When I wrote the other week about why I am opposed to national health care, a number of people angrily demanded to know why I was writing about something that "no one is proposing". Now, this is clearly a lunatic statement. I was writing about something that many people were proposing. I just wasn't writing about the nebulous bills currently wending their way through various committees.
I hadn't intended to. I was writing about my deeper opposition to the entire project of providing, paying for, or otherwise guaranteeing health care. Since for most people on the left, this is akin to declaring that I would like to take up killing orphans in my spare time, I outlined why I think that this is morally correct even if you take the liberal set of initial values, and don't place any moral weight on taxation or other coercive action by the state. I have voiced my various practical objections to the particular options on the table at various moments. But the main thing is that I don't want to give the government a greater role in health care markets. Nay, not even if all the other countries . . . well, all the cool countries, anyway . . . are doing it. To the liberals proclaiming that, unlike those of us in the conservative or libertarian camps, they are practical people just seeking the best way to make us all better off, I say: I think your utilitarian calculus is badly wrong.
Now, I felt this was relevant, because in fact, no one I know who is interested in national health care views these bills as the final iteration of American Healthcare 3.0. Everyone agrees that these bills are very bad, fix few-to-none of the underlying problems with the American healthcare system (cost inflation, the tax break for employer-provided insurance, etc.) But we have to do this because we can't just do nothing, now. So we'll do this now, add a whacking great new line-item to the budget, and then fix it later. The implied fix is things like cost controls on pharmaceuticals, comparative effectiveness treatment to decide which treatments "work" (and by extension, which ones shouldn't be provided), and an ever-expanding role for government treatment mandates. The goal of everyone, to a first approximation, on the "pro" side of these health care reforms is a European-style system where the government basically runs the whole show. Maybe they contract out the billing services to insurance companies, which you may choose between (though you can't choose covered services, etc). Maybe there's a safety valve in the form of a private system that the very affluent can buy into. But for 95% of the population, the government dictates what treatments are covered, and usually, how much should be paid for them.
I mean, pardon me if I've been totally fooled by all the people saying yes, these bills suck, but they're better than nothing, and they'll open the way for all sorts of government awesomeness later. But assuming that they aren't funning me, why on earth would I confine my discussion to what's on the table right now?
I think most of the people demanding that I discuss nothing but current legislation understand this very well. That's because they feel exactly the same way about pro-lifers advocating for bans on partial-birth abortion, various sorts of counseling, waiting periods, and parental consent.
The fact is, leaving aside partial-birth/late-term abortion (I will not here dive into the debates over whether the health of the mother includes mental health, or whether late-term abortions are or are not performed upon women who simply decided they'd rather not have a baby), these restrictions do not strike very many people as unreasonable. They recognize that outside of the pro-choice movement, most Americans think that having an abortion is a Really Big Deal, and gently discouraging it by asking women to think the thing through is not crazy.
Nor is demanding that teenagers have an abortion for some reason other than, "I don't want my parents to know I was having sex." I'm sure that had I gotten pregnant in high school, I would have had an abortion on my own rather than telling my parents--and not because my Upper West Side liberal parents would have horrifically abused me. I also think that that would have been the wrong decision in many ways, but most basically, because abortion is not something you do because you'd rather not have a difficult discussion. Yet a lot of teenaged decisions are predicated on preserving as much privacy as possible from their parents, rather than, say, what will ultimately give them the happiest, most fulfilling future life. The whole reason we don't let most teenagers live on their own is that we recognize that they're not ready to make a lot of major decisions.
Now, the pro-choice side generally does debate the provisions on their own terms, and comes up with horror stories about women who are horribly inconvenienced by waiting periods, teenagers whose parents beat them up because they're pregnant, etc. But these are not arguments against reasonable laws; they're arguments for finding ways around them, like a judicial override for teenagers who really believe that telling their parents would put them in danger, funds to help women who cannot afford to travel back and forth while they wait, or teleconferencing. That's why pro-choicers so often lose those debates.
