I know, most of you have already figured out why I oppose national health care. In a nutshell, I hate the poor and want them to die so that all my rich friends can use their bodies as mulch for their diamond ranches. But y'all keep asking, so here goes the longer explanation.
Basically, for me, it all boils down to public choice theory. Once we've got a comprehensive national health care plan, what are the government's incentives? I think they're bad, for the same reason the TSA is bad. I'm afraid that instead of Security Theater, we'll get Health Care Theater, where the government goes to elaborate lengths to convince us that we're getting the best possible health care, without actually providing it.
That's not just verbal theatrics. Agencies like Britain's NICE are a case in point. As long as people don't know that there are cancer treatments they're not getting, they're happy. Once they find out, satisfaction plunges. But the reason that people in Britain know about things like herceptin for early stage breast cancer is a robust private market in the US that experiments with this sort of thing.
So in the absence of a robust private US market, my assumption is that the government will focus on the apparent at the expense of the hard-to-measure. Innovation benefits future constituents who aren't voting now. Producing it is very expensive. On the other hand, cutting costs pleases voters this instant. This is, fundamentally, what cries to "use the government's negotiating power" with drug companies is about. Advocates of such a policy spend a lot of time arguing about whether pharmaceutical companies do, or do not, spend too much on marketing. This is besides the point. The government is not going to price to some unknowable socially optimal amount of pharma market power. It is going to price to what the voters want, which is to spend as little as possible right now.
It's not that I think that private companies wouldn't like to cut innovation. But in the presence of even rudimentary competition, they can't. Monopolies are not innovative, whether they are public or private.
Advocates of this policy have a number of rejoinders to this, notably that NIH funding is responsible for a lot of innovation. This is true, but theoretical innovation is not the same thing as product innovation. We tend to think of innovation as a matter of a mad scientist somewhere making a Brilliant Discovery!!! but in fact, innovation is more often a matter of small steps towards perfection. Wal-Mart's revolution in supply chain management has been one of the most powerful factors influencing American productivity in recent decades. Yes, it was enabled by the computer revolution--but computers, by themselves, did not give Wal-Mart the idea of treating trucks like mobile warehouses, much less the expertise to do it.
In the case of pharma, what an NIH or academic researcher does is very, very different from what a pharma researcher does. They are no more interchangeable than theoretical physicists and civil engineers. An academic identifies targets. A pharma researcher finds out whether those targets can be activated with a molecule. Then he finds out whether that molecule can be made to reach the target. Is it small enough to be orally dosed? (Unless the disease you're after is fairly fatal, inability to orally dose is pretty much a drug-killer). Can it be made reliably? Can it be made cost-effectively? Can you scale production? It's not a viable drug if it takes one guy three weeks with a bunsen burner to knock out 3 doses.
Once you've produced a drug, found out that it's active on your targets, and produced more than a few milligrams of the stuff, you have to put it into animals, then people. Does your drug do anything in animal studies? Does it do too much, like, say, killing the patient? How about humans? Oral dosing is just the start. Does your drug actually get somewhere after it's swallowed, or do the stomach/liver chew it up? Is there any way to wrap it in a protective package long enough to let it reach its target? Do clinical trials show efficacy compared to placebo, or other drugs? How big is the market (in other words, how many people want it, how badly, and how much of an improvement is your drug)?
This is the stuff academic pharma doesn't do, and as you can see, without it, you don't have a drug; you have a theory. What the NIH does is supremely valuable. But so is all that "useless" effort at the pharmas.
Now, maybe government institutions could be made to produce innovations; I certainly think it's worth trying Dean Baker's suggestion that we should let the government try to set up an alternate scheme for drug discovery. Prizes also seem promising. But I want to see them work first, not after we've permanently broken the system. The one industry where the government is the sole buyer, defense, does not have an encouraging record of cost-effective, innovative procurement.
At this juncture in the conversation, someone almost always breaks in and says, "Why don't you tell that to an uninsured person?" I have. Specifically, I told it to me. I was uninsured for more than two years after grad school, with an autoimmune disease and asthma. I was, if anything, even more militant than I am now about government takeover of insurance.
But you can also turn this around: why don't you tell some person who has a terminal condition that sorry, we can't afford to find a cure for their disease? There are no particularly happy choices here. The way I look at it, one hundred percent of the population is going to die of something that we can't currently cure, but might in the future . . . plus the population of the rest of the world, plus every future generation. If you worry about global warming, you should worry at least as hard about medical innovation.
The other major reason that I am against national health care is the increasing license it gives elites to wrap their claws around every aspect of everyone's life. Look at the uptick in stories on obesity in the context of health care reform. Fat people are a problem! They're killing themselves, and our budget! We must stop them! And what if people won't do it voluntarily? Because let's face it, so far, they won't. Making information, or fresh vegetables, available, hasn't worked--every intervention you can imagine on the voluntary front, and several involuntary ones, has already been tried either in supermarkets or public schools. Americans are getting fat because they're eating fattening foods, and not exercising. How far are we willing to go beyond calorie labelling on menus to get people to slim down?
These aren't just a way to save on health care; they're a way to extend and expand the cultural hegemony of wealthy white elites. No, seriously. Living a fit, active life is correlated with being healthier. But then, as an economist recently pointed out to me, so is being religious, being married, and living in a small town; how come we don't have any programs to promote these "healthy lifestyles"? When you listen to obesity experts, or health wonks, talk, their assertions boil down to the idea that overweight people are either too stupid to understand why they get fat, or have not yet been made sufficiently aware of society's disgust for their condition. Yet this does not describe any of the overweight people I have ever known, including the construction workers and office clerks at Ground Zero. All were very well aware that the burgers and fries they ate made them fat, and hitting the salad bar instead would probably help them lose weight. They either didn't care, or felt powerless to control their hunger. They were also very well aware that society thought they were disgusting, and many of them had internalized this message to the point of open despair. What does another public campaign about overeating have to offer them, other than oozing condescension?
Of course, the obese aren't the only troublesome bunch. The elderly are also wasting a lot of our hard earned money with their stupid "last six months" end-of-life care. Eliminating this waste is almost entirely the concern of men under 45 or 50, and women under 25. On the other hand, that describes a lot of the healthcare bureaucracy, especially in public health.
Once the government gets into the business of providing our health care, the government gets into the business of deciding whose life matters, and how much. It gets into the business of deciding what we "really" want, where what we really want can never be a second chocolate eclair that might make us a size fourteen and raise the cost of treating us.
I realize that to most people, these are airy-fairy considerations that should be overridden by the many "practical" considerations of the awesomenes of central health care. Well, I'm actually pretty underwhelmed by that awesomeness, for reasons I'll happily elaborate elsewhere. But not here, because fundamentally, to me, the effect on the tax code and the relative efficiency of various sorts of bureaucracy are mostly beside the point. The real issue is the effect on future lives, and future freedom. And in my opinion, they way in overwhelmingly on the side of stopping further government encroachments into health care provision.
Copyright © 2010 by The Atlantic Monthly Group. All rights reserved.
Megan:
I'll have to read this longish post of yours at leisure, after work, to grasp the entirety of your arguments.
But what I want to know is, what's the alternative to increasing the government's role in the provision of healthcare? That role already accounts for something like 50% of healthcare dollars, and for that we leave millions of people uninsured or underinsured. And that, in turn, in addition to being the cause of various cruelties, also has negative spillover effects for the wider economy (personal bankruptcies, job lock, etc).
Now, I don't deny one can make a principled case for the pure libertarian viewpoint, ie., that the government should just get out of healthcare (or retirement savings, or education, or what have you) entirely. But is that what you espouse? Because if not, then are you arguing for the incredibly inefficient status-quo? Or are you perhaps arguing for a different approach altogether? (IIRC you detailed your ideal healthcare plan some time ago, before arriving at The Atlantic; perhaps that's what you still favor?).
All I'm saying is: I can understand going Galt or going Denmark with respect to American healthcare. But the status quo pretty much sucks.
Jasper,
Here is my suggestion as posted in a previous thread:
"The economy needs stability and not discussion about completely overhauling 15-20% of GDP.
It needs 1-2 years of that type of stability before we can re-introduce major economy-wide overhauls, of which many are needed.
In the meantime, the federal government could take steps to help remove the state-by-state infringements to public health insurance options, the state-by-state variations in healthcare costs, the cost overruns of medicare and the various problems in medicare, help reduce the cost of current and future pharmaceutical and medical devices by doing new things with patents or even FDA requirements, tort reform, and other things that would have very widespread and substantial (in aggregate) improvements to our healthcare system.
Without actually trying to re-build the system. And almost all changes that would be appropriate under either a multi-party or single-payer system.
It would be a far more effective use of time to bring these things up one by one as simple bills that can be easily discussed and voted upon in short order.
There is no reason, none, for any American to support these obscene omnibus bills that are brought out of committee within days of a vote. "
What I'm trying to say is: Sure our system is messy right now. And yes, it needs substantial reform.
But there are currently loads of low hanging fruit that could be introduced and would eventually benefit both single and multi-payer health reimbursement systems. Massive efficiencies could be gained.
And more people could be insured...
And, at the worst, we'd delay a few years on massive overhaul and instead have LESS change to integrate all at once when that comes.
But let me ask a clear question: What other system so messed up would we consider essentially scrapping and re-inventing instead of trying to improve all the messed up areas?
To give an analogy: We accept that our school districts on the whole graduate less and provide a lower standard of education than we would like. Do we have a bill being worked on that would establish a new school system that promises government efficiencies and standards to improve child education and graduation rates while simultaneously ensuring that there were far fewer options available for those children?
To quote Reagan, "Government is not the solution to our problem. Government is the problem"
Everywhere we look at healthcare inefficiencies and problems, what are we seeing? They are substantially problems in regulatory and governmental mandates. The market problems we see are put into place by governmental (by state and federal) dictate.
We aren't seeing a failure of market, we're already seeing a failure of government.
MFer....lost a nice long comment I typed in reply.
Unfortunately, here's the summary without the context:
In most cases when we identify a problem with our current healthcare system, we trace it's roots to government regulation and intervention. Both state and federal.
And yet we are looking to government for the solution.
We are not facing a crisis in free-market healthcare. We are facing a crisis in how the government has managed the healthcare system.
The current solution is to remove governmental roadblocks and let the system benefit. Furthermore, huge problems we face today could be dealt with by the healthcare system, benefitted, and then if massive problems persist in a few years the changes would benefit a single or multi-payer system.
The benefits of this are obvious on several fronts:
1. It's far easier to pass 10 reforms to the healthcare system (i.e. tort reform, removing blocks to cross-state insurance options) and get them instituted now, rather than trying to overhaul the whole system.
2. The economy currently needs a great deal of stability and constantcy, rather than a re-making of 15-20% of GDP.
Doh, nevermind, now my post appears....naturally....
Part of what I find so frustrating about this "debate" about health care is the way the political types want to simplify if down to sound bites and end up saying nothing of interest.
What we call "health care" should probably be divided into at least four separate, but interrelated categories:
#1: Acute care- This would be things like chest pain, difficulty breathing, high fever, vomiting, bleeding. Maybe life-threatening, maybe not, but definitely urgent. Libertarians are on dope when they suggest that the market can handle this. People who are acutely ill are not in a position to shop around and negotiate and as a society we are not willing to let these people die in the streets. Therefore we need access to emergency rooms and urgent care facilities 24-7. People aren't willing to pay for this voluntarily and know they don't have to (at least up front), so we need some system to involuntarily extract money from those who are able to pay and subsidies for those who aren't, and third party intermediation to make sure the providers aren't getting fat at the trough. A valid job for government, or maybe a government mandate and well regulated insurance providers. Expensive, but necessary.
2. Chronic care: High blood pressure, diabetes, HIV, etc. etc. Important, potentially life threatening stuff, but more amenable to shopping around. Good place for health savings accounts, high copay insurance, etc. Probably still need some kind of mandates so that people get minimal coverage. Should probably also be cost incentives and penalties to encourage healthy lifestyles and discourage overuse.
3. Wellness care: Routine checkups, screenings, etc. Important in terms of prevention and keeping costs down, but don't really lend themselves to insurance, because they are costs that everyone is going to incur. HMO model works well here, with some kind of budget billing to spread out the costs predictably. Also a good place for libertarian style shopping around. Government's job? Making sure people know what they're getting and get what they're paying for.
4. Lifestyle improvement: Stuff like tummy tucks, cosmetic surgury, erectile disfunction, therapudic massage, in-vitro fertilization, birth control. Stuff that doctors do that make your life better but which aren't really necessary to keep you alive. This is stuff that should be paid out of pocket with no low income subsidy.
In general, I think government should restrict itself to providing a minimal standard of #1, #2 and maybe #3 to the poor and regulating everything else as a neutral umpire. Insurance/HMOs should be bought by individuals with their own money (maybe with a government mandate for minimal -- that means minimal, not politically favored -- coverage). Let people do their own cost control
Is health care expensive? Yes. Will it continue to be? Yes. Can we guarantee that everyone gets everything they want whenever they want it and someone else will pay? Not in this universe. Can we make the system better by reducing waste and increasing freedom? Probably. Can we/Should we make sure everyone has the basic health care they need to live? Definitely. Will the Obama plan fix things? I sincerely doubt it.
Bravo Megan, again. I've been reading a book by James Humes who shares alot of anecdotes and sayings of founding fathers & Churchill. And the amazing thing that is so constant is that these brilliant men, who spent a good portion of their lives building and protecting democratic governance, were so clearly against the growth of power of centralized government unless as a last resort. They felt that history taught them better at every turn, and that they had seen the evils of centralized planning.
Somewhere along the line Americans stopped fighting so vehemently against this concept and have begun giving in for each thing in their lives they want better. Or at least, they turn away from "This will no longer be a personal choice" and turn towards "Here's your choice".
I have no problem with federal government, as long as federal government is acting to enable me and my future generations to have more choices. Any bill that works against that premise is, yes this is over-used, anti-american. It quite literally goes against the foundations of our nation.
We are seeing this mindset though in education, healthcare, and many other arenas. And it only seems to have been growing for the last ~20 years.
Just my .02
Joe
"I have no problem with federal government, as long as federal government is acting to enable me and my future generations to have more choices. Any bill that works against that premise is, yes this is over-used, anti-american. It quite literally goes against the foundations of our nation."
What a ridiculous statement. The foundations of our nation itself was a set of laws overriding what states could do on their own; to reduce the choices regional subsets of people had in the interests of a shared greater prosperity. You and your future generations were told you couldn't choose to have slaves anymore. That you couldn't choose to marry eight wives. That you couldn't choose to keep 100% of your money and enjoy the military and other protections given by a national government. To call those anti-American is the very essence of hyperbole.
And I'd love to see you explain what creating a new public option for health insurance would do in terms of choices to the tens of millions of Americans stuck in their jobs because they would lose their insurance if they left. Or the choices of anyone wanting to start a small business but afraid of losing their insurance. The whole premise of this reform is based on choice, because right now much of the country has had their choices taken away by insurance companies.
Adam -
I find your analysis of what I said to reflect poor reading comprehension or a rush to judgment. Since I know you are pretty bright, I figure it's the latter.
To look at your examples: The act of emancipation was one of giving more people more choices, not reducing choices.
The national military systems are about national defense and are not a reduction in choices or freedoms in and of themselves (though they can grow to be).
Federal statutes of marriage involve the rights behind legal marriage. I can sleep and live with 8 women all I want. I can't have certain legal rights and protections for each. Again, not a reduction of choice.
Your statement, "I'd love to see you explain what creating a new public option for health insurance would do in terms of choices to the tens of millions of Americans stuck in their jobs because they would lose their insurance if they left"
That is yet another poor rush to judgement and really strong hyperbole on your part. I have stated previously in many threads that I am a huge proponent in providing either a national major medical care option (free of charge) or some ultra-low cost continuation of care product for them during a transition period (say, 2-weeks free during job transitions or a low-cost option matching unemployment status).
But seriously, 10s of millions of people are stuck in their job because they'd lose their insurance if they left? Yeah, they'd also lose their income if they left. And maybe their house soon after.
Are you saying that 10s of millions won't leave because they wouldn't have health insurance? Or that they want to leave their job without having another job lined up? I don't really understand where these 10sof millions are coming from, but I do understand the fear during transitional periods.
Lastly, "The whole premise of this reform is based on choice, because right now much of the country has had their choices taken away by insurance companies."
What? Huh? First off, how are insurance companies taking away our choices? Second, if they are large enough to be taking away choices, they wouldn't they be broken up by anti-trust laws?
This reform is based upon(in reality) a substantial, permanent, and growing new taxation. Let me be clear: there are good reasons for taxation, but each new growth in tax is a reduction in personal freedom. Your productivity produces that much less. Less resources means less choices.
Further, a government choice available to the whole population should and is predicted to eliminate private insurers and re-imbursers. This is a reduction in choice for individuals.
I wholeheartedly agree that insurance and healthcare should not be tied to employment. Why is it currently? Because of two reasons:
1. Tax breaks.
2. People found that by creating groups to insure, they could gain benefits.
If you remove #1, you'll start removing the tie-in with employment and provide people more personal options.
Not if you just switch it from employer-based to government-based.
Joe, I'm wondering how people have come to want the government to solve all their problems. I think there's two major forces at work:
1. Before government became the almighty savior, what did people used to do when they had problems? They pulled together as family and community. But half our families are fractured through divorce, some families start out struggling as never married single mom low income families, our increasingly mobile society means we move and don't know our neighbors (like Lucia Whalen not knowing her neighbor Skip Gates) and we're so far from our families, that extended support network has broken down. Decline in religious belief and practice means a lot of people aren't even connected to a faith community who can rally round and help them out. So government becomes more important as the helper and problem solver, as a replacement for the family, church, and community.
2. Politicians and their pork. Politicians know they have to get photo-oppable gold shovel projects in their communities to show the constituents that they're doing something for them. It's easier to get a bridge built than it is to do the unglamorous work of maintaining it, as the collapsing I-35 bridge in Minnesota so vividly demonstrates. Or the levees in NOLA. So those stories make our local papers and we cheer and show up for the free food and networking at the reception sponsored by the Chamber of Commerce. And it celebrates the government being Santa Claus and problem solver and rescuer. Pork becomes our lifeblood. When you have pork for blood, eventually you're going to have a fatal heart attack.
