-08-06T10:32:48.054-04:00

I recently came accross your blog and have been reading along. I thought I would leave my first comment. I dont know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

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2009-07-22T03:54:12.870-04:00

I recently came accross your blog and have been re...

2009-07-20T08:56:29.323-04:00

@ vonwerder Louisiana’s charity system will care ...

2009-07-18T13:03:40.766-04:00

@ vonwerder

Louisiana’s charity system will care for uninsured indigent people. However, Louisiana’s working families can’t use the charity system until they cease being “working” and become “indigent”. So if an unemployed indigent person can theoretically show up at a Louisiana hospital and get that heart transplant, working people will have to bankrupt themselves and their families before the charity system kicks in. But being forced to declare medical bankruptcy isn’t that difficult in Louisiana, according to Healthcare for America Now. I paraphrase for brevity:

*Health insurance premiums for Louisiana working families increased 75 percent from 2000 to 2007. The average annual combined premium for family health coverage for employers and employees rose from $6,536 to $11,455. The full cost of employer-sponsored insurance in Louisiana now equals 29 percent of median family income. Without meaningful health reform, that number will grow to 60percent in 2016. The full cost of employer-sponsored health insurance is projected to grow at an annual rate of 7.9 percent, compared to a negative 0.2 percent growth rate for income.

*For family health coverage in Louisiana, the average employer’s portion of annual premiums rose 76 percent from 2000 to 2007, while the average worker’s share increased 74 percent. From 2000 to 2007, the median earnings of Louisiana workers increased 23 percent, from $20,467 to $25,147.

*Sixty-one percent of the total non-elderly uninsured population in Louisiana are working adults.
In Louisiana 10.5 percent of working adults spend 20 percent or more of their income on out-of-pocket health care expenses in 2004, a 33 percent increase from three years earlier.

*A recent report estimated that 62 percent of bankruptcies were directly related to medical bills; in Louisiana there were 14,945 non-business bankruptcies in 2008.

Louisiana’s working families need healthcare relief. Or else they can stop working, go live under a bridge, and let the charity system absorb them. Sounds like a plan! ;)

http://healthcareforamericanow.org/page/-/affordability%20reports/affordability%20fact%20sheet/Louisiana.pdf (includes sources)

I would be in favor of reform if Congress adopted ...

2009-07-18T00:33:31.898-04:00

I would be in favor of reform if Congress adopted Elmendorf's two suggestions: (1)changing the way Medicare reimburses providers to create incentives for reducing costs (I believe Obama supports this); and (2) ending or limiting the tax-free treatment of employer-provided health benefits, which is a federal "subsidy" that encourages spending on ever-more-expensive health packages (basically John McCain's proposal, which the unions are against).

I have no problems with either of those proposals, so that's another area of agreement. The problem is that Obama kind of boxed himself in on the second one during the campaign, so it's going to be hard for him to reverse himself no matter how sound the policy reasons are.

As for the CBO, I don't want to grasp at straws, but the NY Times article says: "The budget office, in its calculations, cannot take into account — or 'score,' to use Congressional budget lingo — many of the savings that Democrats say will result from their legislation because those savings fall outside the direct control of federal law." So the CBO may not be the last word on the subject.

Still, some cost control measures are needed. The House bill won't be the last word either. There's still a long ways to go.

I think (and this is mostly speculation) that something will get through if only because it would be too devastating to Democrats and Obama to fail to pass anything. I would not predict what the final form of that something would be, though.

And from a political point of view, it seems that Republicans see no electoral benefit in providing a single vote for reform. I'd guess that if something does pass, it will be without any Republican support. Sad that politics takes precedence over substance, but that's the way the game is played.

The Louisiana rep gains nothing from health reform...

2009-07-17T12:59:18.483-04:00

The Louisiana rep gains nothing from health reform as Louisiana operates a statewide charity system already. Its very good. We even do heart transplants for the indigent.

The feds proposal would offer substantially less than we offer now.

dsimon, here is a Washington Post article on what ...

2009-07-17T08:11:59.116-04:00

dsimon, here is a Washington Post article on what Elmendorf said yesterday: http://www.washingtonpost.com/wp-dyn/content/article/2009/07/16/AR2009071602242.html

From the article: Some provisions of the bill have the potential to trim spending further, Elmendorf said, but "the changes that we have looked at so far do not represent the sort of fundamental change, the order of magnitude that would be necessary, to offset the direct increase in federal health costs that would result from the insurance coverage proposals." I think that answers your question on overall health care spending.