And while some pro-choicers are hard-core libertarians who resent the slightest intrusion by the state, how many of them would really get excited about these provisions if they didn't perceive them as battles in a longer war? They think that these are just the first step on a slippery slope--a way for the pro-lifers to get the camel's nose under the tent. And since the pro-lifers seem to view it exactly the same way, I think they are absolutely right to believe this.
So it makes sense, in the context of a debate over waiting periods, to discuss your broader philosophical opposition to inserting the heavy hand of the state between the woman and her doctor. Pro-lifers can say that it's not on the table, but that's just so much flim-flammery. It's always on the table. Likewise, in the health care debate, single payer. So there's never a wrong time to bring it up.
At the heart of it, in most of these debates, both sides are saying "I don't want to go here because once I do, I'm afraid I'll end up there." They don't trust the other side, and usually, they're right not to. In this case, I think that the political logic of an expensive new health care plan will push us faster and further towards price controls on key inputs, and somewhat hamfisted "one-size-fits-all" standard-of-care recommendations. I am reinforced in this belief by the fact that many of the people pushing health care reform are also enthusiastic proponents of . . . price controls on key inputs, and national standard-of-care recommendations. I don't trust them when they ask me to focus on just this bill right here.
They shouldn't trust me either. Except they should, because I'm being right out front about this. I don't want this bill, and I don't want any other bill that increases the number of people for whom the government pays for care. I may point out why you shouldn't want this bill, and I will try to be intellectually honest about it--i.e. focus on things the bill actually is likely to do, rather than "death panels". But I wouldn't like it any more if it was more like something you want. In fact, I'd probably like it less.
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Megan,
I'm genuinely surprised you had to make this post. I've read your previous posts, and I thought it was pretty clear that you considered the various iterations in the House of Reps a pathway to government run healthcare, and not government-run healthcare in and of itself.
That being said, I did see a fair number of commenters saying "But that's not what's being discussed."
Similarly, as far as mis-interpreting, I notice alot of new sources are calling protestors "Anti-healthcare-reform". In other words, if you protest this bill you are against healthcare reform.
Joe
What do we DO in the perfect conservative world with people who require expensive health care and can't pay for it? In many cases (certainly not all) it's ridiculously inefficient to let them die.
Some kind of emergency loan program?
Interesting question.
Considering most of those loans will not be repaid, where would the funds come from? Will non payment mark a subjects credit? If not, what is the point of calling it a loan? And if it does, wouldn't it lessen the usability of credit score?
Here's what you DO:
1) Cut Medicare benefits across the board, increase the eligibility age to 70 (with a stratified phase-in for people currently over 60 years of age), and increase patient co-pays in the Medicare population
2) Give all individuals under the age of 35 the option to "opt-out" of Medicare completely, removing them from the list of future beneficiaries. However, these individuals still have to contibute 50% of their current Medicare contributions for X years, where X is age of eligibility minus the age of the individual
3) Remove the employer tax deduction to sever the tie between employment and healthcare insurance, releasing the millions of people currently covered by employer plans out into the market - and collecting more tax revenues from business
4) Tort reform and a complete overhaul of the medical malpractice litigation system, capping damages, reducing malpractice insurance premiums, decreasing medical costs
4) Allow for a "Compassionate/Humanitarian Emergency Medical Treatment for Life-Threatening Illness" tax break/credit for all hospitals, clinics, and private practioners to offset the costs incurred for emergency medical treatment of uninsured/underinsured.
4b) The money for 3 comes from the savings in 1 through 3
sorry too many "4's"
and the money for the tax credit (heck call it a subsidy) comes from savings of 1-4
Matt,
Just to add a point, if you don't mind, remove the state to state barriers that also limit competition between health insurance companies, allowing better companies to obtain larger groups of insured, leading to better bargaining, more paying in, etc.
2) Give all individuals under the age of 35 the option to "opt-out" of Medicare completely, removing them from the list of future beneficiaries.
Won't work because they will become old, reliable voters who will then just get what they want anyways. They will also just get care under option 4, effectively saving zero money.
3) Remove the employer tax deduction to sever the tie between employment and healthcare insurance
How do you plan on re-creating the risk pools that employer health insurance provides?
"How do you plan on re-creating the risk pools that employer health insurance provides?"