Diamond ranches? Pffft. You're getting taken. We're using the mulch we get from liquidating poor people to finance our fur-bearing trout farms. *That* is where the Real Money (TM) is at!
Soylent Green is people! But nutritional, high quality protein, low-fat, no artificial ingredients, not GMO, contains no Bovine Growth Hormone and is more earth friendly than cremation, burial, or using the liquidated mulch for trout or diamond ranches. We're ready to go into production, and taste tests show that consumers prefer us to fur-bearing trout. Obama is on board.
Beyond that quibble... Great post.
I think there is still a pressing need to establish a baseline of care that everyone is assured they will have (like not being left for dead if you have a freak heart attack). The current system provides this fairly well on the front, but the financing side is a series of distortions that doesn't work to anyone's advantage.
The political system is quite capable of arguing about what that baseline should be, and coming up with an answer that is either too low or too high (Social Security benefits an example of the latter). However, I don't understand how a formally provisioned baseline eliminates the market for treatments that are beyond that baseline.
Is there something about the proposed legislation that will prohibit insurance companies from charging more for plans that would cover more of these high-end treatments than the government is willing to cover? Or are we assuming that all Americans will wish to purchase only the cheapest option?
Hey Tim,
I can name 3 places within 50 miles that would treat me for severe injury and not bill me (as long as I presented no ID and pretended to speak another language).
I mean, someone would pay, but not me.
Btw, can you point me to a copy of the latest version of the legislation? The last one I saw was about 10 committees ago.
Joe
Right, as I said in another thread -- assuming that you don't have insurance, if you experienced a major health problem you would essentially demand a bailout, and get it. The rest of us pay for your bailout in various ways, but that's not the way to design a sane system.
Either we have to stop the bailouts or insure everyone.
Absolutely right. I don't get that logic. "Well, I prefer to provide a huge subsidy to people with no insurance by treating their ill at great cost and inefficiency." If you're going to do it ANYWAY, you might as well get the healthy uninsured on board. At least then you'd be subsidizing cost.
Do you think that our politicians would be capable of holding the line on baseline care? To me whatever affliction is currently at the top of the list for most sympathetic in the press our politicians are completely incapable of saying no because they really don't have any incentive to keep the cost down.
Honestly I don't think they would. I suspect in the US a whole bunch of treatments would be covered that arguably were not worth the cost.
Megan, however, is arguing the opposite.
At the state level, politicians haven't been able to hold the line. Look at the various state mandates. See, e.g. here.
what's the alternative to increasing the government's role in the provision of healthcare?
Just as a start we could say that anyone who files a 1040 with a AGI above $60k has to submit proof of insurance.
Why? Why force people to self-insure?
Why? Why force people to self-insure?
Even if you're healthy one accident is all that stands between you and a $250K+ health insurance bill that will be completely borne by others. Since we don't refuse emergency treatment for individuals, then they need to be financially responsible for the amount. One of the reasons the healthy can get away with having no insurance is because emergency health care will be given even if they can't pay.
It's the same argument for mandating car insurance. You may cause somebody else damage, so you need to prove you'll be able to be financially responsible if it happens.
Exactly right. If you're not going to make people have either insurance or the ability to self-fund emergency expenses, then you need to stop giving them emergency care. Because the costs for that end up being passed on to the rest of us through higher premiums.
And I don't know all that many libertarians that would seriously argue that hospitals should be turning away dying people because they can't afford the expensive treatment. If you want to make an argument for that, I'd love to hear it.
Of course, the best solution would be to give people cheap preventative care, so that they don't end up letting their health problems get worse and worse until they end up in the emergency room at a much greater cost than it would have been to fix it in the first place. You know, the way every other country does.
Not really, I don't have the option to walk when it's a mandate.
Are you suggesting 250k uninsured accidents are common enough to mandate the insurance purchase, then? That the uninsured are using emergency rooms as their PPO's is one thing -- and a preventable one (You aren't bleeding out? Come to our clinic, open on Monday). But car accidents are not the cost driver here.
250k uninsured emergency room trips aren't all that common, no. But they do happen, and while perhaps not the major cost driver are certainly a significant one. The big issue isn't car crashes; it's emergency room trips for stuff that could have easily been prevented or treated earlier for a small fraction of the cost. People who don't see doctors until they're very ill end up costing far more to treat, costs which are passed on to us. So yes, as long as we're on the hook for emergency treatment I'd like to see some mandated responsibility to try to make that as rare an occasion as possible.
Byrk
The whole point of insurance is that it spreads the costs among a higher group of people in the pool. If insurance is mandatory, the pool includes everyone, and the costs of a 250K accident are still born by everyone, just like they are now.
Adam:
Even if you require everyone to buy insurance, you cannot force people to go to the doctor.
It is very popular to argue that primary care would prevent expensive ER visits, but there's a real dearth of evidence that it's so. People come to the ER with all sorts of trivial complaints that could be seen in a clinic, but mostly they're just abusing the system. People come in with issues that have been bothering them for weeks on end. People come in with toothaches (and no, not big abscesses). People come in because at 3 AM it's the only place open to potentially give you a work excuse. They don't come in for preventative care, and when they get established with preventative care they so rarely take the treatment given.
It's also worth noting that, under EMTALA, patients cannot be sent home from an ER until evaluated by a physician - a nurse cannot tell them that their cold (e.g.) can wait until the next morning. The amount of work required to declare them not an emergency and send them home is almost as much as is required to treat them.
If health insurance were risk management instead of also a healthcare payment system you'd have an argument. As it is you're simply demanding those who subsidize others participate for those others benefit.
Tree,
Because the poltical will doesn't exist to let those who chose not to buy insurance suffer and die.
Personally if a 25yo wants to spend $350 a month on a Ducati rather than insurance and he takes a spill - I have no problem letting him bleed out. But the reality is, he will be treated, declare bankruptcy, be back on his feet in 10 years, and the rest of us will be left to pick up the tab.
If the will doesn't exist to allow those who choose to self-insure die - they must be compelled to buy insurance. It's just a poltical reality.
Again, if the 25yo does buy insurance, he would have paid a very small amount of money into the pool. So the cost of his spill are split among everyone else in the insurance pool. Since you want insurance to be mandatory, the pool includes everyone. So the rest of us still get to pick up the tab
Ken,
But the vast majority of those who make 50k+ and unisured are healthy and are very unlikely to make claims. What we want is for them to be stuck paying $500 a month for 30 or 40 years(like the rest of us) before they start making any significant claims.
Jmo:
I believe there are already incentives to do just that. It is much cheaper to buy a plan when one is young and keep it for a long time, than it is to buy a plan late in life.
But what you are basically saying is that you want people to save for their health care (or the health care of their pool) from an early age. Fine, I'm OK with that, but drop ducati argument.
But the vast majority of those who make 50k+ and unisured are healthy and are very unlikely to make claims.
Because they know the most likely claim is some type of emergency that will be covered 100% even if they don't have insurance. Why buy even emergency insurance when you can just free load? It's the same reasoning behind mandated car insurance.
Byrk:
The wisdom behind mandatory liability car insurance is that your insurance will pay for the other persons vehicle you damage. It will not cover your vehicle.
This would be the equivalent of requiring people to carry insurance that will cover the cost of treating those they infect, but not themselves. Which is a proposal I have not yet heard.
Here's the problem to me. Currently government covers 15% of the population and has been so unwilling to control costs for that 15% that by the democrats own admission it is going to bankrupt our country. Now we are supposed to expand that coverage and expect our politicians to care more about controlling costs when there are more voters who have a vested interest in getting more coverage for less money out of their pockets? I do not see any chance at all that our political system will be able to control costs in that situation. Voters would want to see more covered, doctors and pharma would want more spent on healthcare, politicians want to see voters and special interests happy. I do not think that our political system is capable of doing this in a way that makes any long term sense.
This is depressingly typical of the rhetoric I hear, and while I applaud you for explaining it as thoroughly as possible I remain more convinced than ever you're utterly, completely wrong on this issue. Here's the key line for me:
"Once the government gets into the business of providing our health care, the government gets into the business of deciding whose life matters, and how much."
That may be true. Keep in mind of course that this applies primarily against the UK-style plan you've used as your strawman for much of your post, and single-payer to a lesser extent. No plan remotely like that is being considered here. That's why it's the public *option* (and who knows if that'll even make it through). But I digress.
Presumably you mean to invoke with this line the unspoken comparison between a government making these decisions and you making these decisions. Libertarians typically do this, and often conflate the argument while doing so. It's the key failure in the argument, because you aren't making the decision in the status quo.
The "business of deciding whose life matters, and how much" is made by private, for-profit insurance companies, not by you. Corporations that pay a great deal of money to a lot of very smart people for the sole purpose of finding every way possible to provide you with the least amount of health care possible. Every dollar they save in the health care they don't provide is a dollar of profit. You're a strong free-market advocate; you know exactly how unfettered capitalism works. The only choice is who you want making decisions about your life: people who at least marginally have your best interests at heart, or people who are solely concerned with making as much money as possible off you.
And yet the only part of your magnum opus about health care that even *mentions* insurance companies is the anecdote where you, an already committed libertarian formerly known as Jane Galt who suffered from some minor health issues while uninsured, remained unconvinced through that no doubt harrowing experience. And then you proceed to spend many more words than that on the problems suffered by the very rich and well-insured who might not get the very latest cancer treatment or an extra month of life at enormous cost.
This is, of course, a relevant point. But like most products the very best cost significantly more than the next best. We see in many areas twice the cost for something that's maybe 5% better. So the question then is whether we are better off as a society to ensure that everyone gets a treatment that while maybe not the very top of the line is still effective, or whether the priviledged few get the very best regardless of cost while tens of millions make do with little or virtually nothing. It is indefensible to argue that we would not be. You can say only that it is not appropriate for the government to take steps to make this so in the face of the utter failure of the free market to do so when given decades of opportunities. And here, I'm afraid we face a fundamental difference that ultimately ends every argument.
is made by private, for-profit insurance companies
40% of health insurance companies are non-profit.
The way that private companies make more money is by providing quality, timely care.
A privatized industry is more likely to have lower costs for better quality services. Laser eye surgery started out pretty expensive, but soon enough it'll be a cheaper option than buying and replacing contacts, glasses and monocles.
No, this is not remotely true. The way private insurance companies make money is by gaining a huge share of the business in a state, becoming the sole option of insurance for most of that state's employees, and then constantly raising premiums and denying claims knowing that the employees have few options.
As for "privatized industry is more likely to have lower costs for better quality services", this is blatantly proven incorrect simply by looking at the relative costs for *every other modern country* compared to ours. Some spend half as much for roughly the same level of care. All spend noticably less.
And laser eye surgery, of course, was virtually never covered by insurance companies. Its price went down because it was deemed too expensive to cover and too expensive to afford outside of insurance. Similar logic would apply in spades to any public option with large bargaining power. There's no quicker way to bring down the costs of procedures than for the government to refuse to cover them, which is why the health care industry is fighting so hard to deny a public option bargaining power. Now why would they want to do that?
The way private insurance companies make money is by gaining a huge share of the business in a state, becoming the sole option of insurance for most of that state's employees
How does a private company do that? By price dumping and hostile takeovers of the competition? Or by getting control of the state's regulatory powers and rewriting the rules in its own favor? I vote for the latter.
As to cost efficiency of the state-provided medical care, or insurance, or whatnot... I pay for my medical insurance and/or care. Not the government. Knowing the income levels and taxation levels in some of those "other modern countries" pretty damn well I am not at all convinced that this change will save money for me.
What is this "we" thing that keeps getting mentioned in this discussion?
>was deemed too expensive to cover and too expensive to afford outside of insurance. Similar logic would apply in spades to any public option with large bargaining power.
Utter nonsense. You are talking about government here. Please tell us a situation where government procurement has brought about astounding innovation and cutting of costs.
Derek
Adam,
For someone so adamantly against insurance companies, you sure seem ignorant of their global (and not individual) practices.
For one thing, insurance companies operate on a rather small profit margin. Here's the finances for Aetna: http://finance.yahoo.com/q/ks?s=AET
Here's UnitedHealth Group: http://finance.yahoo.com/q/ks?s=UNH
Notice that both of them operate between a 4-5% profit margin.
As others have pointed out, a health insurance company cannot become the sole option in a state unless the state regulates them into place. And anti-trust laws were born for these reasons, but are not being exercised....two failures of government.
By the way, you confuse two statistical measures in this statement, "Some spend half as much for roughly the same level of care. "
No, they spend half as much per capita for the same OUTCOMES. Level of care is not an outcome, and there are boatloads of problems with those statistics anyway.
By the way, the health care industry is not fighting the public option nearly as much as think, insofar as the large businesses are concerned. The main people fighting it are the organizations representing individual providers.
I guess the question is: Since all these other countries seem to be getting the same "outcomes" for 1/2 as much, what exactly is being proposed that would cut the cost of health spending in 1/2 per capita?
The CBO doesn't know. Nor does anyone else.
But somehow we have people like yourself saying that this legislation is going to do it. Somehow.
There's no quicker way to bring down the costs of procedures than for the government to refuse to cover them, which is why the health care industry is fighting so hard to deny a public option bargaining power.
1) Nationalize health care.
2) Cover nothing.
3) Profit!
"As for "privatized industry is more likely to have lower costs for better quality services", this is blatantly proven incorrect simply by looking at the relative costs for *every other modern country* compared to ours. Some spend half as much for roughly the same level of care. All spend noticably less."
This is simply incorrect. Other countries spend less to deliver worse care. Virigina Postrel has written about unavailability of herceptin in New Zealand, for example.
In general, US cancer survival rates are better than Europe or Canada.
No, this is not remotely true. The way private insurance companies make money is by gaining a huge share of the business in a state, becoming the sole option of insurance for most of that state's employees, and then constantly raising premiums and denying claims knowing that the employees have few options.
And yet the federal institutionalizing of such a system will to pave the way to the land of milk and honey?
And laser eye surgery, of course, was virtually never covered by insurance companies. Its price went down because it was deemed too expensive to cover and too expensive to afford outside of insurance.
What you are saying is that when first-hand bargaining arises between buyer and seller markets are made and prices fall!!??
When you get the third party adminstrators out of the way?
Hey, maybe we should try more with that!
Milton Friemdan pointed out that the same thing happened with dentistry, by twist of history it was left out of all the initial federal medical programs and regulations, and enjoyed far higher level of productivity gains, cost control and customer price satisfaction than did the "covered" areas of medicine.
BTW, laser eye surgery wasn't omitted from most insurance plans because it was "expensive" -- lots and lots of covered procedures are far more expensive than it is, and the insurers get it all back plus more in the premiums that make them so rich! You know that.
Insurance companies have a contract called a certificate of coverage that explains your policy and what's covered. You have rights under this certificate. If the insurance company does not live up to their end of the contract, you can sue them. They aren't trying to deny all participants all treatments and all tests all the time--they'll trigger a bunch of expensive law suits and have the state insurance regulators and the state legislators breathing down their necks.
The slander against insurance companies is often ignorantly made by people clueless about actuarial science.
Some comments aimed at the replies to this...
1) In fact, roughly 15 states have essential health insurance monopolies, or near monopolies.
In North Dakota, excluding governmental programs such as Medicare, 90% of those with private health insurace are covered by BCBS North Dakota.
In Arkansas, it's 75% covered by BCBS Arkansas.
In Nebraska, its almost 50% covered by BCBS Nebraska.
The US Treasury defines any market where 42% or more is controlled by one company to be "constrained". When you hit 90%, you're talking a true monopoly.
2) Derek - the VA Healthcare system. For decades it was considered a horrible organization, providing horrible care (check out the 1992 film "Article 99" for the public perception of the VA).
In 1993, Bill Clinton made improving VA care a priority. He got Congress to dramatically increase the VA's budget, but more importantly he put people in charge who knew how to actually run such an organization.
Over the next six years, they totally rehabilitated the VA. Along the way, they came up with centralized and computerized records systems, use of tablet PCs by doctors, software that checks prescriptions for patient contraindications, and on and on. In fact, today, the open-source software system the VA invented is now being used in dozens of major medical centers nationwide with great results (savings in the millions per year, thousands less errors in medical care).
Result? In 1999 and 2000, the non-profit and non-partisan private organization NCQA awarded the VA Healthcare system their "Best Healthcare System In The U.S." award back to back, beating out the likes of the Mayo Clinic, Cleveland Medical, Brigham & Womans, UCLA Medical...
Oh, and recent polls find that while its true that about 70-75% of people with private insurance are satisfied with their coverage, amongst those under VA care that percentage is over 85-90%!
LASIK and cosmetic surgery--not covered by insurance--are the only areas where costs are coming down (besides expiring patents causing drugs to go generic). Great argument for free market solutions!
Wrong.
Check out this from Paul Krugman (Nobel prize winning economist).
Important to note:
Well, if a comprehensive government controlled and subsidized program is not your goal, then you and I don't disagree. But it is your goal, and this public option is being fairly explicitly touted by, like, every liberal I know as the way to get the camel's nose under the tent, so there you are: we do disagree.
"Once the government gets into the business of providing our health care, the government gets into the business of deciding whose life matters, and how much."
That may be true. Keep in mind of course that this applies primarily against the UK-style plan you've used as your strawman for much of your post, and single-payer to a lesser extent. No plan remotely like that is being considered here.
No plan like that was remotely considered in the UK when their plan started, and they promised it never would be when selling it.
Capitation was never considered in the Mass plan, way, way, back when it started. Look at it now.
The point is, once the politicians start making the decisions, then the politicians are making the decisions, for whatever political reasons are best for them. Their former promises don't bind them by contract.
The progress of the Mass plan in three easy steps:
1) "Greedy insurers are looking for reasons to deny people care, just to save money! This is outrageous! We need a govt plan to assure everyone gets all the care they need!"
2) The govt plan is enacted -- costs explode beyond all projections.
3) To cut costs the govt plan adopts capitation, a fixed amount of spending per individual. Now providers are forced by the govt to find reasons to look for reasons to deny care just to save money. "That's good! Costs are finally under control. See, we told you a government plan was the key to that!"