I would be in favor of reform if Congress adopted Elmendorf's two suggestions: (1)changing the way Medicare reimburses providers to create incentives for reducing costs (I believe Obama supports this); and (2) ending or limiting the tax-free treatment of employer-provided health benefits, which is a federal "subsidy" that encourages spending on ever-more-expensive health packages (basically John McCain's proposal, which the unions are against). I also think they need to strike the provision in the current legislation that prevents private insurance from writing insurance policies after the date the legislation is passed. I'd also decrease the level where the government is subsidizing people to pay for health insurance, which the current bill has at 400% above the poverty line, which is an individual making $88,000 a year. Do individuals making $88,000 a year really need a subsidy to pay for health insurance? I'd suggest $75,000, but also make it adjusted to where you live ($75,000 in DesMoisne is more than $75,000 in San Francisco).

I'd support the health care reform package if all of those were part of it. I'll stick by my prediction--bill passes the House, gets stuck in the Senate, no health care reform this year. I do think that is a shame (those opposed to the current bill are not all "obstructionists," some just want a better plan). I think the one area we both agree upon is that what we have now is unsustainable.

Richard: Stossel and the New Yorker article both a...

2009-07-17T00:02:33.876-04:00

Richard: Stossel and the New Yorker article both agree that insurers and insurance, whether private or public, is not the answer.

No, I think that's not the conclusion. It's that insurance is not the only part of the answer. It is probably a part of the answer. Just look at administrative costs here versus administrative costs in our peer country groups. Again the Frontline "Sick Around The World" program says they spend only a few percentage of costs on administration (as does Medicare), as opposed to over double digits with our private insurers. That's nothing to sneeze at.

On thing other countries have in common is competitive but non-profit insurance, some with a public option and some not. Seems to work for them.

Show me one study that suggests that "overall" per capita health care expenditures will be reduced.

Can't know for sure. But can't know that they won't be reduced either. Again, I may be wrong but I don't think the CBO is tasked with computing overall health care expenditures.

Frankly, the Stossel article is off on several points. As I mentioned in a post above, co-pays can take care of the overuse problem. Shame he doesn't even mention it. Moreover, he says there's something wrong when women are healthier than men yet go to doctors more often. Did he stop to think that maybe they're healthier because they go to doctors more often, like when they're getting sick, or for preventative care? I don't know, but there's no effort to separate correlation from cause. That's seems really sloppy to me.

And really when Stossel says "When politicians interfere with free markets, unintended consequences harm everyone," that's pure ideology at work. Has he seen the wonder of the unfettered free market at work in the financial markets? How does he think we got here, by too much regulation?

Now, I'm basically a free market person. But I'm not going to ignore evidence that an unfettered free market doesn't always get the results we want, in which case some modifications are called for.

The New Yorker article, combined with this article...

2009-07-16T16:47:01.582-04:00

The New Yorker article, combined with this article by John Stossel (http://www.reason.com/news/show/134684.html) and chart: (http://blogs.abcnews.com/.a/6a00d8341c4df253ef011570a5b478970c-pi) explains most of the reasons why health care cost are higher in the US.

To your amazement, I probably agree with much of what is said in the New Yorker article, especially this:
"Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world."

Stossel and the New Yorker article both agree that insurers and insurance, whether private or public, is not the answer. Like the New Yorker suggests, I'd rather have the medical communities making decisions, in conjunction with patients, but that is not what is being done with this so-called health care reform. Unfortunately, the reform package being offered is about more insurance and puting the public insurers in charge. It contradicts what the New Yorker suggests is necessary.

Got New Yorker article now. Must have been someth...

2009-07-16T16:18:29.596-04:00

Got New Yorker article now. Must have been something on my end.

This is an awfully big reform package that is bein...

2009-07-16T16:14:09.643-04:00

This is an awfully big reform package that is being rushed through the Congress to be unsure whether "it might reduce costs in premiums." Show me one study that suggests that "overall" per capita health care expenditures will be reduced. Believe me, if they had a study, they would be trotting it out about now, given their own CBO is telling them costs will increase, not decrease. My prediction is that the House will pass a bill, but the bill won't get out of the Senate this year. (New Yorker article not available)

Richard: This is the reason why Hilary Clinton was...

2009-07-16T15:46:33.661-04:00

Richard: This is the reason why Hilary Clinton was being more honest than President Obama on the campaign trail. She was arguing that insurance would have to be mandatory for all individuals because of this issue.

That's one reason, but not the only one and not necessarily the most important one. Another reason for an individual mandate is to pool risk and bring down costs.