The risk pools are the insured lives categorized by risk behaviors and demographics.
Byrk,
- No, it will work, because believe it or not there is a percentage of people out there (how many I don't know) that simply do not want a government handout. I plan on using all my Social Security checks for a bonfire one day. You watch.
- The risk pools will be created the same way they are now, off of current demographics, medical history, etc...
I'm pretty sure that the first number "4" is unconstitutional thanks to the seventh amendment's guarantee of the right to "trial by jury" in "all suits at common law" over an amount of "twenty dollars"
Trial by jury in suits at common law means the jury decides damages.
So capping it will require an amendment.
Good luck with that.
No. Juries can decide the factual question as to what the damages are. That's an entirely separate question from the legal issue of how big the judgment will be. No amendment required.
There are a number of states that already cap damages for personaly injury settlements. Perfectly constitutional.
Charitable emergency care doesn't cut it.
The real problem is in people with expensive chronic conditions, which is a hell of a lot of people: diabetes, Alzheimers, heart failure, MS, Parkinsons, AIDS, etc. It's not like those are just a few rare, tragic cases here and there. Look at 60 year olds and you have a large share of the population who fall into one or another "expensive chronic condition".
You can cover a diabetic who ends up in the ER due to a heart attack or glucose coma, but what they really need is expensive ongoing care.
The real problem is in people with expensive chronic conditions
The real problem is that the people with these expensive chronic conditions bear too little of the cost for treating them.
That's part of the reform - cutting Medicare benefits across the board, and forcing the elderly and the ill to pay more for their treatment. Not all of it, but more of it.
We should all be paying more the vast majority of medical care we receive. Just like we pay for everything else that sustains our lives. Government and insurance plans need to pay less, we need to pay more. That will both drive down costs and future expenditures.
If we all had catastrophic medical insurance plans, instead of the healthcare subsidization plans we currently have, this would be a non-issue.
What does "more" mean? Any of those conditions can run you $20,000/year in treatment, forever, with a major risk in any given year of complications costing a lot more. At a median gross income of $50,000, it's hard to see every year isn't "catastrophic" for people with those conditions.
anirprof;
I agree with you here, but this is a very small portion of the country. I would have no problem with a government backed catastrophic insurance for these types of cases that pay on top of whatever health insurance they already have. It would be a lot less expensive to solve the problems of the percentage of population paying over $20,000 a month than it would be to continue on the road legislation is taking us now.
Nola:
The problem is that the numbers are NOT small. Diabetes care, for example, averaged $12,000/year per diabetic back in 2006. And there are 26 million diabetics with numbers expected to hit more like 50 million in the forseeable future.
There are about 6 million people with Alzheimers, at an average annual cost of $20-40,000
Heart disease averages $18,000/year per person, for yet more millions.
The problem is that the numbers are not small enough that you can just create a small program to help the afflicted and pay for it out of slop elsewhere in the budget.
It's in the 40 million? 50 million? people who have expensive chronic conditions that you have the big expenditures. A subsidy program aimed only at them is still huge and expensive -- hundreds of billions to over a trillion. It's not like if we decided to spend a hundred million subsidizing goat farmers; it's so big you either have to have a big new tax or to squeeze it out of the rest of the system.
anirprof;
Diabetes is certainly the most prevalent of the expensive chronic conditions. The American Diabetes Association (http://www.diabetes.org/diabetes-statistics.jsp) says currently there are 23.6 million diabetics with a total of $116 billion in medical costs.
I'm not trying to say these are just a few tragic cases here and there. My point is that, according to HHS in 2002 (sorry the data is a little old, but still germane in at least a relative sense), only the top 5% of the country consumed more than $12,000 dollars per year in health care expenses. This, compared to an average adult health insurance plan costing $7,000.
http://tauntermedia.com/2009/07/28/unconscionable-math/
My point is that, with a government funded catastrophic plan, we could install a roof on what insurance companies must pay per year (obviously it would be a varying roof, but this is just a general description). Above this roof, the national catastrophic insurance would kick in. This would also inhibit rescission by insurance companies (a rare occurrence anyway). Patients with these conditions may have to pay more, but in many of these conditions they will have been paying for insurance for many years, especially considering Alzheimer's and other dementia related diseases. (As an aside, when we know that 80% or more of health care expenditures occur in the last 2 years of the average person's life, we need to encourage saving for these expenditures).