No plan remotely like that is being considered here.
Of course, that doesn't matter, because five years from now the politicians will do with the plan what they are considering then.
But I bet you don't even know what Obama's people are considering now.
For instance, here's what one of his very top health care advisors, Ezekiel Emanuel (Rahm's brother) is considering right now, about triaging the old and seriosly ill out of care that would be, well, let's admit it, wasted on them.
Hey, they are considering some pretty "radical" thoughts already!That's just frightening. At the risk of triggering Godwin's law, the Nazi regime started by going after the ill, disabled, retarded, etc. Which is probably why German health care costs are lower now...because of the purge of the unfit half a century ago. I can't believe a Jew would endorse such a thing. Traitor.
How preposterously shrill.
You're a strong free-market advocate; you know exactly how unfettered capitalism works.
Ha! The idea that "unfettered capitalism" exists anywhere today in our regulated-to-the-gills health care system is my laugh of the day!
Here's what actually happens when "unfettered capitalism" dares poke its head up even for a moment -- chop, off it comes!
Example: Here in New York a doctor came up with plan offering basic health care services for a flat rate of $79 per month in offices across the city.
The government put him out of business immediately. It said flat rate fees for service are a form of insurance making him an illegal, unregulated insurer, charging anti-competively low rate.
Yes, they forced him to increase what he charged!
~~~ quote ~~~
"If they leave me alone, I can serve thousands of patients," he said.
The state believes his plan runs afoul of the law because it promises to cover unplanned procedures - like treating a sudden ear infection - under a fixed rate. That's something only a licensed insurance company can do.
"The law is strict on how insurance is defined," said an Insurance Department spokesman.
~~~
So if you ever get yourself a flat rate for service from the phone company, remember you are buying insurance!
Corporations that pay a great deal of money to a lot of very smart people for the sole purpose of finding every way possible to provide you with the least amount of health care possible. Every dollar they save in the health care they don't provide is a dollar of profit ...
Surely all true, but you understate the ill of the situation! Things really are much worse, health care is the least of it!
Think about it: The typical person can go for decades without seriously needing medical care -- heck, the human race survived hundreds of thousands of years without any of what we'd call medical care.
But without shelter, clothing, food, anybody will be **dead** in just days. All provided by corporations that care only about their own profits. Every dollar they saving on providing the basic necessities of life itself goes straight into their profits -- and they don't care at all whether you live or die!
Babies! The corporations profiteer from providing milk to babies!!
What chance does a mother have at gaining milk at a decent price for her baby, when up against all the powerful corporate interests -- mega-farmers, trucking and railroad corporations, the giganta-mart supermarkets, all of whom care only about their own profits and not a whit about the welfare of her baby?
There must be a better way! Single-payer government agencies providing food, clothing and housing? After all, isn't better to be provided the basic necessities of life by a government that at least marginally cares whether you live or die?
(Haven't some nations tried this?)
The only choice is who you want making decisions about your life: people who at least marginally have your best interests at heart, or people who are solely concerned with making as much money as possible off you.
Um, you are very cynical about motives in the private sector yet a dreamy idealist about politicians.
Really, what makes you think a politician would even marginally have your interests at heart if she could improve her chances for re-election and fill he campaign coffers by selling your health care down the river?
Politicians never arrange for themselves to profit at the cost of the citizenry, right? Doesn't happen, right? ;-)
If politicians fuck up healthcare they're unlikely to be re-elected.
How is that? Legislatures are infamous for dodging responsibility for failures.
Idk if you've heard of them, Bob, but there are these things called "elections".
Holy shit, Megan's responding to her critics with snark and strawmen!
For me, the turning point came when I saw a post on Greg Mankiw's blog that showed health care spending on pets tracking that on people very closely. Then I realized that if I could simply feed uninsured people with expensive diseases to my cat, it would solve two problems at once.
For me, the turning point came when I saw a post on Greg Mankiw's blog that showed health care spending on pets tracking that on people very closely.
Except that the number of pets has increased faster than the number of people.
That observation does not invalidate the point at all. Pets are not foisted on people at gunpoint, or brought by the stork. They are purchases as a luxury good by people who are prepared to pay their vet bills, and do so. Fortunately, a larger pet population enables a more efficient absorption of the uninsured.
Poor people get pets too, and can't afford to pay big vet bills. What do they do if their pet gets sick and they can't afford to foot a big vet bill? They dump them at the side of the road to die.
The ancients did the same with old people and sick babies.
And let it be an object lesson--when the government can't afford to pay your "vet bill," they'll dump you at the side of the road to die.
I would concur with Adam, the government is in the business of providing healthcare, Medicare accounts for 47% percent of healthcare spending, private insurance is roughly 35% of current spending. The remainder is either paid for out of pocket or is paid by other government agencies and charities covering the cost of emergency room care etc.
In the financial crisis we let private corporations create ad-hoc fiscal policy. So now for health care we are allowing the same? What better care or coverage is provided by this? What better standards of health are achieved. Doctors are rewarded based on specialty and their ability to negotiate the reimbursement maze.
I don't want the best healthcare, I just want good healthcare for my wife, my son and myself. What is the best healthcare anyway? How does one define it?
Government can and does provide excellent service. We need to break free of the Reagan inspired rhetoric and acknowledge that government can provide effective services.
Why must we be the slaves to the capitalist whims of the few? Why must the profit motive drive everything? What does this say about us as a people when so few no the true facts about such a critical debate? Oh woe is us.
Oh render unto me a freakin' break. Government does NOT have a history of providing effective services. Rather, like most monopolists, its service is rather shoddy and ineffective. Who prefers the post office to UPS or Fedex? Public education over private education? And then there is the little problem that the government consistently manages to lose money on pretty much everything, with Medicare facing a particularly acute fiscal crunch.
The profit motive works because people want to be compensated for their effort. Everytime we abandon this reality, such as with communism, we meet with disaster.
Who prefers rent-a-cops to government police? Who prefers Blackwater and Halliburton to the Army? Do we have any private firefighters? Is there a private competitor to FEMA? When Bush eviscerated it, we saw what happened. Even Megan makes the point that the NIH performs a task that private industry can not.
And, of course, when public schools can select their own students and are funded at half the levels of private school, they tend to outperform private schools. The private sector does not always do a good job of controlling costs while providing an effective service. Health care is just one example of an industry that people want to reform because it is run inefficiently by private companies.
FEMA has always been a bad idea. It seemed to work at first because it was coasting on the momentum from Civil Defense.
President Carter disbanded Civil Defense, which organized disaster response at the local level. He thought it made us seem to be preparing to fight a nuclear war. We had various versions of Civil Defense long before we had nuclear weapons.
Civil Defense worked because it was run by your neighbors. It was usually run by retired people. It became their hobby. Sometimes they got above themselves, but you knew who to blame if they didn't do their jobs.
You don't want the best health care for yourself, your wife and children? Well, obviously, you haven't yet had a serious illness or accident to test that commitment. I hope your wife never gets HER2+ breast cancer...chemo should be enough for her, right? Even though Herceptin would save her life and make the chemo actually effective?
You're OK with settling for bandaids and neosporin but they don't cure everything.
Tell your wife your commitment to less-than-the-best health care while celebrating your next anniversary.
Most people would swim through shark invested waters, walk on their lips through broken glass to do everything necessary to get the best care for their seriously ill spouse or child. You don't love them very much, do you?
Anybody remember the time when people used to say "It's a free country" when someone tried to tell them what to do? You never hear that any more. Megan's reasons are excellent, but they're not really aimed at what seems to me to be the most fundamental problem of all. Some years ago, my wife had a problem that called for a neurosurgeon. She asked a friend (a pathologist) who the best neurosurgeon in town was and then consulted that surgeon. Under the proposed health-care reform, no one but the very rich will be able to do that any longer. No one who thinks chiropractors are quacks will be able to buy an insurance policy that doesn't cover chiropractors. No one will be able to buy a high-deductible policy for catastrophic care only, paying cash for the everyday stuff. It is a scandal that a country that sometimes calls itself "the land of the free" is seriously considering these things.
"She asked a friend (a pathologist) who the best neurosurgeon in town was and then consulted that surgeon. Under the proposed health-care reform, no one but the very rich will be able to do that any longer."
None of the proposed health-care reform plans would remotely affect anyone who can currently do this. Which brings me to the larger point: already, nobody but the very rich and those with gold-plated insurance can do this. For the average person, they don't get to pick the best doctor, they get the one their insurance company tells them they get. I'm glad your wife doesn't have insurance like that, but don't extrapolate that to the rest of us.
So no, it's not a free country right now, unless you mean we're free to give our money to corporations and in return have them tell us when and where we can receive our dose of health care, if they deem us worthy of receiving it. I guess that's what the right wing calls freedom these days. Some of us think freedom is more aptly demonstrated by not having to worry about unaffordable health care costs or being uninsured, like the citizens of virtually every other modern country.
For the average person, they don't get to pick the best doctor, they get the one their insurance company tells them they get.
I call BS. In 15 years that I and my family have been living in the US, I can recall one case where the doctor I wanted was not in network (which basically meant I'd have to pay up to deductible instead of copay). The anecdotal statistics from my friends is similar. Of course, 80-90% of the time one either goes to the same doctor, or looks one up in the insurance company's list -- there's no working equivalent of Amazon's customer reviews for medical care.
This is in TX. If your state drove most of the providers and insurers out with regulations, cry me a river.
I'm going to go ahead and take a wild stab that both you, a reader of the Atlantic's economics blogs, and the people you choose to associate with, are well above the average socioeconomic status, most likely with good-paying jobs and excellent insurance plans. Surely you're sufficiently intelligent not to take the anecdotal evidence of people in such a strata and use it to conclude no problem exists. But I guess to do otherwise would be that whole empathy thing you guys don't like.
Gotta agree with you there. Adam is very misinformed.
Examples:
the best solution would be to give people cheap preventative care, so that they don't end up letting their health problems get worse and worse until they end up in the emergency room
The experience in Mass is that when you are able to provide preventitive care costs go up not down. His idea that preventitive care is the key is a myth.
they get the one their insurance company tells them they get.
Huh? That's not how it has worked for me or anyone I know. Most doctors accept most insurances - it's just how the business operates.
Whose evidence do I have to use? Yours? Partisan sources you choose to quote? I'd rather believe my lying eyes.
Partisan sources you choose to quote? I'd rather believe my lying eyes.
Partisan like the NYTimes and Boston Globe? What are your acceptable sources?
The fact that contrary to expectations, providing nearly universal primary care hasn't resulted in fewer ER visits or lower costs isn't being disputed by anyone, as far as I know.
jmo3: we overlapped the posts... I was responding to Adam, not you, and was too lazy to quote.
As to NYTimes -- sure it's partisan! :-)
You can call BS all you want, but that doesn't make your experience typical. I was very happy with my doctor, but for some reason he dropped off my insurance - the insurance company has gobbled up dozens of little ones, so it has no idea how he got on in the first place.
So I found a new doctor. In fact, a whole new practice. But then my company switched insurers because the old plan cost too much. None of the doctors in my practice were on the new insurance. And the insurance company refuses to do the leg work to get them on.
In three years, I've had to switch between three doctors. never my choice. Oh, and my insurance is more expensive than it was before, with half the coverage. Wonderful.
"None of the proposed health-care reform plans would remotely affect anyone who can currently do this. Which brings me to the larger point: already, nobody but the very rich and those with gold-plated insurance can do this. For the average person, they don't get to pick the best doctor, they get the one their insurance company tells them they get. I'm glad your wife doesn't have insurance like that, but don't extrapolate that to the rest of us."
Nonsense upon stilts. Any PPO plan lets you go to any doctor, though you have a larger co-pay if the doctor is not in the network. And PPO plans for employees are common. Even the $50-a-month high-deductible plan I bought my son when he wasn't covered by my employer's plan allowed this. One of the many things that freedom gives people, even middle-income people, is the freedom to pick the kind of insurance plan they'd like from a wide rsnge of options. Congress's plan pretty much kills that off after five years when, as a practical matter, all employer plans will have to have the same coverage as the government plan, and you won't get to pick any doctor except your primary-care physician (and this in the name of "competition"). The health-reform crowd is beginning to rival the gun-control people in the competition for most-dishonest advocacy.
Sure, people who are very poor don't have the same range of choices that those who are better off have. If this is an acceptable argument for restricting the freedom of everybody, then there's no room for freedom.
Real story from Canada:
A woman with mood disorders gets assigned a therapist. Their first session ends with them shouting at each other.
But that's her assigned therapist. She can't change.
Real story from the U.S.:
A middle-aged nurse paid her health insurance premiums faithfully for five years.
She was diagnosed with a particularly aggressive form of breast cancer.
Two weeks later her insurance was canceled. Why? Because she had failed to tell her insurance company of a "pre-existing condition" when she got the insurance! What condition? Acne!
Sure, she could sue.
But, had her Congressman not interceded on her behalf personally, she would have died before her lawyers could have ever gotten into a courtroom (and that assumes she could afford the lawyers).
But the important difference here is, no one is proposing a program anything remotely similar to Canada's, so your story is pointless in this argument, while my story is EXACTLY why we need healthcare reform!
Oh, and when the CEO of her health insurance company was before Congress, and shown tens of thousands of other similar complaints about his firm, he was asked if he would give a verbal promise to stop this process (called recession) for all instances except for true fraud. His simple answer was "No!"
"license it gives elites to wrap their claws around every aspect of everyone's life."
This is exactly right. There is absolutely nothing outside the authority of government once we allow them responsibility for our healthcare.
Which is why Canada, France, and Germany are socialist states with the government having authority in every possible aspect of life?
Give me a break. Your rhetoric doesn't work when there are plenty of successful examples of countries doing exactly what you fear with none of the consequences. And in ten years, when this is enacted, you're going to look really silly.
Who needs to go elsewhere when right here in the US, the government already interferes with (off the top of my head) smoking, drinking, seatbelts, soft drinks, chewing tobacco, saturated fats...
I'd read the current news before you spout off pure nonsense.
Right now, in British Columbia, the government is facing serious declines in revenues. We are at the cusp of the Laffer curve in Canada, have been for years. They can't get anymore revenue out of the citizens. And the economy is shrinking.
So what are they doing right now? Closing hospital beds. Cutting some emergency facilities to walk in clinic status, ie no surgeons. Cutting grants to nurse education. Cutting surgical room schedules; putting off 'elective' surgery. The system has been growing 7-8% per year up here, and now they are cutting funding levels.
This is a system that has multi year waits for some procedures, and anything that you won't keel over dead with in the next day or two waits for 4-6 months.
They are cutting much more in other government operations. They don't mow the grass along the highways anymore. They cut the grass around the highway signs.
There is a very simple reason for this. Voters and taxpayers are typically healthy. Sick and dying people don't pay taxes or vote in as large numbers. So the government serves it's constituency. And no one believes anymore that paying more money to the government will improve things. It hasn't and it won't.
So tell me honestly. You folks in the US are facing an enormous deficit. The economy isn't turning around yet, and may not before the end of the year. The best estimates are a few more years of low growth. At one point Congress is going to try to cut the deficit. They will try raising taxes and see quickly that they get less money. So inevitably they are going to start cutting program spending.
Are you willing to hand over the US health care system to the inevitable serious and deep funding shortfalls that are going to be the reality in the next few years?
Derek
Are you willing to hand over the US health care system to the inevitable serious and deep funding shortfalls that are going to be the reality in the next few years?
I'm not sure what your argument is, as we already hand over a significant portion of our population to Medicare which will be facing the same problems. Who here is advocating a UK/Canada style system anyways?
Replying to Byrk:
This must be a new talking point. Other than Medicare the government isn't going to pay for any health care now? Is that what you are saying? And what, monies collected will not be called taxes, but be some 'Public Plan Insurance Fee'? We have something like that here already.
Derek
Oh Derek, how I miss those small Tory minds after a decade in the US...You must be the only Canadian who would reference the Laffer curve...Isn't "carbon tax" vs "cap and trade" the big issue in BC these days?
Derek, believe it or not there are lengtht wait in the US for healthcare too. My cousin needed disk surgery a couple years ago. Total elapsed time between diagnosis and surgery: six months. The last two months she was bedridden and in terrible pain (or well-doped up). Luckily her job offered 90 days medical leave benefits during which her health insurance continued, a concern Canadians do not have.
And yes, most people are healthy, but people are not isolated monads. Many healthy people do have relatives who are not. So the pool of voters who have a personal interest in the healthcare system is much larger than just the population that us chronically ill.
And if Canada's system is so dreadful, why is it so popular? Yes, people there kvetch about the details, but everything I've seen about Canada shows that support for radical change in healthcare is in the low single digits.
Spoken like someone who actually HAS comprehensive medical insurance, and HASN'T experienced the reality that millions of us face. Blathering about "choice" is simply propaganda, no matter what shade of lipstick is on that pig. As stated by other posters, ONLY the very wealthy can afford to exercise their "choices" when it comes to medical care. The net outcome of your carefully crafted nonsense is that you WOULD condemn those without the good fortune to be insured, to whatever fate awaits them. You are simply shilling for an industry, whose economic model you don't actually understand.
Spoken like someone who actually HAS comprehensive medical insurance, and HASN'T experienced the reality that millions of us face.
Read the post closer. I quote:
"At this juncture in the conversation, someone almost always breaks in and says, "Why don't you tell that to an uninsured person?" I have. Specifically, I told it to me. I was uninsured for more than two years after grad school, with an autoimmune disease and asthma. I was, if anything, even more militant than I am now about government takeover of insurance."
Megan grew up on the Upper East Side and went to Penn and the University of Chicago. She may have been uninsured, but she has wealthy parents and personal savings. I thought Megan's whole point (on many occasions) was that the wealthy East Coast elites who attend private schools can't understand what the rest of us face? Do you know anyone else who's uninsured who thinks Medicare, Medicaid and the VA are bad ideas?
That post has more errors than sentences.
So you've attended a public school? You didn't grow up on the Upper East Side? Your parents aren't wealthy compared to the average America? Did your supposed lack of funds keep you from going to the doctor? You think "East Coast Elites" do understand the rest of America?