There are a lot of reasons we spend more than other countries on health care, some due to inefficiencies in some parts of our system (always room for improvement), but I believe it has more to do with other factors that are not being addressed in what is being offered by the Congress in this package of reform measures.

I agree that other measures need to be addressed. Hence the New Yorker article I referenced. But I just don't see how those "other factors" could possibly result in a nearly 50% reduction of costs that other countries seem to get. Still, I gather that we agree that other nations get comparable results at far less cost, though we may disagree about why that is. Again, the New Yorker article is instructive on why costs vary so widely even among comparable populations in the US.

Also recommended: the Frontline episode "Sick Around The World" which looks at the health care systems of some selected other countries.

Also, just read a news article that reported that Congressional Budget Office ("CBO") Director Douglas Elmendorf stated that "the legislation that he has seen so far would raise costs, not lower them."

Costs to whom? Of course subsidizing the uninsured would raise costs to the federal government. But it might reduce costs in premiums. And the figure that I thought was important was the per capita cost of heath care. Just because federal spending goes up does not mean that overall per capita heath care expenditures will go up. If federal expenditures go up but overall expenditures go down with the same health results, that's a more efficient and less expensive system.

Also, if the rate of federal health care spending is "unsustainable" and the number of uninsured is growing (after all, the costs are increasing to private employers who are choosing to shift expenses to employees or not offer health benefits at all), what's the solution? As Obama has said, the status quo is not sustainable--unless one wants to deprive an increasing number of people of decent access to medical care, which is of course a form of rationing.

For those of you here who keep saying that everyon...

2009-07-16T14:04:58.907-04:00

For those of you here who keep saying that everyone will still have a choice of a public or private option after the Democrats "reform" health care, I would recommend you either read the bill or this article: http://www.ibdeditorials.com/IBDArticles.aspx?id=332548165656854. Per the legislation, everyone will be stuck with whatever insurance policy they have now. Any new private insurance policy will be prohibited after the date the new legislation becomes law.

Also, just read a news article that reported that Congressional Budget Office ("CBO") Director Douglas Elmendorf stated that "the legislation that he has seen so far would raise costs, not lower them." Senator Kent Conrad, D-ND asked Elmendorf whether the bills being considered in Congress would "bend the cost curve." Elmendorf responded: "the curve is being raised. Subsidies to help uninsured people would raise federal health care spending, which is already growing at an unsustainable rate." This is from the Democratically appointed Director of the CBO! Who are the FACT deniers now?

dsimon, I believe we will need to agree to disagre...

2009-07-16T12:41:01.126-04:00

dsimon, I believe we will need to agree to disagree. I just don't see the "hard evidence" that you posit. There are a lot of reasons we spend more than other countries on health care, some due to inefficiencies in some parts of our system (always room for improvement), but I believe it has more to do with other factors that are not being addressed in what is being offered by the Congress in this package of reform measures.

dsimon, The pre-existing issue is definitely a cu...

2009-07-16T12:09:35.618-04:00

dsimon,

The pre-existing issue is definitely a cunundrum. If insurance companies have to take anyone with a pre-existing condition, then why would anyone pay for catastrophic insurance before they needed it? A rational person would just simply wait until they had a condition before obtaining insurance. This is the reason why Hilary Clinton was being more honest than President Obama on the campaign trail. She was arguing that insurance would have to be mandatory for all individuals because of this issue. Obama was campaigning for insurance companies covering pre-existing conditions too, but not requiring that health care insurance be mandatory for all. He has changed his position now, but, again, I find it disengenuous at best.

I was trying to show that we can never get the "pe...

2009-07-16T12:08:32.646-04:00

I was trying to show that we can never get the "perfect" system, that there will always be tradeoffs.

And I was trying to show, through the hard evidence provided by other countries, that those tradeoffs need not be significant compared to what we have now, which also involve tradeoffs.

If you want to bring down costs of the system, which I think we both agree upon, then there must be a tradeoff with either quality or speed/access issues.

The stubborn fact remains that some of our peer nations have been able to get comparable results while we spend almost twice as much. And their populations certainly have greater access. And from what I've read, the speed issues are greater for some things but less for others (while, again, spending far less). I don't think that the examples provided by other countries has been fully addressed.

Tradeoffs have to be made. The Dems just don't see this or, more than likely they do, but don't want to speak honestly about it to the public.

Again, tradeoffs are being made right now, but some of those against reform don't want to speak honestly about it to the public. If our system is as inefficient as it appears to be, then we should be able to consider more efficient tradeoffs than the ones we're making today.