I suppose that my point is that health care expenses (not insurance, actual health care) are not as unaffordable as many believe. 90% of the population pays less than $12,000 a year, and 80% pays less than $3,500 a year. There is no reason some combination of catastrophic government insurance + regular private insurance can not cover the people with these expensive conditions.
I appreciate you voicing your reservations, because it helps me clarify what I would like to see in any health care policy or system the US should adopt, craft, what have you. I keep coming back to the extreme cases: too costly to pay out of pocket, too individual to develop profitable industries to address (for the time being; I hold out hope for the future). It just seems like the best way to address the risk is to have the largest pool possible. That's a good use of insurance. Taking insurance to mean the right to take advantage of reduced pricing on a service that I will need to use at some point, however, doesn't strike me as insurance at all. I don't take out lunch insurance, I pay out of pocket. For run of the mill medical costs, I'd love to see a system where we pay out of pocket for what we would utilize for day to day care. But going back to catastrophic illness; is there any optimized libertarian alternative that would surpass a nationalized program? Again, not debating specific policies, just the general idea.
I don't believe there is anything un-libertarian about insurance. Spreading risk, is very similar to how banks allow borrowers to get sizable loans from many different depositors. I certainly never heard anyone argue that banks are un-libertarian.
People naturally want to smooth their cash flows.
Banks or insurance, I mean.
I'm still curious what the solution is for someone who is facing a huge, long-term, ongoing, and 100% certain expenses on care -- people with conditions ranging from MS to diabetes or whatever.
"Insurance" is those cases is only possible in the same sense that you can "insure" a house that is standing right in front of an advancing lava flow: you hand the insurer the whole value of the house plus a few bucks in fees and then they hand it right back.
If a straight risk analysis says that the expected value of someone's medical care in the next 12 months is $50,000 (not at all unlikely for someone already known to have heart failure or diabetic complications), and that person's total gross income is $50,000 (roughly the actual median), then what?
anirprof - People with an income of $50K often have a net worth of well above $50k.
OTOH your basic question makes sense. Make the expense $500K, or $5mil, and your still in a situation where without previously established insurance, or charity (free or partially free care, people donating to pay for care), or coercion (paid for by involuntary taxes), the patient is unlikely to be able to afford the treatment and may die.
Possible answers would be a mandate for catastrophic insurance (I'm not a fan of government mandates, but it would be less intrusive than a full government take over of health insurance), a much larger amount of charity, having the person become poor paying the bills until he's eligible for Medicare to take over, or old enough for Medicaid to cover it, or just have the person be at risk of death because of lack of treatment (that options been mostly rejected by our society, but he may still be at risk because of less treatment or lower quality treatment). None of these options is ideal. This isn't a situation where there is a perfect solution.
The problem with health "insurance" right now is that it isn't a classic bet-with-a-bookie that car, home, and life insurance are.
With health "insurance", the bookie isn't allowed to check the odds, the potential payout is unlimited, and the bookie is required to take bets on races already run. No wonder the system is twisted.
Feature, not a bug. We don't want sick people, particularly in the many cases where there is no real moral fault for their poor health, to bear the full brunt of their costs, because, quite frankly they can't and many would die. Even assuming we stop at letting them die, you really want to bankrupt every middle class person who gets a serious health condition?
It still leads to wierd behavior by the "insurance" companies. They're bookies. They have to win >50 percent of the monetary value of their bets to stay in business.
"I am reinforced in this belief by the fact that many of the people pushing health care reform are also enthusiastic proponents of . . . price controls on key inputs, and national standard-of-care recommendations."
You omitted one compelling piece of evidence. Many of those who will determine the final legislation (in a position to vote, part of the policy groups, etc) have publicly stated that this is a step toward single payer. Your belief isn't theoretical, it's openly espoused.