The majority of the population DOES have comprehensive medical insurance. I dunno who's those "us" y'all keep talking about.
ONLY the very wealthy can afford to exercise their "choices"
And that's where you're wrong. The average middle class, tax paying voter has pleanty of choise and is happy with the choices of hopitals and doctors they have available.
You're not going to convince anyone by making statments that conflict with the experiences of the vast majority of people.
making statments that conflict with the experiences of the vast majority of people
Exactly. Who are we going to believe, Obamen [sic] or our lying eyes?
80% of Americans are satisfied with their health care insurance plan, including some uninsured! (Probably young and healthy and using their meager early career earnings for other things.)
I'm not sure government dependents should have all the choices that people who pay their own way in life do. After all, those of us who pay taxes and/or health insurance premiums are subsidizing the dependents at least twice over. We deserve choices for paying more than our fair share.
The elderly are also wasting a lot of our hard earned money with their stupid "last six months" end-of-life care. Eliminating this waste is almost entirely the concern of men under 45 or 50, and women under 25.
What do you propose we do about end-of-life care? It accounts for a wildly disproportionate share of health care spending, although it's hard to find reliable statistics, and more to the point it accomplishes very little.
Let them spend their own money.
You get all sorts of problems trying to ensure a positive right.
My question would be this: how often is it that the decision to prolong a life for a few months through expensive procedures is made by family members acting on behalf of an incapacitated patient? How many terminally ill patients are awake and aware and tell a doctor to prolong their life for 3 more months of hospital stay? The answers to those questions would clarify things a bit--how much of the expensive end of life care would actually be desired by the patient? I think that if I knew to prolong my life for a month meant years of financial hardship for my wife and children, I would not put them through it. Yet if I were incapable of stating that to a doctor, would my wife and children be able to let me go earlier for their own welfare?
How do you define 'end of life' care? By age? By potential of success?
A pacemaker for a 75 year old that lets them live comfortably for another decade? Major reconstructive surgery for someone with a genetic disease that has a typical lifespan of 35 or so? Cancer treatment for a 56 year old with low percentage of success?
These are all situations among acquaintances.
Derek
A commenter at MarginalRevolution, MHodak, reminded me of a potential method of addressing costs in such situations- give the patient and their family some incentive to not pursue every last avenue to the bitter end. The insurer could buy out the remainder of policy.
Can you imagine the politics of that? People would say it amounted to "Here, we'll give you money to just shut up and die".
How do you know it's end of life care?
People, even elderly people, sometimes bounce back from health problems that looked likely to be fatal. One of my great uncles was fully expecting himself to die before seeing the new millenium, he's still alive, living independently, driving, etc.
On the other side of the story, end-of-life care can be expensive anyway. One of my aunt's father developed Alzheimers and eventually his memory loss detoriated to the point where he started attacking my aunt, who was caring for him, and they had to put him in a home. All his children agreed that they only wanted pallative care and eventually a case of the flu killed him, but the pallative care was resource intensive anyway.
Jasper asks "what I want to know is, what's the alternative to increasing the government's role in the provision of healthcare?"
1. Reduce the systemic service delivery obstacles. 2. Reduce the matching errors in the system. 3. Target only the remaining people. 4. Choose not to bankrupt the country in a fantasy quest for perfection.
1. Why are 3-5 million people temporarily without insurance? Why are the millions of chronically unemployed without insurance? Because we based our insurance on what we believed was a static employment model, stupidly believing that having business pay was a free lunch. So what benefit do we get from employer based insurance worth this cost now that we know there are no free lunches? I see ease of selling on the part of insurance companies, anything else? Since it seems obvious this isn't worth the price (and is unfair to everyone but the largest employers as well) eliminate employer based insurance.
2. Employer based policies do a poor job of matching risk. Within a few broad and inadequate groupings everyone pays the same premiums. So within a given employer a family with one child pays the same as a family with five. A 60 year old employee and spouse pay the same as a 25 year old couple. Within different employers two twin families will pay different premiums because the number or demographics of their coworkers differ. Certain groups are subsidizing others. Once the amount of the subsidy moves beyond nominal they opt out. We can reduce this by matching premiums to (non-discriminatory) risk factors (mostly age but also factors like smoking and HWP).
3. People who make decent money but are self employed or are retired pre-medicare would be able to access insurance without some of the nasty side effects of being outside the normal insurance contract profile. Subsidize insurance policies for those of low income and wealth.
4. Stop worrying about people who have perfectly good "access" but choose not to exercise it.
4. Choose not to bankrupt the country in a fantasy quest for perfection.
Where were you eight years ago?
4. Stop worrying about people who have perfectly good "access" but choose not to exercise it.
Care to further explain? Access to what? The ER?
I've been in the same position my entire life. The illogical position holds that spending for medical is bad when implemented by an R, but anyone against 20 times as much spending when implemented by a D hates the poor. That's right, your position.
This is a reference to people who can afford insurance and choose not to. Since my previous point was to subsidize low income and wealth individuals I'm pretty sure anyone reading honestly can follow.
Since it seems obvious this isn't worth the price (and is unfair to everyone but the largest employers as well) eliminate employer based insurance.
And replace it with what? Single payer? I'm all for that.
Replace it with insurance purchased by the consumer directly from the insurance company. Have you so internalized your party's policy preferences you can't think of anything else?
Re: So what benefit do we get from employer based insurance worth this cost now that we know there are no free lunches?
Risk pooling and negotiating clout. That doesn't necessarily require employer groups as such, but so far no one else has come up with a way to create large groups that do the above outside of employment groups.
Jon
Risk pool: You don't need a group, the insured lives are the group.
Negotiating Clout: Maybe, although this is countereffected by the difficulty for employers to change insurers. I think this is vastly outweighed by the ability of individuals to match their circumstances to the policy offerings.
My goodness. There are so many hooks in this post for my particular brand of... whatever it is I do here.
But I think I'll just leave it with this: excellent post, Megan.
Not just this one- the entire series is incredibly lucid.
Thank you for this and the other posts on healthcare reform you have been writing lately. Very good arguments.
Now, for the complaining commenters, tell them again how any reform should seek to redistribute so those who cannot afford health insurance can, and eliminate the restrictions that limit choice and the ability for consumers (patients) to bear (some) of the costs of their decisions.
In a nutshell, I hate the poor and want them to die so that all my rich friends can use their bodies as mulch for their diamond ranches. -- MM
Really? And here I thought you just wanted to harvest their kidneys for fun and profit!
That's a side business . . . it does up the ROI, but the real money is in mulch.
I was told we could bake the poor into pies. If there are no pies involved, then I may need to reconsider.
The poor wouldn't melt so I put it in the pie
Hands across the water....water....
But seriously: on this:
It gets into the business of deciding what we "really" want, where what we really want can never be a second chocolate eclair that might make us a size fourteen and raise the cost of treating us.
Have you ever had a chocolate eclair in France? Have you ever had TWO chocolate eclairs in France? Amazingly, it's still allowed there, even though the government sets all the rules for insurance reimbursement and guarantees care for everyone from birth.
And, yeah, the US is culturally different from France. But one way the US is culturally different from France is that Americans really like to eat chocolate eclairs -- well, HoHos, anyway -- and I simply can't envision the US government's jackbooted calisthenics coaches taking Americans' twinkies away. Much as I might like them to, being myself a card-carrying member of the liberal fascist gestapo.
"I simply can't envision the US government's jackbooted calisthenics coaches taking Americans' twinkies away"
No, they won't take them away. They'll force them to change the ingredients until they become tastless. Governments prefer to have businesses do the dirty work.
I kind of thought they were that way already without any government involvement. What other "food" product could be used as the possession target in a lacrosse game and still come out of the package unscathed? And at what point in its shelf life could that product have anything conflatable with flavor?
This blog is primarily devoted to economic issues, but in her younger days Megan sometimes favored us with posts of more general political interest. During this period the Bush administration brought us the doctrines of Thomas Hobbes, as interpreted by Carl Schmitt. Habeas corpus must give way to the President's power to protect us, we were told. Ditto regarding the Sixth Amendment . Torture? It's OK if the President says it's OK.
While all this was going on, Megan maintained a patriotic reticence. Nothing to see here folks, move along. But when Obama's health plan comes along, she reacts with horror. I simply don't understand the right wing mind.
I can only conclude from this that you have never before actually read Megan's blog.
It's like you're attempting the tu quoque fallacy, but have Megan confused with, I don't know, Sean Hannity or somebody.
All this talk about innovation, and I'm still trying to figure out what novelty the insurance companies have brought to health care beyond the permanent elevation of the nurse practitioner.
Kaiser Permanente started computerizing their records in the 1980s. The result is that I can visit a website and see every diagnosis, vaccination, and allergy they've ever recorded for me. Their doctors have even more access; they can look up any notation ever made by any doctor in any chart anywhere in the system or see the results of any test that's ever been run in a Kaiser lab. I'm fairly sure this system has both reduced costs *and* increased quality of care.
That's private sector innovation so potent that Barack Obama and Gordon Brown are working to rip it off as we speak. But Kaiser paved the way, and at great expense and great risk. In the bright, shining government health care system of tomorrow, who's going to do this sort of thing? Who will try something new and risky that could have remarkable benefits, or could fail spectacularly? I have a hard time imagining it'd be competition-free mid-level government bureaucrats with salaries paid from tax dollars. After all, cost savings might put them out of a job.
So when you hear a Democrat talk about "health care IT", remember, that's a private sector innovation. There's more where that came from—unless you hamstring the system by legislating even more market distortions.
Stan - I think Obama's health care plans (if he HAD a plan, and not just a vague, rapidly changing idea) has much more serious implications for the economy than Bush's Habeas Corpus ideas. Is it that hard to understand my Ms. McArdle addresses it?
To second some of the posters above, Megan has set up a perfect straw man argument - she's against a single payer system, like Canada and the UK, which is not currently on the table. In the words of John Stewart, "Thank you, Megan, for having the courage to oppose what no one is actually suggesting."
And it's not just the single-payer system: now it's the 'elites' who want to wrap their fingers around every aspect of our lives. Damn those . . . malefactors of . . . great blood pressure? We've moved on from a straw man argument to a slippery slope argument. If you give this shadowy cabal any power, they'll use it to kill the elderly and put people into fat camp.
Setting that aside, let's look at her horror story: Canadian breast cancer survival ratesgaspshock! Which are ... 87% - A full 3% behind the United States.
Now, I'm not saying that those differences don't matter. They matter a hell of a lot to that 3%. But these are not horrible statistics. They're among the best in the world at a fraction of our cost, and people who focus on dramatic individual cases, out of context, like Megan does, do so to distort the remarkable efficacy of BOTH health care systems.
How many of those Canadian breast cancer patients are coming to the US for their surgery and/or treatment?
What happens to Canadians if the omnicrap bill passes? Will it be illegal for them to seek treatment in the US? We won't be able to afford to be their Plan B any more, I think.
You know, you can now buy wait list insurance in Canada.
http://www.acurehealth.com/
How many Canadians come to the U.S. for treatment? Very, very few.
Only 90 of 18,000 respondents to the 1996 Canadian NPHS indicated that they had received care in the United States during the previous twelve months, and only twenty had indicated that they had gone to the United States expressly for the purpose of getting that care. - Canadian National Population Health Survey
But don't let facts get in the way of your polemic.
Oh, and those nasty waiting lists? That exist only for non-emergency procedures? You could always read the primer below. It's not all good information. It's not all bad:
http://www.amsa.org/studytours/WaitingTimes_primer.pdf
How many Americans fly to Thailand and India every year?
By last count, over 500,000 per year!
Why would recipients of the "best healthcare in the world" fly to third-world nations for their care?
What it really boils down to is whether health care is an industry, or a service.
But why should the health and well-being of US citizens be all about the benjamins? Innovation? I'm sorry, but in my experience with health care, I have not seen innovation make an impact on my health care, albeit I'm only 25.
For years now, Americans have looked at healthcare as a service. Many have the mentality of "When I go to the hospital, I want to be better- NOW." As an industry, healthcare has scrambled to embrace the ideology of an immediate cure.
Ask many healthcare providers around the nation- addiction to prescription painkillers is up. Why? Because beginning in the 80s, the healthcare industry decided that "palliative care" would be the next big thing. Instead of explaining to patients that, unfortunately, in most cases pain cannot be 100 percent alleviated, hospital CEOs tell RNs, FNPs, ER Directors and the like to administer as many painkillers as possible.
The philosophy of industry over service has also been statistically proven to increase the number of specialty procedures done in local markets. Case in point: Casper, Wyo., with a population of about 55,000 people has roughly seven neurosurgeon/spinal care specialists. Result: Casper also has the highest number of spinal procedures per capita in the nation.
While I am highly skeptical of the American government's ability to effectively administer healthcare, I do think something needs to be done.
In contrast, your philosophy of industry drives innovation/we're infringing on our citizens' rights to personal health choices offers nothing but an endorsement of irresponsible lifestyles.
I'm a big fan of personal choice, but not when a person's choices begin to cost our nation money and workforce. If you can't see the financial burden healthcare already bears on our nation's infrastructure, then you have been blinded by industry's empty promise of choice and innovation.
I'm a big fan of personal choice, but not when a person's choices begin to cost our nation money and workforce
If this is not an endorsement for slavery, I don't know what is.
That is not what I'm advocating. Instead, I am saying that perhaps we should look at penalizing those who decide that eating lots of ho-hos is noble goal for their life. I don't care if you want to have elevated blood pressure or diabetes. But for you to make personal choices that in turn cost me, and everyone else money, is stupid. Kind of like smoking. Sure, smoke 'em it if you got 'em. But don't expect any assistance from me when you're diagnosed with lung cancer- you're the individual who decided to kill yourself.
Why stop there? Why not penalize not finishing college, since that lowers one total lifelong output, thereby making all of us poorer? What about those who choose careers they are ill suited for? Or careers that produce little for society? I don't care if they want to devote their life to the pursuit of art, as long as they still produce for society at the factories! What about dangerous hobbies? How much do bikes, climbers and sky divers rack up in hospital bills?
What you are talking about IS slavery. You want to take away peoples choice in life to do that things that someone (who?) considers harmful.
So, does that mean we need to penalize people with HIV and AIDS?
The same logic applies, right?
top n cueing on apsuman...
along that same line of thought, anal cancer, which is caused by anal receptive sex + HPV.
Sorry Farrah...you're secret's out.
So what if Casper has the highest number of spinal procedures per capita in the US? Do Casper's spine surgeons turn away anyone from outside the city limits?
Large rural hospitals operate very, very differently from urban ones, mainly because they have geographically large catchment areas - it isn't unusual for hospitals in towns of 30-50000 to draw on an area of 800k people.
Not sure of this, but isn't Casper full of miners? Mining is hard on the back. As is much hard physical labor. If you use electricity, roads, gold, batteries...a miner's back is being damaged for you. I live in the Appalachian coalfields and there are a lot of back injured miners here. Yes, many use painkillers when other things didn't work. What, you think they should live in constant severe pain? Easy suggestion for you to make, healthy 25 year old person. Don't tempt fate. I had my first cancer at 26 and two more since. None of them lifestyle related.
Innovation? I'm sorry, but in my experience with health care, I have not seen innovation make an impact on my health care, albeit I'm only 25.
...and male, it appears. That sentence right there pretty well shoots down your disbelief, since 25yo's (and especially male 25yo's) are generally very healthy. Barring an auto accident, contracting HIV, or some other extraordinary event, you won't discover the best aspects of modern healthcare for a good while yet. But you will.
Immunizations, hygiene and infection control procedures might have saved his life already, 20th century innovations. But it's not glamorous enough for him to notice. I had an aunt die at 5 years old of diptheria in the early 20th century. That's just ridiculous from today's point of view.
I'm sorry, but in my experience with health care, I have not seen innovation make an impact on my health care, albeit I'm only 25.
Ahh - young, arrogant and stupid.
Recent advances in interventional cardiology saved my life when I was 49.
Wait until you are a bit older. By that time, you might have a home, family, career - stuff you've worked for over the years and really value. You might appreciate innovation a bit more when the unexpected happens.
Mohs microsurgery
laparoscopic cholecystectomy
perf'd ear drum patch using skull muscle tissue
radioactive iodine treatment
thyrogen to prep for scans without taking a month off work and life
herceptin
tamoxifen
aromatase inhibitors
fluticasone
computer controlled adjustable lead plates on radiation machines to narrow the target of radiation administration and prevent widespread damage
MRI
CT
PET CT fusion scans
ultrasound
thyroglobulin immunoassay
dental implants
That's just off the top of my head...recent/modern medical advances that have made my life better or saved my life, starting at 26 and continuing through now, age 44. Plus NICU techniques when I was born and had some severe problems and almost died.
Give it time, child.
You lost me with your implication that innovation doesn't matter, because you have yet to see innovation impact your health care in your lifetime--with the caveat that you are 25.
Do you not realize that ALL anti-HIV meds have been developed since your date of birth? Do you have any clue how many horrendous deaths have been prevented with AZT alone (and the use to interrupt mother-child transmission)? Do you really believe it's okay to let tens of thousands of people die because it doesn't affect you?
There are also innovations in cardiac catheterization, new childhood immunizations, new cancer treatments, better supportive care for premature infants, new antibiotics to treat resistant bacteria, new biologic therapies to treat arthritis, lupus, and other chronic autoimmune diseases--all developed, tested, and employed--in the past 20-25 years. People are living longer, healthier, more fulfilling lives unprecedented in human history. Because of innovation.
And legalized abortion! 90% of Downs syndrome children are aborted. There are a lot fewer mentally retarded people around now compared to when I was a kid. Medical and legal innovation means you don't have to put up with a bunch of inferior people.
(please detect the snark)
And a lower crime rate that started declining 16-17 years after Roe v. Wade. Your world is a lot safer because of medical and legal innovation.
Every chile a wanted chile.
i don't see why I have to oppose government to support innovation. what about government's role to protect the consumers against pecuniary incentives and private competitors from infringing upon each other? like the federally issued patent for example that innovations have come to depend on? what about the vast amount of governmental funding allocated to National Insitute of Health to suport broad-based background scientific research? without the massive investment of public funds in basic science support we have no second-stage commercial development. you seems to be anti-government as a matter of ideology and faith, not on a well-reasoned basis.
i don't see why I have to oppose government to support innovation.