By the way, on lifestyle choice: it's not clear that all those choices cut in the same direction. Yes, Americans are generally fatter, but I think Europeans smoke more. Also, one should be able to sort out the per capita health care costs of various subgroups (obese, smokers) in each system. I could be wrong, but I suspect our costs would still be vastly higher with not much effect in outcomes.

It's useful to look at at the New Yorker piece from last month. Even communities with similar demographics have wildly different health care expenditures with little difference in outcomes.
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

dsimon, I was trying to separate cost, quality an...

2009-07-16T11:45:32.755-04:00

dsimon, I was trying to separate cost, quality and speed/access issues (please read above) and I conceded that the US system is too costly (I believe the high cost is mostly due to the disconnect between the payment of insurance and the actual cost of the health service provided, which leads individuals to use more health care than they would, if they knew what the actual cost are). I was trying to show that we can never get the "perfect" system, that there will always be tradeoffs. If you want to bring down costs of the system, which I think we both agree upon, then there must be a tradeoff with either quality or speed/access issues. If you want to increase speed/access, which most of the reform proposals coming from Congress seek to do, then they are being disengenuous that the costs will not go up for a majority of people or that the quality will not suffer. I know everyone thinks Obama is "Superman," but he is not going to get it all. Tradeoffs have to be made. The Dems just don't see this or, more than likely they do, but don't want to speak honestly about it to the public.

Richard: I would say it is inconclusive whether US...

2009-07-16T10:28:43.102-04:00

Richard: I would say it is inconclusive whether US has worse health outcomes.

But the point wasn't whether the US has worse outcomes than our peer nations (and I believe I said that the outcomes were comparable, not necessarily worse.) The point is the expense: that we spend almost twice as much as other countries while getting only comparable results. If we're spending so much more, is it a good deal to get results that are only marginally better?

And yes, there may be lifestyle differences. But how much of such a vast disparity in spending can it be responsible for? Even if lifestyle results in less healthy Americans, I have a hard time believing that we can attribute our nearly 100% greater expenses to it.

I would favor patient "A" deciding what level of insurance is best for him/her, based on his/her lifestyle, paying for the actual costs of that insurance and then if a particular treatment is covered under the policy, then the decision to undertake the treatment is made by the patient in conjunction with his/her doctor.

I don't believe anyone is proposing anything that would prevent this scenario. What is being proposed is an alternative for those who can't get insurance to begin with, and an option for those who might prefer a different plan.

Even if the dubious notion that a public plan will "crowd out" private plans turns out to be true, anyone would be free to purchase supplemental insurance to provide the freedom you describe.

This may sound harsh, but the other way is just passing the actual costs of poor lifestyle choices onto society

I don't think so, because those costs are already being passed along to society. People who don't have access to health care services get sick, miss work, and go to emergency rooms. Those costs are already socialized. Having real health care and regular access to a doctor may encourage better lifestyle choices and reduce those costs.

Moreover, many people who have insurance today make poor lifestyle choices, so there wouldn't seem to be much difference between a public and private system in that respect.

Finally, your proposal would seem to me to exclude anyone with a preexisting condition. The costs of treatment for many people make them essentially uninsurable. That's one huge problem with private insurance: the incentive is to insure only people who are healthy, and deny care whenever one can arguably do so. A public system does have different kinds of problems, but at least there's no profit motive in the process. (And, as I wrote before, those who are concerned about "rationing" and can afford it can buy additional insurance.)

Mike in Maryland, Before saying I'm a FACT denier,...

2009-07-16T10:06:14.720-04:00

Mike in Maryland, Before saying I'm a FACT denier, please provide me with at least one link to a study that supports the notion that the quality of health care in a country with a single-payer SYSTEM is better than the quality of health care under the U.S. system. I provided two links of detailed studies that concluded that if there is any difference at all in health outcomes, it isn't due to the system of health care provision, but rather, due to the poor lifestyle choices made by individuals in the U.S. This is a simple notion in systems analysis research. If you have a higher quality item going into the system, then that system will have better outcomes than a system with lower quality items.

The socialist-liberals make this same argument when comparing suburban schools to urban schools. Rightfully, they point out that the students in suburban schools are better prepared than the students in urban schools going in, so it is only natural that the suburban school students are likely to have better "outcomes" on standardized tests. The real analysis of the educational system (this analogy should be used in evaluating health care systems too) should be with how far each system broght the child along. For example, if the average child going into an urban high school has a fifth grade reading level and the school brings that student up to an eigth grade reading level by the end of the ninth grade, is it better or worse than a suburban school system that brings an average student from an eigth grade reading level up to a ninth grade reading level at the end of the ninth grade? If you just looked at outcomes, you'd say that the urban school is failing. Why not use this analogy when comparing health care systems? Of course, the good studies will do this. The ideological studies will leave that part out.