Where do I start? First of all, government work doesn't tend to attract the type of people who are innovative in the first place. Rather, it attracts small-minded, petty bureaucrats who put processes over people and whose main objective is to keep their own jobs even if the "problem" they were hired to do no longer exists. The average bureaucracy is a solution in search of a problem--not exactly the stuff that innovation is made of. Plus, the average innovator would find him/herself strangled by arcane government rules and tends to thrive in the private sector, where new ideas are actually appreciated, rather than seen as a threat to the precious status quo (i.e. the useless bureaucratic jobs of which I speak).
Nice post, Megan. Good luck on your wedding plans. I see a lot of comments here and interesting ones, but virtually not one addressing your main point: Government health care will attempt to help the uninsured, but will kill a lot of others. Can I take it that your point is passed by acclamation?
On the topic raised by the very first few comments: Are there types of reform ("low hanging fruit") that we conservatives would agree with? I myself would think that some alternative to using emergency rooms for primary care would be a good start. That is, allow emergency rooms to turn away non-emergency cases, but provide - pay for - some way for people to get it if they are unable (not unwilling) to pay for insurance.
I do think that since it is by now pretty clear that health care reform isn't going to save the economy (the only reason this sentence isn't a bizarre non-sequitur is President Obama saying it would!), it's not a bad idea to table it for a year or two and concentrate on things that will.
The reason that nobody is talking about that point is because its completely stupid. The idea that lesser profits are going to completely drive R&D in applied medicine out of business is stupid if you consider the plans that are on the table. I can promise you that if any of the plans under actual consideration come into being the next hypothetical drug that could change the world will just as likely be invented as if any of these plans don't pass.
Its a talking point that Megan has used in the past and I'll refuse to truly dignify it with a good rejoinder until she gives some level of actual argument rather than bloviating nonsense about how she believes things will be without any actual facts to back her up.
"I can promise you that if any of the plans under actual consideration come into being the next hypothetical drug that could change the world will just as likely be invented as if any of these plans don't pass."
"Its a talking point that Megan has used in the past"
All I can say is, is bizarre. I'm afraid I have to take one of the firmest conclusions, most clearly demonstrated, of economics from the last century - over your promise. Free markets lead to innovation, command economies do not.
We conservatives care just as much about the uninsured as you do. But we care about everybody. Lack of innovation kills people. Recessions kill people. Perhaps a lot more than you think you're saving.
So there has been no innovation in health care in other countries like say France or Sweden or the UK?
Really?
No one does research in those countries?
No one is talking about creating a command economy in health care. Its a ridiculous strawman. No one is talking about creating a british style health care system. Its about regulating the insurance companies, creating actual competition in a market where some insurance companies have 80% of a state enrolled and making sure that everyone has health insurance that doesn't bankrupt them.
Megan has given no actual thought as to the details of the plans under consideration and how her ideology matches up to it. Instead she pretends that what we are going to have is some sort of, as you said, command control system when that is not on the table.
jules, people do research in those other companies, and then form companies in the US and get the patent here, to overcharge Americans to maximize their profits and pay for it. Their socialized medicine relies on the American free market and patent system to thrive. If it disappears, goodbye innovation.
I agree with this. The funny thing is the author merely assumes that a patent is basically a function of the free market. Funny, I thought it was a government granted monopoly to support innovation. Sure, patents spur innovation, but they only exist due to government intervention in the market place. They are hardly a staple of a true free-market economy.
The recent Kindle scandal shows some differences in the concept of intellectual property in different countries. Amazon repossessed all electronic copies of George Orwell's works bought through Amazon US. Why? The seller didn't own those works, still protected under copyright. In Canada and Australia, and websites based in those countries, Orwell's works are already public domain.
Why?
Elsewhere--life + 50 years
US--life + 70 years
Is that wrong? Matter of personal opinion. However, I'm wondering if life was redefined upwards in the US due to lengthening lifespans, if the point is author's life plus another lifetime. And if the political pressure was huge in the US, given the vast music publishing industry here.
There is no difference between public option and single payer--the subsidized public option will drive out most private insurance within a few years. How long, for example, do you think a strapped state government will retain Blue Cross for its employees? Virtually the entire public sector will be public option within a legislative cycle.
I realize that to most people, these are airy-fairy considerations that should be overridden by the many "practical" considerations of the awesomenes of central health care.
See, when you put practical in quotation marks, I cringe. Not because I think you are uncaring, but because I'm sure you do, and so it is hard to take when you appear to be scare quoting a term that contains within it the actual human cost of our system.
So I've had some weekly business at a local health clinic. It's a stopgap solution. Everyone working there thinks that they do good work; everyone working there thinks that the clinic is not even close to a substitute for a universal health care system. This is a fact that no libertarian, no conservative, no opponent of universal health care can meaningfully object to: there are millions of people in this country who lack access to adequate health care because of their financial or employment situation. And that lack of access causes immense suffering. Any interrogation of our health care system that does not reflect the pragmatic and moral realities of those facts is not the work of an adult.
At this juncture in the conversation, someone almost always breaks in and says, "Why don't you tell that to an uninsured person?" I have. Specifically, I told it to me. I was uninsured for more than two years after grad school, with an autoimmune disease and asthma. I was, if anything, even more militant than I am now about government takeover of insurance.
That's not good enough. Do you really think that you are a meaningful example of what it's like to be uninsured in America? Do you really think that your experience is materially useful as a proxy for the American uninsured? I'm not asking you rhetorically, or as an indictment. I'm genuinely asking you whether you think that a young woman with an Ivy League degree who would go on to be an editor at the Atlantic (and whose lack of health care was relatively short-lived) is a good example to use to understand our problems. And I further ask you whether you think that simply because you once lacked health care, that means you can dismiss the desperate need of millions of people who do now and want it badly. Again, I am asking that genuinely, not indicting.
Here is who you have to talk to: you should talk to the man who, I'm told, recently came in to the clinic suffering from incredible pain because his teeth were literally rotting out of his mouth; he had no health insurance and couldn't possibly afford a dentist. Tell that to the clinic worker who told me about a woman who came in, years before, complaining of severe abdominal pain she had been dealing with for months and months, only to learn that she had cancer. Had she gotten necessary preventative care, her outlook for a full recovery would have been much higher. Talk to the man who told me that he had permanently lost movement in a finger that he broke but didn't bring to the emergency room to set, because he couldn't afford to pay the bill and couldn't take on the debt that an emergency room visit would have meant.
Talk to the family of Deamonte Driver, a 12-year old boy, killed by a toothache, because his coverage wasn't comprehensive enough when he had it, because he lost it, because no one could force dentists to accept his Medicaid when he had it, because his mother tried and failed to find an affordable way to get desperately needed dental care for a child due to the absolute failure of our system. Would you call his mother and tell her, "Had I the ability to have chosen to get you adequate health care coverage and in doing so saved Deamonte's life, I wouldn't. Because of public choice theory. And I once went without health insurance, so I am qualified to say so." Am I misreading this post? Isn't that what you are asserting you are prepared to do? If I'm misreading, tell me how.
Or, if that's too confrontational, just go to a local health clinic and ask them for their worst horror stories.
You are a smart person and a brilliant writer, but the idea that your experience makes you somehow fit to push away the experiences of millions of suffering people is not fair.
Now I don't care how you cover people, at the end of the day, if it means that people stop lacking adequate coverage. I have my preferences, which I'm sure are far more statist than people around here would care for. I also like the Will Wilkinson plan-- when people need health care and can't afford it, the government cuts them a check. But in a country capable of producing Cribs and The Fabulous Life of the Latest A-List Asshole and ice sculptures that piss Grey Goose vodka at parties and $500,000 cars and second homes that cost $12 million dollars, in a country where we can spend billions of dollars on absolutely redundant naval and air technology, in a country where I recently turned on my TV to watch a 12 year old bragging that he owned hundreds of pairs of shoes that he would never wear-- in a country of such endless opulence and wealth, for Deamonte Driver to have died for want of a $75 tooth extraction is an obscenity. It is a moral obscenity.
Many of your commenters, of course, will tell you differently. I am not unaware of how they will snort and gibber and squeal about the very idea of a moral duty to Deamonte Driver and everyone else who has suffered enormously because of this system. That's okay. They can say whatever they want. But you take the time to write the things you do, to write posts like this, because you care enough to think things through on such an epic length and a deep level. It is only because I respect the effort that I am telling you, from my position, that you have not adequately considered the moral ramifications of what our system does to those without adequate coverage. I am not asserting that you don't care. Far from it. And I mean no disrespect. But when I consider the depth of the little piece of the suffering our health care system causes that I have been exposed to, this just doesn't seem sufficient.
"I am not unaware of how they will snort and gibber and squeal about the very idea of a moral duty to Deamonte Driver and everyone else who has suffered enormously because of this system. "
I won't snort or squeal, but I will tell you that the moral duty rests with the parents in this case. As tragic as your story is, what I find more tragic is that you don't assign fault or responsibility to the people who are the most responsible...his parents / guardians.
People make choices and choices have consequences. I am rewarded for my work with the ability to insure my family, this alone is enough incentive for me to continue to be a productive member of society. If other people don;t have this same motivation why should I be left holding the bag for their morale failings?
$75 dollars isn't a lot of money, and most people could scrape this together in a few days, I wonder did they have cable tv? Did they pay for internet access? Did they eat out at restaurants? This kid dies because his parents were unwilling to make sacrifices and instead waited around with the hands out waiting for somebody else to pick up the bill.
The problem with your preferred reforms is that it continues to reward bad behavior, because the people who already are getting government health care will continue to get it, while those of us who have worked to afford quality care will still be paying higher taxes to support their lifestyle all while being forced to downgrade our own.
Liberals talk a great game in regards to equality, but their plan isn't about raising the standards it is instead about depriving benefits from those who have earned it...crappy health care for everybody means that we are all equal!
Charities exist so that the willing can help the suffering. If you wish to help, donate. But all your desire to help does not give you the right to force others to donate to your favorite cause.
Lord. The two replies above remind me why I stopped being Republican. Freddie leaves a long, deeply thoughtful post. You can disagree with it's mechanics, whether it's even logical to use a free clinic as a testing ground for public policy (it caters to the most disenfranchised, so it's going to give you an unecessarily negative cross section) or even whether the state has a moral duty to it's citizen, but instead we get:
"Poor people suck. They make bad decisions, so they suck more."
Guess what! There's no statistical factor, from age, race, IQ, that more heavily weighs on future success than your parents wealth. From the standpoint of regression analysis, rich people are the greatest moral welfare recipients in the world.
I appreciated the thoughtfulness and passion of Freddie's post and I agree that no child in this country should die for lack of decent dental care.
My problem with the conclusion is that government-mandated or government-provided insurance would not have been the guarantor of Deamonte's life. He was, from what I could glean from the Washington Post article, fully eligible for government-provided medical and dental care. When his family "lost" Medicaid, it was apparently due to a paperwork issue, not due to funding or lack of eligibility. His family saw a dentist that accepted Medicaid--but his mother thought her other son was in greater need, and the dentist wouldn't see them again after the other child was uncooperative.
Freddie describes that Deamonte's mother "tried and failed" to get her son needed dental care. This is true, but there were other options open to Deamonte's mother--a regular pediatrician could have prescribed antibiotics, though obviously couldn't have done the surgery. A pediatrician or a nurse practitioner could have served as an advocate in the system, locating a dental surgeon (we did this often) that could work him in sooner. Showing up in an ER and asking for help might have worked. And the absence of current Medicaid status should not stop this, as Medicaid coverage is usually retroactive. (People can come to an ER, get treatment, and apply for Medicaid at the same time, often with the help of a social worker, and Medicaid will cover that visit.) She didn't have to cancel the appt with the oral surgeon when she "lost" Medicaid; she should have called the office and asked for help reapplying in time for the coverage to apply to that visit.
But you say, all this is incredibly complicated, how can a single mom with no fixed address be expected to navigate this nightmare? And you are correct, it is difficult--but how would it be any less difficult with the monstrosity of a bill now before the House?
As far as bad decisions go, just what can a government do to help a child whose mom won't bring them in for needed medical care even when you send a taxi out to the house at a prearranged time to bring them to the doctor's office? How does government-mandated insurance change that? Want to take the kid away for medical neglect? Is it worth that trauma to the family? Is it worth destroying whatever tenuous parent-physician relationship you might be building? Sometimes there is no easy answer to helping kids stuck in poverty. It's not their fault, but handouts to the parents don't seem to help too much sometimes.
Even the illiterate janitor at the courthouse or the school gets great state employee health care better than most private sector insurance. Ms Driver could have cleaned houses for less than one day to raise the money she needed to pay for a tooth extraction. Where did she learn the helplessness? It's truly sad.
You don't need to be wealthy to ensure that your children are successful or taken care of, what you need is a desire to provide for them no matter what it takes.
The government can provide health care, welfare benefits, and other entitlements, but none of those things will ever encourage people to strive for a better existence...all they do is make people put their hands out for more.
Like I said, decisions do have consequences but they also have rewards. Want health insurance? Work for it. I have nothing but sympathy for children who suffer and nothing but contempt for those (their parents) who put them in that situation.
Want health insurance? Work for it.
Yes, work away that degenerative disease which you inherited.
marvel - thank you. That was articulate counterargument.
As for your points, agreed that you can't guarentee that individuals would be able to navigate a government system - but how is this any different from the difficulty in getting proper insurance compensation, being diagnosed with non-covered illnesses, or the occasional capriciousness of the private system?
Difficulties will abound with any form of health insurance, so it's not the argument that's wholly in front of us. It's whether extending those difficulties on to the non-covered American's is better than giving them no health insurance at all.
As for the rest, we're dangerously close to starting a discussion on general poverty allieviation. Maybe on another blog. :-)
Freddie, did you even read the actual story of Deamonte Driver? His family was covered by Medicaid, originally. Yet they couldn't find a Medicaid dentist, and do you know why that is? Because the government procedures for accepting Medicaid patients arrive with onerous price tables and procedural rules and provide lots of opportunities for the practitioner to be charged with criminal fraud in the course of trying to run the rest of his business.
Government healthcare failed this boy and his family, by making it almost impossible for any sane practitioner to work within its dictates. Your prescription? More government healthcare, justfied with Burning Moral Outrage because someone out there, somewhere, had the audacity to create an ice sculpture that spouts liquor.
It boggles the mind.
I dare say the vodka spouting ice sculpture was likely created by a gay man caterer small business man, so in being against it, you are:
1. homophobic
2. oppose creativity and artistic pursuits
3. hate small businesses
Stop the prejudice against the little guy!
In many ways the type of small steps Megan calls for are the ideal way to go. You don't really want the government to take on too much, or all at once. (Though I don't buy into the arguments that government cannot do as well as the private sector. It's a mantra oft repeated, rarely proven accept via anecdote. Private sector failures in every industry cease to exist and are removed from the scoreboard.)
We also note that type of small changes that needed to be made, were never made under the types of politicians who are the chief proponents of incremental change: Republicans.
Someone also suggested above (and ridiculously)that Obama has no plan. He is allowing Congress, who must ultimately pass the legislation, to take a major role and he has mentioned about four items that he finds central to health reform. These include a Federal plan as an option and everyone having to be a participant by carrying insurance of some type; he won't get all his desires, but the method he is using is entirely legit.
Further, in terms of policy, it's often smart to begin by asking for the world, knowing full well that after the legislation works its way through everyone, it will be scaled down to something reasonable. If you start with the reasonable or small, you often end up with nothing.
Or endless debates.
I think you just contradicted yourself there. See, when private sector failures happen everyone gets to see them and since profit is in play dollars freely walk to another solution.
Sometimes the private sector catches their error and corrects, think New Coke.
Sometimes it is just a really bad idea, think how Montgomery Ward decided it's future was in the established downtown locations. Sears embraced mall stores. Where is Monkey Ward now?
The private sector is full of that creative destruction.
If I saw the Department of Labor in direct competition with the Department of Interior with one winning based upon how efficient they are with one GOING AWAY FOREVER. Then maybe I would be a believer of government doing as well as the private sector.
imho.
Well, I am thinking that in that "creative destruction," a lot of people get hurt, at minimum.
Take your example of error and correction: New Coke. How much money and effort was wasted in that example? Or when AT&T went through its various permutations, buying NCR and cable companies, then selling them off. More waste. Billions lost.
Yes, you figure that for every private sector failure, there is someone else in the wings to "pick up the pieces" and make a buck.
But in that "going away forever" process, you still have a percentage of the whole private sector effort a complete waste.
If there are ten companies competing to make widgets, and five fall by the wayside, then we can conclude that while some individual private sector companies have done well, 50% of the private sector effort has...failed. And failed in a market where they can control their customers and don't have to be open to all takers. They can define their market.
Generally any plan the government comes up with, it must make applicable to citizens as a whole, thus it comes in with higher restraints on flexibility. But it's power to compel everyone to participate in the insurance process should, in theory, make the act of "insuring" easier. Especially given the insurance works when the costs are spread, and tends to deteriorate as the customer base shrinks.
I am not concerned about freely walking dollars, but who is capable of wasting those dollars.
setting healthcare aside -- this is basically an argument against a free market, capitalistic system.
and its an argument that history has proven time and time again to be spectacularly wrong.
"setting healthcare aside -- this is basically an argument against a free market, capitalistic system.
and its an argument that history has proven time and time again to be spectacularly wrong."
Yeah man, we should let the bankers regulate themselves, since the bankers know about banking best.
"I don't buy into the arguments that government cannot do as well as the private sector. It's a mantra oft repeated, rarely proven accept via anecdote. Private sector failures in every industry cease to exist and are removed from the scoreboard."
That's exactly the point of competition. Failures are culled out.
Compared to government failures that live on forever, no matter how large the required subsidy becomes.
As Mrs Crabapple told the kids taking that standardized test in The Simpsons: "Remember children, the worse you do the more money the school gets, so don't knock yourselves out."
Real-world version of that: NYC public schools now consume $19,000 annually per student.
On another front, just yesterday the Feds denied "stimulus" money for law enforcement to New York City because the NYC police have proven too effective and sucessful in recent years. Can't give money to an organization that has proven it will use funds effectively! The money is instead being sent to more ineffective, failing police departments that have greater "need" of it, to prop themselves up as they are, squandering it.
Examples on every scale are countless.
Hate to belabor this, but people are still writing long, thoughtful comments which don't address Megan's point: Perhaps health care reform will kill more people than it saves. We all sympathize with those who cannot afford insurance. Now find a way to save them that won't kill even more others.
Oh, no, we got her point: if one fictional Randian factory owner dies one day early because his taxes on earnings over $1 million a year went up one percent, then it is not worth reforming the American medical system, even if it saves the lives of millions of people. Because, as Ayn Rand has taught many a nerdy high school student: those poor uninsured people are poor and uninsured because they are inferior and their continued survival merely represents a drain on the "productive" industrialist members of society.
As someone noted above, Megan's "libertarianism" lacks, you know, empathy. Megan might want to address that before she starts talking about what uninsured sick people need.
You didn't get my point, Mark. You're privileging people we can cure right now over people we can't. Why are they more deserving of life? Don't rant about other people's failings: tell me where your empathy is for them.
To put it concretely, let's say that a certain cancer is treated currently with a combination of radiation and chemotherapy. The treatment is effective 50% of the time, and the ordeal is excruciating. We change our policy so that everyone has access to this treatment through the government, yet had we not done so, a pharmaceutical company would have developed a simple pill that halted or prevented the cancer within 10 years. How much suffering have we inadvertently created by doing so? That's the heart of what Megan is arguing--the loss of innovation is not the just the loss of the next Viagra, it's the loss of the next statins, the next Glucophage, the next Herceptin, etc. That's the kind of loss we're going to experience when the innovation of our drug research industry goes away. Sure it advertises. Sure it spends billions to make lifestyle drugs. But it also harnesses tremendous talent and puts it towards creating drugs that do save lives. As she stated, the NIH does great work, but not the same kind of work, and the loss of our private pharmaceutical industry is a loss not just for the US but for the world. Acknowledgment of this trade-off is something those pining for a statist solution should put forth with their arguments.
Freddie related the story above of Deamonte Driver, who died tragically for want of what is today a very routine and simple procedure. But how many will die in the future for want of an equally routine and simple procedure that cures a disease that is currently incurable?
Megan - But that's a false point. You're assuming unlimited gains from innovation to save 'the people we can't'. Where are your proof of those gains? It's also counterfactual to your arguments in earlier posts, that the low hanging fruit has been picked and innovation in health care is following a curve of diminishing returns. In that situation, it's absolutely logical to save those we can, now, because it's cheaper, more efficient, and leads to the greatest application of resources.
CM79 - I understand your attempted point, but it ignores the reality of the situation. You create a false equivalence between a cheap, pre-modern treatment that could reasonably be available to everyone at minimal government expense, and a revolutionary, expensive drug that applies to a tiny subset of the population.
Again, it goes back to the law of diminishing returns. It's why it's more effective to distribute mosquito nets for 2$ a piece in malaria zones than boxes of antibiotics - because you target the diseases that combine the highest levels of morbitity with the greatest efficacies of their treatments.
To put it another way - let's say that tomorrow, we found a revolutionary cure for the Creutzfeldt–Jakob prion, which affects about one in a million people a year and is absolutely lethal. The cure expensive, difficult to produce, and effective. But at it's cost per dose, you could provide basic medical care for a thousand children.
Since I've regularly accused people of making false arguments (:-)) I personally admit that the numbers are never this easy - few diseases are as rare/deadly as Creutzfeldt–Jakobs. But it is, again, the law of diminishing returns, and we could achieve much more in public health, for more people, by more effectively applying the knowledge we already have.
Straw man. You reflexively support a private system despite the worst outcomes in the OECD, and then your argument for keeping it is that multinational pharma companies won't develop drugs if they aren't subsidized by American taxpayers?
Your claim to understand the uninsured rings so hollow. Did you stop going to see the doctor because you were uninsured?
And if you did, why are we talking about the infinitesimal probability that some magic drug might be discovered in the future and not talking about the very finite probability that you could have become very sick as a result of not treating a minor illness?
The American health care system should have the best outcomes in the world. You are trying to justify staying at #50.
Reply to Mark--
Did you stop going to see the doctor because you were uninsured?
That's not fair, Mark. She went to the emergency room when her asthma acted up. Just because the tax payer had to pay for her medical care when she wasn't working doesn't mean the tax payer should have to pay for other people's care.
Susan - my bad. I always forget that "libertarians" are only opposed to other people getting money from the government :)
"if one fictional Randian factory owner dies one day early because his taxes on earnings over $1 million a year went up one percent"
Wow. Can we speak seriously? We're talking about poor people dying too. And middle-class people dying. And rich people dying. Innovation saves lives, lots of them. I work at the lab of one of the largest research hospitals in the country. We are continually buying and trying new equipment, new drugs, new treatments. If they work out here, everyone else will be using them too. And we don't buy them because they're expensive. Ask any doctor, for goodness sake - we buy them because it seems to us that they are markedly better, safer, faster, etc. than what we were doing before.
Don't tell me about how the "rest of the world has no better outcomes than the US". That's just distraction, and it's bull. We have better outcomes than we did last year, in many tiny detailed issues which are hard to quantify. So does the rest of the world, if they're keeping up. Absolutely none of that stuff is developed by the NIH. We are getting them because someone is trying to make a lot of money on them. We will keep improving our outcomes as long as that continues to be true.
Innovation saves lives, lots of them. I work at the lab of one of the largest research hospitals in the country. We are continually buying and trying new equipment, new drugs, new treatments. If they work out here, everyone else will be using them too. And we don't buy them because they're expensive. Ask any doctor, for goodness sake - we buy them because it seems to us that they are markedly better, safer, faster, etc. than what we were doing before.
But saying that innovation will suffer assumes that there is no innovation or research going on in other countries and that is just.not.true.
The US pays more than everyone, and has more unnecessary deaths. Our system is broken.
ALL other countries, pay less, those with anything like comparable incomes live longer, and experience a hell of a lot less aggravation & tribulation along the way.
Megan is just blithering. We need a good health care system. If it offends her sensibilities, that's just a bonus.
How do you propose to keep us healthy? Assume for the sake of this question that whatever system exists will provide all care currently provided by gold-plated Blue Cross/Blue Shield to everyone in the United States. Ignore cost.
There are a lot of problems that do not arise from lack of money. Despite the fact that Medicaid will pay all expenses related to pregnancy and birth, my hospital routinely sees women who have absolutely NO prenatal care - they first come to the hospital when contractions start. Most of them are not on their first pregnancy, either, so ignorance of what to do is not the problem. (The average age of women having their tubes tied is under 25, as well. It's a public hospital.)
The hospital provides a clinic where doctor visits are $55 cash, if you have no other means to pay and don't qualify for the patient assitance program. Many of the patients in general are diabetic, but don't take their insulin (free under a state program). They are hypertensive, but won't take $4/mo blood pressure meds. By what mechanism can we make these people live longer?
A big part of the difference is that Americans spend a lot more on voluntary procedures like cosmetic procedures. The boob job spending is skewing the statistics. We have the Barbiest population on earth.
Your piece ends with "And in my opinion, they way in overwhelmingly on the side of..."
I think you mean "they weigh in" not "they way in". No pun intended I'm sure.
For those who, like myself, like their lives controlled by a centralized bureaucracy fortunately there are alternatives. Many of you are aware that the Catholicism gets a bad rap, but, if you haven't looked into it in the past few centuries, there have been some important changes. They no longer send Inquisitors to your house. Contributions feel almost voluntary. In addition, the Sacrament of the Sick hasn't gone up in price in, like, forever. Sure the schools still teach Latin but never, as far as I know, mention Spinoza's Ethics and give only cursory notice to Horace. Nevertheless, Catholicism is a religion where the desire for 'hope and change' is a constant.
OK that's just a bizarre commentary. Penalty flag.
Truth be told, I thought Megan made the ultimate point in this debate. If I were to add details it would be that I think we need to expand on what we have in terms of coverage for the uninsured, something where they give a little (or a lot). That is the situation with the VA or county hospitals that are associated with teaching institutions. Those institutions can provide supervision and structure for physicians as well as patients. We could use ombudsman to guide people as to their options. The NY Times had an article Saturday about the Cleveland Clinic and Obama's visit there, in which it was pointed out in no way did his health plans encourage such excellent institutions which 'did not encourage extra tests etc.' All that is small potatoes though compared to Megan's well made point. For the proponents of the current change, it seems really however a matter of faith and morality. I was merely making a point which might include for the reader a warning about the limitations of such and that there are other contexts for such idealism.
So, if Obama's bill passes, he'll go down in history as a mass murderer, the 21st century equivalent of Hitler and Stalin. This is the most entertaining thread I've read in a long time. It's right up there with the birthers.
Great post Megan.
It's not that I think that private companies wouldn't like to cut innovation. But in the presence of even rudimentary competition, they can't. Monopolies are not innovative, whether they are public or private.
This really nails why the free market is better than more government control.
there are millions of people in this country who lack access to adequate health care because of their financial or employment situation. And that lack of access causes immense suffering.
Millions of people lack access to lots of things, leading to suffering. This motivates them to produce useful goods and services for others, thus acquiring the things (such as health care) they desire. "To each according to his need" sounds nice but doesn't work very well in practice.
Also, the notion they lack "access" is generally untrue; they may lack means to pay, but even if you can't afford to pay, you are generally still treated. It's not unusual to then pay the debt over time.
This really should be done piecewise, if it is done at all. Since the most cited reason for reform is to reduce costs, it is most logical for the federal and state governments to demonstrate that they can actually reduce costs significantly in that portion of healthcare spending that is within their purview. Not a single advocate for reform-to-reduce-costs has shown any believable argument for why one shouldn't expect such a demonstration prior to putting more people on the public dole.
Since the most cited reason for reform is to reduce costs, it is most logical for the federal and state governments to demonstrate that they can actually reduce costs significantly in that portion of healthcare spending that is within their purview.
When has the private sector shown the same thing? It hasn't. And it can't. And it never will.
This is a joke, right?
Clothes, food, and housing all cost FAR less than they did 100 ago. This did not happen in countries without free markets.
I could cite other obvious examples, like the ever-dropping price of telelcommunications and computing power.
How about the ever dropping price of generic drugs? I'm on a medication that was revolutionary in the early 1990's--and I pay $15 for a 90 day supply from Wal-Mart, bypassing my insurance completely.
Calvin,
This still doesn't address my point. Obama and others are promising to reduce costs. I would like a demonstration that it can be done before turning over what is left of the private insurance market over to the government. No reformist on the left ever steps forward to support this idea. I would like to know why.
I haven't seen enough basic math in healthcare blog post comments. Here is my contribution:
CBO ten year estimate annualized: $104,200,000,000
Annual amount for each of 47,000,000 uninsured: $2,217.02
Annual cost of $159.00/mo plan*: $1,908
Government plan more expensive by: $309.02 or 16% annually
* I have employer provided health insurance and don't have any idea of how much it costs. I went to an online health insurance broker and found a reasonable sounding basic-coverage Bluecross/Blueshield plan for $159 based on a 35 year old nonsmoker living in ZIP code 77035.
** Bias disclosures: I work in a IT services capacity at a large health-care institution. I am a student in healthcare informatics.
Good job, Adolph!
To be sarcastic, let me point out analysis of costs like yours are rare due to the "universal education" we get in the US.
How come nobody is pointing out the great job the government is doing with providing the universal education in this country? We have universal requirements for math in US schools yet very few people are capable of understanding a nice analysis Adolph made using CBO costs that seem too low to me anyhow.
"When you listen to obesity experts, or health wonks, talk, their assertions boil down to the idea that overweight people are either too stupid to understand why they get fat, or have not yet been made sufficiently aware of society's disgust for their condition. Yet this does not describe any of the overweight people I have ever known, including the construction workers and office clerks at Ground Zero. All were very well aware that the burgers and fries they ate made them fat, and hitting the salad bar instead would probably help them lose weight. They either didn't care, or felt powerless to control their hunger. They were also very well aware that society thought they were disgusting, and many of them had internalized this message to the point of open despair. What does another public campaign about overeating have to offer them, other than oozing condescension"
I will say this - your own anecdotal experience about every fat person you know eating burgers and french fries all the time should not be taken as gospel truth that all or even most fat people eat like that.
Not even close. Please do the research Megan. UCLA. Gina Kolata. Paul Campos. Just pointing out that the complexity of obesity in this country is far more nuanced than your anecdotal (or even mine) make it out to be. You are being far more glib than you realize.
Just to echo silentbeep's point: it's really, really not true that obesity experts or health wonks think the reason why people are fat is that they don't understand how they get fat, or experience insufficient stigma for it. Just about every behavior change expert in the world, on health or otherwise, recognizes that knowledge by itself doesn't necessarily change behavior. They learned this lesson by about 1980 in the anti-smoking saga, and it was reinforced in the struggle against AIDS. Just knowing that a behavior is going to kill you doesn't make you stop doing it, if it's pleasurable, if it's embedded in your social rituals, your sense of self, your imaginary ritual for the day, or whatever.
In fact, the whole point about difficult-to-alter behavior changes like cutting down on overeating is that people can't do them by themselves. They need help from society. It used to be that the libertarian response to the Morgan Spurlock line on fast food was that "people can just drive by the McDonald's and not walk in". Megan obviously recognizes this isn't true. So what exactly is she trying to say? That people can't stop obesity on their own, but we shouldn't try to help them -- we should just resign ourselves to being hopelessly obese? Because that's kind of pathetic.
I'm saying we shouldn't "help" them by coercing them (and everyone else), which leaves . . . haranguing them, AFAICT.
I agree with you there Megan, that haranguing is not helpful. If hate, harrasment and condescending advice were enough, we wouldn't have fat people in this country. However, I think I agree with you in a slightly different way.
It's not because all fat people, or even most, eat like the anecdotes you gave. Yes some do. Some people are 30 lb.s overweight and if they cut back on soda, maybe they'd lost some lbs. I only say this because I knew someone who did just that. I also know people who stopped drinking soda all together and are still fat. I know vegans who lost weight after becoming vegan, true, but they are still chubby. Like I said before anecdotes are not enough to make a broad conclusion about an entire population of people. It's just a variety of anecdotea, let us know there are many stories and many experiences that inform our experience of obesity in this country: it's not all just one way.
I am arguing for a more careful mesuring of what we mean by obese, fat, merely chubby...etc. And that depending on the person, the reasons, the lifestyle, the variance of weight and size and how people got there, it's actually quite broad. It's not all "lifestyle." Some people no matter what they do, aren't going to be thin. Maybe they can be less fat, or maybe they can get thin by dieting for awhile and doing the "yo-yo" thing, but people are not robots...that's now how the human body works.
"That people can't stop obesity on their own, but we shouldn't try to help them -- we should just resign ourselves to being hopelessly obese?"
Really, look at this
http://en.wikipedia.org/wiki/Health_at_Every_Size
This HAES movement is not saying don't excercise or don't eat healthy. Quite the contrary. Just that even if we all ate healthy and excercised, it doesn't necessarily mean we will all get thin. We will be healthier by adopting healthy habits, but not everyone will get thinner. I think we need to question this assumption that thin automatically equals healthy at all times, just as we can start questioning the assumption that fat automatically equals unhealthy at all times.
The real issue is the effect on future lives, and future freedom. And in my opinion, they way in overwhelmingly on the side of stopping further government encroachments into health care provision.
Freedom to do what? Where were you in the FISA debate? When GWB was trying to expand government powers? I notice you(or most of your like-minded ilk) didn't make any noise when it was disclosed that Darth Cheney wanted to send the Army to arrest the Lackawanna Six. I laugh when you(or all those Paulites) talk about freedom/liberty. You don't live in a Utopian bubble.
How would FISA impede on your freedoms? That's right you can't say except in the abstract. Whereas, with ObamaCare the freedom to have the health plan you want today is seriously in jeopardy. But nice try and a non-sequitur.
I can see that Megan is getting quite a few snarky replies from left-wingers. I mean how dare she dissent from Obama!
I try to think of the first point as a feature rather than a bug. As it is, we live in a system in which it is expected that everyone will be given every last treatment possible, regardless of expense regardless of cost (not to say that that always happens, but that is the expectation). That world has too much expensive innovation. With no cost containment pressure of any kind, medical innovation would continue until it swallows 100% of GNP.
Handing it all over to government is a way to drastically slow the innovation. I don't really see any way around it, although I'd like to forestall it as long as possible, so we bequeath as much medical technology as possible to future generations.
FWIW, my preferred public policy would be to give everyone free catastrophic health insurance, in which the government picks up the tab for all (or 90% of) medical bills over $15,000 or something like that. I think most people are most afraid of coming down with some terribly expensive disease which will bankrupt them. Eliminate that worry and the more or less totally free market will look a lot less problematic.
Scott Wood - the left insists that the innovation arguments is a GOP lie, they point to Europe as a "hot bed" of innovation despite single-payer.
That's because once they invent something, they patent it in the USA! Nice try. Automatic ball return.
but computers, by themselves, did not give Wal-Mart the idea of treating trucks like mobile warehouses, much less the expertise to do it
No, that would be the massively subsidized and favored socialized road system. God do I hate it when libertarians hold up road- and sprawl-related industries as the paragon of the free market...no wonder nobody trusts us!
Actually, they generally quit trusting you, by which I mean you personally, when you hold up legitimate public goods as a "massively subsidized and favored socialized 'x'".
Everyone had the roads. Only Wal-Mart revolutionized logistics. You might rather we didn't have the roads, or the Wal-Mart. But we do, and the point stands.
The interstate system was made at the request of Sam Walton hisownself, speaking to the POTUS in a smoky back room. It's a conspiracy, I tell you!
I agree Megan.
Anyway, what amuses me the most is that people are about to create what will amount to a health care monopoly and they think that the expense will go down.