Mule Rider - "The problem is that I don't see anyt...

2009-07-15T23:39:24.594-04:00

Mule Rider - "The problem is that I don't see anything the Democrats/liberals have pushed forward thus far in Congress as potentially meeting most, and certainly not all, of the criteria you mentioned."

Have you looked at HR676?

Richard (and all the other FACT-deniers), One are...

2009-07-15T20:52:55.439-04:00

Richard (and all the other FACT-deniers),

One area of medicine where the US is better than most of the rest of the world is corneal transplants.

In the US, a surgeon can set a date with the patient days, weeks or even months in advance, and perform the transplant on that date. In the rest of the world, the patient is usually informed the day prior to surgery of the date of surgery.

But why? The US has a better medical system?

NO

The US has a much higher rate of organ and tissue donation that ANY other country in the world.

Corneal tissue can be stored for up to a week. The US has a system of Eye Banks.

THAT is about the only reason that, for instance, Canadian citizens might (notice the word might?) consider going to the US for a corneal transplant. And even then, the Canadian insurance system most likely will pay for the surgery - every bit of it, not the 50% (or 75%) of the 'usual and customary' fee of $10,000 to $25,000 for such an operation. And most of them would NOT go to JHH, but rather to Portland, Oregon; Indianapolis, Indiana; Fr. Myers, Florida; San Francisco, California; or other locations that were performing newer corneal transplant techniques YEARS before JHH stared to perform those newer techniques.

Mike in Maryland

My Blogger ID is http://www.blogger.com/profile/02848893412251095965

Yeah, I did a quick search on wiki - and other pla...

2009-07-15T18:34:56.816-04:00

Yeah, I did a quick search on wiki - and other places - and Persuter is spot on...black migration may have been spurred by racism and other problems but to suggest they were "evicted" by the "millions" is indeed over the top.

http://en.wikipedia.org/wiki/Great_Migration_(African_American)

Oh good, glad to see you're keeping away from the ...

2009-07-15T18:32:29.994-04:00

Oh good, glad to see you're keeping away from the name-calling and angry statements as usual, Mule.

I didn't call you one name in the paragraph you quoted and responded to...I did later refer to you as ignorant, but due to your absurd interpretation of the data, that's the only logical conclusion. And labelling ignorance isn't necessarily name-calling. You probably can't help it that you don't understand mathematics as well as you should. And I didn't mean to sound "angry." I was maybe a bit biting and sarcastic, but not angry.

Your argument is that Democrats do not do enough for black people.

No! My argument is that Democrsts do the same level of pandering to blacks Republicans do for southern whites. There's little difference between the two. It's not to say that either political party does nothing, or not enough, for those groups...it's saying that they do more lip service to extract their vote (which they're good at, look at the numbers - blacks for Dems and southern whites for Reps) and fall well short on action. Which, to most people, brings to mind the word "exploit."

That is/was my argument.

How the fact that black people's out-of-wedlock birth rates increased more slowly than white people is even a bad thing for black people,

You're getting hung up on the rate of increase while I'm trying to harp on the rate itself. It's at 70%! That's over two-thirds. It's an incredibly high rate for anything and especially troublesome for an issue that has been pinpointed as a leading indicator of other troubles down the road - i.e. poverty, crime, lack of education, etc.

The fact it increased fivefold in the white community is also very bad. But it's still "only" 25%. That's way too many but at a 1-in-4 rate, it's much more manageable. Looking at a relative increase in out-of-wedlock birthrates between blacks and whites is about as relevant as looking at the rate of aging between a grandmother and her grandson over a 5-year period. Assuming the kid was 5 and the grandma was 50 at the beginning of the "study," five years later you would say the kid's age doubled, or increased 100%, whereas the grandmother's age increased only 10%. So freaking what. The kid's now 10 and hasn't even hit his "peak" years while the grandmother is entering her senior years and likely to experience additional health problems, despite her much less rapid "increase" in age.

Does that make sense now? Even talking about the "rate of increase" is an irrelevant topic.

much less the Democratic Party's fault, is totally beyond me, and you certainly have made no attempt to explain.

I didn't try and lay it at the feet of the Democratic Party. I'll go back to my original point/argument that the Democratic Party simply does more to pay lip service to blacks and extract their vote than what they actually do to improve their livelihood. I concur that they do something. They have to or otherwise blacks wouldn't support them with such vigor. However, I made no connection to failings in the black community being one party's fault.

You exhaust me.