Basically, for me, it all boils down to public choice theory.
The simplest prediction of public choice theory is that politicians will blow out the budget long-term for short-term gain.
Here's the verification of that pictured around the world. And, yes, most of that is for medical care promises, even in those countries supposedly so much better at cost control than us.
Those who really buy the dream that government-run, er, politician-run health care (public choice requires us to remember that politicians run the govt) can cut costs really should look at the experience of the two single-payer health care plans the govt has run here in the USA for the last 40 years -- Medicare and Medicaid. They have some 'splainin to do!
Medicare, Obama's people say, costs about 30% too much! Thus it seems a rather bizzare argument to claim that we need nationalized health care, "Medicare for all" even, as per Krugman, to cut costs!
But Obama's guy Orszag explained the reason to Virginia Postrel. She asked: if 30% waste exists, why don't you just cut it now? Use those savings to fund your health care proposal. They'll be huge.
Orszag replied, AARP and Congress won't agree to any cuts -- even to save 30% waste! -- "unless they get expanded coverage first".
Doesn't this give away the whole game? Congress simply won't cut even into 30% waste. Congress loses votes by cutting benefits people want, "effective" or not. Congress doesn't like to lose votes!
OK, so at most there'd be a one-time tradeoff deal -- some one-shot savings in exchange for expanded coverage that consumes them, then no more savings ever again, as costs go back to rising as before (from a now increased base). Maybe, at best -- since if Congress and AARP get the expanded coverage "first", what's to hold them to providing the savings later?
And that's just Medicare. Everybody forgets Medicaid!
Did you know that by consensus there's at least $30 billion annually of easy, "low-hanging fruit" cost savings sitting there in Medicaid? Savings that wouldn't cost anyone even $1 of true medical benefits!
And over $30 billion in savings annually (maybe a lot more!) could go a long way towards plugging the funding hole in the rest of Obama's health care proposal.
But Obama's never mentioned even one word about it! Nor have any of his people!
Why doesn't he want that money??
Public choice explains why.
The first thing I always remind my leftie friends is something that Greg Mankiw pointed out on his blog: that if you advocate a government solution to any problem, it will have its topmost bureaucracy appointed by People You Hate at least half the time.
So, if you don't want Reagan or Bush appointees or their descendants running your health system, don't have a "public" one.
You make the presumption (grossly unfounded, I must say) that universal coverage somehow means the end of the private healthcare market. This is clearly not the case. Presuming that universal coverage means an end to private insurance and medical treatment is a straw man. This is not what is being proposed. To frame your argument in a manner that suggests that it IS is intellectual dishonesty at best and outright mendacity at worst.
Britain has the NHS; Britain also has private sector healthcare. Those who have private insurance or sufficient personal funds may have all of the experimental and expensive treatments they or their insurance can or will pay for. Why you presume that this would be any different in the US, even with universal healthcare, is confusing. Nor is it clear precisely how the advance of medical science would be halted in its tracks.
I'm also not entirely certain what 'construction and office workers at Ground Zero' have to do with anything at all (unless you felt that you really needed to work a 9/11 reference, somehow).
The point is that they're those ordinary folks who public health experts . . . contra Matt Steinglass . . . spend a great deal of time trying to "educate".
Still rather superfluous to the point; and obesity is a poor example, anyway, being somewhat more complex than your simplistic take--humans, as a species, did not evolve in an environment where they had continual access to foodstuffs high in calorie content, nor did they evolve to lead largely sedentary lifestyles, as the average office worker does today; obesity is no more solely due to greed and sloth than poverty is solely due to laziness and a lack of education.
So let's change it to another medical problem as a consequence of poor choices:
drug addiction
alcoholism
HIV-AIDS
Herpes-STIs-PID-infertility resulting from
lung cancer
anal cancer
etc.......
Megan makes a good point that nationalizing formerly private sectors does not change the fact that the workers are still ordinary people. The new health jobs will be filled by the old health workers intially.
Government already has an incubator project (two) in the form of running auto industries. Three, if you count Wall Street. They seem to be good at deciding they can do a better job at running existing organizations rather than forming new ones, because after all, government is parasitic by nature and not a host. Government can use force to make people buy products, whereas private industries have to use innovation and customer satisfaction. Like Dan Akroyd said in Ghostbusters, the private sector demands results.
Even if citizens are required to buy insurance, 100% will not be insured. In a perfect world, maybe. People drive without their seatbelts on, no insurance or licenses all the time. Pieces of paper called PPO do not protect against someone determined to harm you. Lawyers deal in paperwork and words, not the physical world. If we were all 2 dimensional, all their plans would work out if they could add mathematics to their background. Then they would be economists.
Government does not innovate, even in the defense area, the innovation is done by private firms.
There are only two facts I need to know about the British National Health Care System.
1. Routine Pap smears used to be allowed after age 20. In a cost-cutting measure, routine Pap smears are now available only after age 25. (By the time symptoms manifest it's almost always too late to save the patient.)
2. My aunt, in her late 70s and living on a tiny Social Security pension equivalent, was on a long waiting list for cataract treatment. By the time my father died and his only asset, his house, was sold, with provision for his younger sister to have enough money for her cataract treatment, she was totally blind in one eye. The other eye was saved and she was thrilled to be able to read and watch TV again for the remaining six years of her life.
But if you'd like more information, try this. There's supposed to be an 18-week limit on how long a patient must wait for treatment. A site at http://www.nhs.uk/news/2009/03March/Pages/NHSwaitingtimesQA.aspx says: "The average wait for treatment for patients admitted to hospital is now just 8.6 weeks. Outpatients waited an average of 4.6 weeks at January 2009, compared to 7.4 weeks at August 2007." Read further down and you find: ". . . the 18-week target has not been reached in two specialist treatment areas – trauma and orthopaedics, and neurosurgery."
So if you're in a car wreck or break your leg in a work accident or you have a brain tumor, herniated disk or skull fracture, I guess you just have to wait four or five months or more for treatment -- unless you have the money to pay for private care.
You can choose and make an appointment at the hospital you want to go to -- if you've been shortlisted at that particular facility. I guess if you have a brain tumor and you live in Massachusetts, you probably wouldn't be able to go to Duke Medical Center in North Carolina for treatment. http://www.chooseandbook.nhs.uk/
I have several medical problems and several medical bill problems to go with them. A double biopsy is coming up in the next week (need determined by ultrasound just yesterday -- one week wait!). I'll have to make arrangements with the hospital to make a few monthly payments to clear that bill. Even so, I wouldn't swap our system for the National Health Services type.
My mom was with Kaiser. They used to offer annual routine Pap Smears. Now they've changed it to every two years. For women in their 60s!
That's all I need to know about the American health care system: somebody already decided it was cheaper to have women get cancer than to catch it early.
And guess where government healthcare will get you on that front?
http://www.independent.co.uk/life-style/health-and-families/health-news/is-cervical-cancer-really-a-big-threat-to-women-or-just-a-big-scare-724020.html
Does this mean you'd prefer a system where your mother would have no other alternative, or a system where your mother could freely choose an insurer whose policies aligned more closely with her needs?
Um, yeah. She already had no alternative. Kaiser...Or the individual insurance market. The only way she could change plans was to change jobs.
People might take you more seriously if you actually recognized that the vast majority of people in this country already have no choice in insurance.
Cervical cancer is primarily associated with HPV. HPV is sexually transmitted. People over sixty are less likely to have multiple sex partners, meaning their risk of catching HPV is reduced. I read one study that advocated dropping to a pap every other year for women a lot younger than 60 - i.e. over 35. So the insurance company weighed the benefit of a pap annually over sixty versus the cost - and it came up low. Are they cutting mammograms? Consider, Mark, that by cutting out what are likely to be a lot of unnecessary paps for women in that age group, Kaiser may be able to offer things that are more likely to help - such as MRIs or CTs to locate breast cancer. For women over sixty who are sexually active enough that a pap smear every year is still a good idea, you can get one at Planned parenthood, or pay full freight at your gynecologist.
I believe Kaiser also cut mammograms to once every two years.
What a batch/bunch of pure un-adultrated Garbage & HOOPLA!!!
Sounds jus like a ONE LEVER PULLER style of voter to me! Andddd it shore isn't an Independent or Democratic voter either!
Regarding your discussion about the extra health care costs incurred by the obese, a post a couple of days ago by Jacob Sullivan at Reason Magazone quotes a study that found that obese people reduce total medical spending in the long run. Because obese people tend to die sooner than thin people do, the researchers found, eliminating obesity would increase spending on health care!
As a Canadian I just find the fear level astonishing. Maybe American government really just is that bad but if so, it's sad.
American bureaucrats already make health-care decisions: the ones at insurance companies, and the HR departments who decide which plans to purchase. All those who can freely decide which plan to purchase at any point raise their hands.
If pharma R&D starts to falter, likely the global market will adjust overall. There will always be a market for new cures; it isn't just in the U.S. that they are developed.
the fear level is cultural. it's not so much that Americans think there government is incompetent (they have faith in the militiary, the CDC, the NTSB, even the FDA) but rather they are uncomfortable with anything they think smacks of a redistribution of wealth.
it triggers a puritanical reflex that somewhere, somehow, someone is eating without working. someone is getting a free ride. curiously the most ardent opponents of this "free ride" are persons residing in states that receive more money from the Federal government than they give to it.
having convinced americans that everything can be filtered through a cost-benefit analysis, the right is able to effectively stiffle any government program by focussing on cost while excepting military action as an essential service.
Or, maybe Americans have seen what a bang-up job the government does in Medicare, Medicaid, and the non-trauma areas of the VA hospital system; then compared their own experiences at government-run service centers such as the DMV and pre-privatized US Postal Service, and decided they don't want that expanded to cover the entire country's healthcare services.
It could be that.
Truly excellent analysis. This should seriously be taught in schools. You can get through 16 years of Education in America without once stumbling upon the concept that freer markets and freer societies create more innovation and have higher standards of living.
Also, as I have told my congressman, senator, and president in email, there could be a health care bill today if Democrats were ready to compromise and craft a solution that respects the free market and private innovation and incentives rather than stifles it. It works like this.
1. Make health insurance tax deductible and portable so its not linked to an employer or a state.
2. Give parents mandates and vouchers to help cover their kids
3. Reduce actual costs by getting industry participants in a room and saying "what laws, regulations, mandates, etc, are doing more harm than good"? We know some of the solutions, like tort reform, eliminating waste and fraud, etc, but I'm sure we'll come up with many others, perhaps reforming the medical education industry for example to increase the supply of doctors and nurses.
And pass them as three different bills of course - these monolithic bills are ridiculous.
Megan,
Fantastic post.
Of course, for the sake of parsimony, you could have just used Ann Althouse's argument: "The only thing you need to know about national healthcare is that Congress and the President are exempting themselves from it."
Wells, that's a nice quote from Althouse, but I think Megan has made a further and better point in the main post. Obama cannot exempt himself from the negative effect of socialized health-care Megan is describing: no one can. There is no exemption which can be written which will guarantee that Obama, or one of his loved ones, will not come down with a currently-not-quite-treatable ailment in the next few decades.
If Obama gets his way now, it won't be treatable then either.
As I said over at that Althouse thread, the only way I would support even a tiny fraction of this health care bill is if Obama and Congress--and their families--would submit themselves to it for six months or even a year as a sort of trial balloon. My reply to any legislator who supports this is plain and simple: You first.
Kudos. "I'm afraid that instead of Security Theater, we'll get Health Care Theater, where the government goes to elaborate lengths to convince us that we're getting the best possible health care, without actually providing it. That's not just verbal theatrics. Agencies like Britain's NICE are a case in point. As long as people don't know that there are cancer treatments they're not getting, they're happy. Once they find out, satisfaction plunges"
Reminds me of this joke:
Lenin, Stalin, and Brezhnev are on a train crossing Siberia when the conductor comes back to them, saying that it broke down.
Lenin says, “Re-educate those responsible.”
The conductor comes back, saying, “This has been done, yet the train isn’t moving.”
Stalin says, “Shoot those responsible!”
The conductor comes back, saying, “The driver and the engineer have been shot — but still the train isn’t moving.”
Brezhnev says, “Paint the windows black and tell everyone we’re moving.”
Why does the government feel the need to "go big" when they can't even do a good job on a smaller scale. The federal government has their "War on Drugs" when they can't even keep drugs out of maximum security prisons. Now, they want health care for everyone when they cannot treat our military personnel and veterans (Walter Reed and Philadelphia VA hospital)
My thought is that they should fix medicaid and medicare. They should fix medical care for our veterans and active duty military. If they want to cover the uninsured or under-insured allow anyone to be covered under the already existing programs. Tearing down a very good system with the hope of building a better system in its place is impulsive. It is rash. It doesn't make a lot of sense when you consider the government's track record when replacing a market system.
Interesting. I agree with you. My question is...what did you think you were voting for when you voted for Obama? I really sincerely want to know.
Megan did *not* vote for Obama. She forgot to register to vote.
Megan, thanks for the valuable post:
Two specific comments:
1) New, expensive drugs will eventually become cheap drugs. If we do not develop and then buy expensive drugs now, we shall never have more efficacious, cheap drugs in our and our children's future; i.e., generics do appear over time.
2) Megan mentions a common misconception that eating fat makes you fat: "All were very well aware that the burgers and fries they ate made them fat, and hitting the salad bar instead would probably help them lose weight." The reality is that caloric excess makes you fat, as excess calories from either salads or fries are turned into fat once ingested. The problem is that people tend to like fries more than salad. Therefore, any government plan to limit obesity would certainly place the TSA in charge of fast food restaurants. (Megan, on a more serious note, I can provide references from the medical literature to substantiate the comments on the obesity impact of the type of calories ingested vs total calories, if you like to see them.)
A general comment:
A problem with popular blogs such as Megan's is that valuable comments are lost in the vast collection of others. The difficulty is finding the diamonds in huge pile of ________ (add your own synonym for paste, glass, etc)
If you are uninsured, that is your responsibility. The government should do its best to allow the marketplace to function with some protections put in place.
If it means you need to drive a Toyota Corolla instead of a high end Camry, so be it. The best health insurance plan put forth was done by the Bush Administration where tax credits were proposed to help Americans purchase private insurance.
We've set up systems for mandated auto insurance, why can't we do the same with health insurance?
Because your car could hit my car, your driving creates risk for me. It is systemically necessary to curtail the risks from underinsured motorists by requiring it. As with most bureacratic things, though, the ones that obey the law are not the ones we need to worry about. The uninsured motorist is often driving illegally anyway.
With health, if you're uninsured, in theory this shouldn't affect anyone else. It's only because of the looter mentality that we are our brother's keeper, that your uninsured nature is a risk to me.
Here is why health care is not a right, cannot be a right: IF healthcare is a right, then a doctor's knowledge is mine by right. His brain belongs to me, if the care he provides is my right. This is absurd on its face.
Even if centralized health services worked perfectly, it still would not be in Congress' power to provide them, short of a constitutional amendment granting that power to the federal government. The fact that they've gotten away with this much over-reaching since WWII doesn't mean that we should allow them an even longer leash.
All this arguing over statistics and theoreticals and anecdotes misses the fundamental point that this isn't something the feds should be doing in the first place. End the federal programs, and leave these policies to the several States, where they belong.
Totally agree! However, the only way to force the federal government to stay within the constitution is what? Elections seem to increase its powers, so tea party seems the only way left?
Render me a freaking break.
I have sent out packages via the post office every week for the last 3 years with most getting to their destination within 3-5 days. My loses were 3, 3 packages lost in 3 years.
FEDEX/UPS is too expensive for my business.
In case you have not noticed, no one is seriously proposing National Health Care for the US.
They are proposing altering the insurance system, but that is still not National Health Care.
what about innovation coming from all these European pharma companies which are working in the frame work of "socialised" medicine - maybe the super drug right now stems from a US lab, but do you really want to say that super drugs are always only coming from US labs???
They always come from US patents! Those foreign developed drugs form companies in the US and get patents here and overcharge Americans to recoup their R&D and make a profit, while their own countries use monopsony power to buy the same thing cheaply. It's a racket. Like border crossing Canadians who private pay or have Acure wait list insurance, their system is a parasite on America and they should acknowledge and grovel in appreciation. On your knees bitches!!!
Living in Canada since the inception of government provided universal health care I have had the opportunity to observe the benefits and some of the pitfalls of this type of government provided service. The essential difficulty lies in the fact that the government becomes the employer, and the provider of all the health care. It can no longer arbitrate or mediate nor can it come to the rescue in those instances where a private provider fails. One can expand on this difficulty to the point where it becomes obvious that governments can only fail to provide a service that is acceptable. Consider that the public will have to express their dissatisfaction at the ballot box which is really no solution. Most generic health care management, financial or administrative difficulties can only be mitigated by a degree, not resolved. Health care for the individual is hit or miss at the best of times. The expectation that the government can overcome the current problems and help provide a higher level of service will soon be found to be a false hope. The governments involvement in health care should be to monitor and set standards and provide financial help for defined needs and goals. I could write more, regards David Stern
"But saying that innovation will suffer assumes that there is no innovation or research going on in other countries and that is just.not.true."
Several people make similar assertions. This isn't a refutation of anything discussed.
First, the relevant analysis is the difference between innovation under one system and versus another. To my knowledge no one has claimed innovation completely ceases. Even the locution in this statement is false. The setup standard is "suffer", but this is followed by "there is no innovation". Suffer doesn't mean none, it means less. Since critics claim there will be less innovation under a command economy saying some still exists means exactly nothing.
Second, the observation that some occurs in other countries is meaningless. The relevant fact is the amount done which does not rely on a return generated by the American market. New drugs, devices, and treatments cross borders. Non-American biomed companies rely on the American market return for the value of a project to be worth the investment. If the returns decrease for successful projects, fewer drugs, devices, and treatments meet the financial hurdles required and will never go into development.
This is even more likely in the current scenario where Obama has been stressing the cost angle. The plan is to set up an unaccountable insider group specifically to control spending, and we're supposed to believe developers won't perceive this as limiting future returns? Who could possibly arrive at this conclusion?
Like you said.
And like I said, this is something we know darned well from a century of observation. Free markets lead to innovation.
Like the government funding all of the defense contractors from 1945-1990? The defense contractors that developed the most technologically-advanced armed forces in the world despite getting all of their money from the taxpayers? And having projects decided by the Pentagon?
Not to mention space travel...
Mark:
The Defense Department is not a good model for innovation.
Defense contractors are in the position of the car repair shop that you tell to replace the radiator, then the coolant pump, then all the hoses, then the reservoir, just because the coolant is low. They make money each time, but your problem gets fixed (if it does) as a side effect.
The only reason Defense spending is at all effective is the risk that the hardware will actually have to be used. The military tends to want their hardware to work.
Jamesetc:
Don't mention space travel. We don't have space travel. 30 years after the Wright brothers flew at Kitty Hawk, Douglas Aircraft built the DC3, many still in service today. 50 years after Yuri Gagarin orbited the earth we do not have our spacegoing gooneybird!
The Apollo project was a magnificent, glorious achievement. It was also a terrible kludge. The shuttle since then has been the cuckoo in the space travel nest.
Let's not forget about the big conflict of interest here:
The bankrupt federal government presides over the bankrupt Social Security system. Once you stop generating tax income for the government, the sooner you die, the less bankrupt they are.
In taking over the US health care system, the federal government is going to save Social Security by making sure people never live long enough to receive it.
All they have to do is deny just enough medical treatment so that people who would otherwise live to be 88 die at 82 and voila! Then the government will be solvent and they can get back to the important work of fattening up government pension benefits and funneling cash to their union cronies.
I've been saying this from the beginning--government health care as a way to reduce the OAP rolls and save Social Security.
Not necessarily the latter part, but that's a good point.
If a reporter were to come to his editor with a proposed article titled, “President Obama is gay,” the editor would demand supporting evidence, before that article ever saw daylight.
However, if the same reporter submitted an article titled, “Federal deficit is too high,” history says the editor would ask for no supporting evidence, nor would the article contain any. The media merely assume, as a matter of faith, that revenue neutrality is more prudent than deficits.
Economics is rare, perhaps unique, among sciences, most of which demand evidence for their hypotheses. Only in economics can intuition, faith and popular wisdom obviate facts or even the desire for facts. Thus, I have had editors, columnists and reporters tell me it is “obvious” that large deficits are unsustainable, lead to recessions, depressions, inflations and hyper-inflations. When I ask for evidence to support these views, I seldom hear from them again, probably because they feel scientific evidence is unnecessary in a science, but more importantly, they don’t have any.
Even the Concord Coalition, an organization that for seventeen years, has collected vast amounts of money to preach for federal deficit reduction, unashamedly offers no evidence to support its views. Check its website, www.concordcoalition.org, or write to them and you will see they neither offer nor have evidence.
Because our leaders parrot the economic beliefs promoted by the media, lack of evidence has contributed heavily to the government actions that yield repeated recessions. Until the media learn to ask, “What is your evidence?” we will continue to suffer periodic, economic traumas. These traumas may seem inevitable and unavoidable, but in reality they are caused by beliefs lacking evidence.
Rodger Malcolm Mitchell
rmmadvertising@yahoo.com
http://www.rodgermitchell.com
Running deficits in household budgets year after year is the formula for long term success for families, so why not the government! Makes sense to me. Just fire up the printing presses and have at it. Run up the national credit card. Go! Go! Go!
California
Remind me never to hire you for advertising advice.
As another wrote: "California." They are operating at a deficit. Any consequences there? Any talk of IOUs? Any furloughs?
China and Europe are moving away from the dollar. T-bill markets have shrunk.If you're immune to evidence, so be it, but your position is risible.
Maybe you should visit Zimbabwe.
Or Argentina.
Would a "no comment" strategy be best here for me? We are what we consume. But please - let's not shxx where we eat?
Sufficient to say that this gives too much away about most people in the West today. I think the reasons for a claim like the above are the same reasons why nobody gives a flyin' fuxx about any real issues except for fighting the opposite ideology. Not beautiful.
Megan, I have to admit that I'm a little befuddled by this post. You're usually well-informed and well-reasoned, but this time I feel like I'm listening to an undergrad with a copy of Atlas Shrugged under her arm. In the first place, national healthcare a la NICE is dead on arrival, and I KNOW that you're sufficiently well-read to know that. National financing of a health-care option is also somewhat (sadly) on the ropes. We are so far from seeing legislation even vaguely resembling a system that you fear that I wonder if this isn't all a straw man argument.
Admittedly, my knowledge of health reform choices is limited to wide reading, and my opinion informed by personal experience (my brother worked for Big Pharma for a decade, and I have had the misfortune to be insured by Blue Cross/Blue Shield). Blind adherence to free-market economics is so yesterday, but you seem to have a fervor that is undaunted by the realities of oligopolies, government-sponsored inequities and market distortions, and the singular nature of health care as a consumable.
Sometimes the evidence (though anecdotal) seems pretty compelling: Why does Viagra cost $18 a pill? Up from $16 last year and $14 the year before? Not sure, but it's not the cost of production. And, if you read the dubious history of the active ingredient and consider what the real cost of bringing to market should have been, you have to wonder if all that "research" is really research, or perhaps it's also (or mainly?) something else (you know the examples, so I won't elaborate). Or why was the pharmaceutical companies the most profitable sector on Wall Street for a decade? Or, why are they not now? I think it's naive to think it's all economics, but that's what I'm taking away from your argument.
Krugman (yikes!) and less acerbic opinionators have provided reasonable arguments why for-profit health insurance (to pick one bad actor in all this) are never going to provide the greatest good for the greatest number. Case in point: the DAY I moved from Blue Cross (a for-profit risk aggregator) to Kaiser (a non-profit with integrated insurance and health provision arms) I was scheduled a colonoscopy (at age 59, no advserse family history) that BC routinely disallowed. I was given a low-cost prescription for a fungal medicine that the BC/BS "medical panel", judged would be "ineffective". Oh. And, my premium was cut in half.
As for your statement "But seriously, 10s of millions of people are stuck in their job because they'd lose their insurance if they left? Yeah, they'd also lose their income if they left. And maybe their house soon after.". You can't be serious, right? I am, like you, self-employed, but I've held a number of corporate positions and I can tell you for a fact that I've known dozens of people who kept their job because of health insurance -- in many cases making substantially less than they would have as sole proprietorships or startup techies or even stay-at-home spouses specifically because of health insurance (and usually, pre-existing conditions). If you think all of this is anecdotal hyperbole, I'm amazed.
As for NICE: they spend less than half per capita than we do and ration care. If they had our budget, there would be less rationing, and who know whether we would still hear the horror stories of long lines and long waits from the Right. All I know is, having lived in Europe with lots of European friends, they almost to a soul LOVE their health care (along with many other things deemed socialist by the talking heads of Fox).
Andrew or Nate Silver (can't remember which) recently made some good arguments about Medicare/Medicaid, including the fact that the growth in their cost has been slower than that for the free market suppliers. Is that an argument for free market efficiency?
I really think posts like this get people off track from the important stuff. Like: why IS health care cost increasing at 3 times the inflation rate? Is it the extrapolation of the finding that a dozen people in a small Texas area went to the ER over a thousand times? Is it because (unlike the rest of the world), there's no reason why an M.D. should make more than a post-doctoral PhD in astrophysics (but they do, and I'm not convinced the reasons are free market equilibria). Is it the oligopolistic pricing power of hospital conglomerates that have systematically bought up smaller health care provision facilities? Is it the pricing power of Big Pharma? Is it substantial lobbying dollars? I don't know, but I'd like to hear your views on those, too.
And when you're done with that, could you tell me why private college tuition has had an inflation rate nearly as large as medical costs?
Respectfully yours,
Jeffery Bahr, PhD
"Blind adherence to free-market economics is so yesterday"
Maybe. But since 95% of self identified libertarians, including Megan, don't support this what are you talking about?
"I can tell you for a fact that I've known dozens of people who kept their job because of health insurance --"
Not only are you not addressing the issue, the fact isn't an argument for government interference. Having a job isn't the same as being locked into a specific job. Moreover, the job problem exists because of government. Employer based insurance isn't a market creation, it was a reaction to government salary freezes which government later coopted and promoted. So now the government control types realize the inherent weaknesses but somehow conclude free markets are to blame? The solution to employment - health conflict is to get the employers out of the healthcare business.
The essential "problem" that is driving us toward a new healthcare system is the perception that costs are getting out of control. Why do I call it a "perception"? Think a little deeply about the continuous claim from some that "at this rate of growth, healthcare spending will become 50 to 100% of GDP in a half-century." Would this claim even make a lick of sense and/or even be a thing to worry about if people were voluntarily choosing to spend their incomes on this amount of healthcare?
We are spending more of our income on healthcare for two fundamental reasons- we are living longer and longer, and medical technology is becoming increasingly sophisticated, and both of these have positive feedbacks on the other. As we live longer, our demand to live even longer requires more sophiticated medical technology which then helps us live longer, and the cycle repeats. If spending 30% of GDP, for example, is a problem, then people can and will voluntarily adjust their demand functions for the goods they desire, and the rise in spending on healthcare will start to flatten.
The only other way you will be able to flatten or decrease total costs is to do one of two things: you have to put a firm, unbreachable cap on spending by most people, or you have to put such a cap on all people. The first of these inevitably leads to dramatically tiered levels of care based on ability to pay- most people will pay for their level of care through insurance pools both public and private, and a small segment will pay for and receive the very best/latest from their vastly greater incomes. This inequity assaults a lot of peoples' sense of fairness, and it really never seems to matter to most whether or not healthcare for every tier of society has constantly increased in quality and quantity. (This is much like the situation that applies to poverty in the US- it is the relative poverty that matters most politically, not the absolute levels over time.) The second method, capping spending for/by everyone, and the approach towards this outcome, while being the most equitable, is what will impair new medical innovation. Practically all new technologies are initially very expensive, and narrowing the population of potential customers for these innovations cannot but impede the discovery and the dissemination of new products and methods. It is always the tradeoff for equity.
Nice to see that Megan has taken a break from defending her boyfriend to talk about healthcare, a matter in which she clearly has no vested interest whatsoever a-uh, oh yeah:
http://exiledonline.com/journalism-face-off-russian-shadiness-vs-american-objectivity/2/
Whoops.
As for the article itself, the most hilarious section is where she talks about the ever-present, endlessly sinister "elite" (who Megan is, but of course not a member of, as a mere humble writer for the Atlantic & all). She proposes that we're patronising them, then...Proceeds to patronise them by imagining that they give a damn what the elite thinks about them. Clue: if they did, they wouldn't disobey them.
(Bonus points for the random Ground Zero namecheck, by the way.)
Fact is, here in Britain we've got nationalised healthcare & the vague nannying isn't something that anyone in their right mind cares about. They can walk into a hospital ill & receive treatment, with no bureaucracy, not immediate payment, no hassle. That's irrespective of whether they are, or are not a fatass.
Megan would much rather leave them in the hands of insurance companies giving them wonky premiums for their excess weight, or perhaps not covering them at all (especially not if they're the kind of person who'll be needing hospital treatment!). Anything else would lead to them being patronised, see. & who could possibly bear some middle-class do-gooder telling them what to do? I'd rather deal with a degenerative disease uninsured any day than put up with that!
"I don't buy into the arguments that government cannot do as well as the private sector. It's a mantra oft repeated, rarely proven accept via anecdote."
Here's another anecdote. How do you manage to make a monopoly gambling franchise go bankrupt?
Have it be run by the government:
~~~
Saddled with debts of $46 million and facing mounting losses each day, New York's beleaguered Off-Track Betting Corporation is considering the unthinkable -- bankruptcy... "It's sort of a logical thing to look at when you're paying out more than you take in," said one source...
OTB is operating with a negative cash flow of $600,000 to $800,000 a month on a betting handle of $900 million a year...
OTB is a public-benefit corporation created by the state ... Perhaps most troubling to the workers and OTB retirees is that their future medical benefits, worth an estimated $200 million, could be wiped out...
The audit found that OTB management had not conducted a study of its staffing needs since 1981 -- before the initiation of telephone and Internet betting options that account for an increasing percentage of wagering... [NYP]
~~~~
I can't wait until the same politicians who produce this result get a single-payer government health care plan to run.
Hey, they're running one now!
"Monopolies are not innovative, whether they are public or private."
And your example for this is...Walmart? That's the company reviled around the country for being a virtual...monopoly, and running lots of little stores out of business. I've been thinking about that example all night, and can't figure out how it makes your argument.
I agree with other commenters that if you had family wealth or trust fund or other ample safety net when you were uninsured, your personal experience should count for less, at least when opining about your being militantly for other people lacking insurance. Kind of like that rating system someone mentioned...
For the person who can't think of a single government entity that has innovated--NASA? Didn't they basically invent the dialysis keeping that loudmouth Mark Levin alive?
Here's a story that is relevant, I think: When I became self-employed in 1996, my health policy was about $500 a month. Then I got sick with a chronic condition, one treatable with (expensive) medication. By last year, when I lost my business due ONLY to my health insurance costs, my premium was $2000/month. Okay, you say, but you did have $1000/month in medications--true, but the plan only covered $1500 A YEAR in prescriptions. So by mid-February, I was paying all the prescriptions out of pocket. Last year I spent $40,000 in insurance and prescriptions. My wife and I looked for years for a more affordable plan, but couldn't get anything else, being sick and not belonging to a group. Luckily, I got a job with good health benefits.
So, I lost my small business due to health insurance. I thought all the right-wingers idolized the small business person? Or is this just another sad-but-inevitable story of survival of the fittest?
To be more specific, if I understand you, you're saying that Walmart revolutionized their delivery system. But they did it in order to deliver the cheapest, crappiest-quality goods, mostly from China, which helped to drive out of business both smaller providers and American factory workers. So this relates to health insurance innovation -- how? The private sector will innovate the delivery system (doctors, hospitals), then deliver, cheap, crappy care (pharmaceuticals, treatments)? I'm just not sure how the one (delivery genius) leads to the other (pharmaceutical innovation). Or did I misunderstand the argument?
"So, I lost my small business due to health insurance."
A good reason to separate health insurance from employment. There's nothing in your story which supports government insurance.
Freddie, regarding "there are millions of people in this country who lack access to adequate health care because of their financial or employment situation. And that lack of access causes immense suffering. Any interrogation of our health care system that does not reflect the pragmatic and moral realities of those facts is not the work of an adult." I actually do dispute that. Specifically, that lack of access causes immense suffering. Lack of access fails to alleviate suffering, but the condition that isn't being treated is what is causing the suffering. It's an importatn distinction, because I'm morally responsible only for suffering that I actually cause. If the suffering would happen even if I had never been born, then the suffering is not moral justification for armed robbery to alleviate it.
Yancey: I'm pretty libertarian meself, but I don't drink ALL of the Kool-Aid. Regarding "government interference": we're talking about insurance. Who better to aggregate risk than the wealthiest institution on the globe? And, in my experience, any interference of the government between doctor and patient will end up better than my decades of experience with for-profit health insurance companies.
Tim: Apparently, you don't read the WSJ. The entire gaming industry is on the ropes and The Station's holding company filed for bankruptcy today. OTB is just another victim of the recession.
Really. All of this government-bashing is comical. Red state farmers collect their subsidies. Last Frontier Alaskans import large amounts of federal largesse. Really expensive government programs, like the Defense Department, swallow gargantuan amounts of the federal budget (an amount nearly equaling the budgets of all other Departments, and exceeding the total of the world's military expenditures).
I'm an entrepreneur and a small business owner. I don't like paying taxes any more than the next guy. But I'm not crazy enough to believe that . . . oh, pick any one of a hundred anti-government memes . . . for example, that the fact that the USPS is running a deficit, we should just shut them down. Apparently, none of the people who advocate that have figured out that a 47-cent letter, sent by the cheapest private carrier, is going to cost you a couple of bucks.
Even Reagan said "In this present crisis, government is not the solution to our problem; government is the problem." Of course, the qualifying phrase is conveniently forgotten in the conservative memory.
I really think it all comes down to utopianism. The right-leaning believe that greater free-market phenomena will invariably lead to efficiencies, if we could only let it do its job (and how did THAT work out for you recently, Mr. and Mrs America?) And that government services are demonstrably inefficient. Well, work for any big company long enough and you'll know what inefficiency looks like. I am not at all convinced at my ripe age that any large institution is any more inefficient than the next, whether it's the Justice Department or Siemens.
Some steps in the wind...
I hear, in
the strength
that always
remains, the
delicate rhymes
of a deep
sensibility, and
even a pleasure
where the
sun-rise appears...
Francesco Sinibaldi
Megan wrote;
"Of course, the obese aren't the only troublesome bunch. The elderly are also wasting a lot of our hard earned money with their stupid "last six months" end-of-life care."
No doubt those conservatives, and libertarians that now are falsely telling us that the health reform bill contains a "death clause will give Megan a pass on a suggestion, that end of life care is stupid. Really easy to read stupid as meaning, it shouldn't be provided in contextof the article in entirety
Megan also wrote;
"I was uninsured for more than two years after grad school, with an autoimmune disease and asthma."
Megan failed to mention if she was forced to give up necessary medical care during that period, or if she didn't how the care she did receive was paid for. Makes her implied hardship irrelevant at best, self-serving otherwise.
In the end it's a cleverly written article, so cleverly written any suggested improvements to the whay we pay for health care must be hidden. Then I was uninsured for more than two years after grad school, with an autoimmune disease and asthma. I'm blue collar out here in the middle of the lower 48.
Again, based on Megan's Hayekian and Randian morality that is only good if it promotes "Freedom" and then defines "Freedom" as the "freedom means the right to make money and accumulate property with no duty toward others besides myself" this makes sense. You simply ration by price and those who can't afford treatment die (I guess Megan would grudgingly allow the Government to tax her and the other Randing Supermen to contract out services to dispose of the bodies).
In Megan's world Pinochet's Chile was a freer place than Blair's Britain because the wealthy got to keep more of their "hard" earned gains and for the same reason antebellum Virginia, with 40% of the population actually enslaved, was a freer place than antebellum Massachusetts that taxed its wealthy citizens to pay for free public schools.