This can't be said often enough.
teenagers whose parents beat them up because they're pregnant
Huh. How is this teenager going to get an abortion without meeting a mandated reporter who must report even the suspicion of child abuse?
And how can anyone hear a teenager say that she fears violence from her parents and not suspect that she's already suffered it?
Probably 'cause a lotta teens say a lotta crazy crap.
yes, so why are they getting abortions on that ground?
Especially since girls have gotten abortions on those grounds, gone home, started to bleed -- and died because getting their parents to take them to the ER would have revealed the source of the problem.
I generally agree, and the abortion analogy is accurate if possibly inflammatory. But this I'm not sure about:
I don't want this bill, and I don't want any other bill that increases the number of people for whom the government pays for care.
There are millions of people (less than the 40 million figure that's tossed around, but still lots) who can't afford health insurance, either due to poverty or preexisting conditions that make them uninsurable at any realistic price. What do you do about them? They either need some form of welfare, or they don't get health care beyond what they can pay out of pocket, which for the poor isn't much and for the chronically sick isn't nearly enough.
I'd go with the food stamp model: help the minority who need it directly, while letting the market work for the majority. For some reason this seems not be an option presented by either party.
The 40 million number covers people who do not have health insurance, not those who cannot afford it. Of those, roughly 10 million qualify for assistance under existing programs but don't sign up, another 10 can afford insurance but choose to spend their money elsewhere.
Cite?
Calvin, the link you provided shows that the number of uninsured has increased - it says nothing at all about private employers "dropping health care coverage by leaps and bounds"
Further thought: this just shows that we need to unlink health insurance from employment, not that government needs to provide health insurance.
this just shows that we need to unlink health insurance from employment, not that government needs to provide health insurance.
Yes please. McCain had a reasonable plan to start that process by replacing the employer tax deduction with an individual tax credit, which the Democrats incessantly demagogued as "OMG they want to tax your health insurance!!!"
and about 10 Million are illegal immigrants, and 3-5 Million are temporarily without insurance as they switch jobs. The actual number is about 10 million chronic uninsured.
Cite? And you do know that private employers are dropping health care coverage by leaps and bounds, right?
"And you do know that private employers are dropping health care coverage by leaps and bounds, right?"
Cite?
mj beat me to it. Calvin Jones, you were asking for it.
The actual number is about 10 million chronic uninsured.
And a large number of them have access to Medicaid, while those who don't meet Medicaid means-testing can generally, by definition, afford to pay for it over time.
TallDave,
The 10m figure is generally understood to be after medicaid and SCHIP eligibles are deducted.
Calvin: My bad...the 10 Million uninsured non-citizens includes both legal and illegal.
http://risch.senate.gov/public/?p=BreakdownoftheUninsured
Can you provide a cite for employers dropping coverage left and right, or do you want to remove yourself from the debate? Because I bet those dropping coverage are outnumbered by employers dropping JOBS...unless you think the government should step in and hire the unemployed also...
Here's another source, Calvin. I think the numbers are broken down in this Kaiser report fairly well (I'm always up for being corrected, btw, if this isn't the study Ken was referring to).
10 Million is a rough number (including children, parents and childless parents I get more like roughly 9 million), but this was done back in Ought Five, data certainly has changed.
http://www.kff.org/uninsured/upload/7613.pdf
MJ & Autolycus:
Here you go:
http://www.americanprogressaction.org/issues/2009/02/health_in_crisis.html
http://www.census.gov/prod/2006pubs/p60-231.pdf
And here's one from the Census bureau showing about 10 Million of the uninsured are not US citizens (p. 21) since you were probably going to state that the Republican Senator would post false information on his website and no one in the Democratic party would notice or call him out.
This is too easy.
mj,
Ah, thank you.
So based on the chart, we're left with 12 million who aren't poor enough to qualify for Medicaid but who make less than $75,000/year, or about 4% of the population.
Also, I wonder how many of those are in the $40,000 - $75,000 range? Many of them ought to be able to pay back expenses over time. I'll guesstimate we're left with about 2% after that. Some crisis.
If lefties want to expand Medicaid eligibility to cover the other 2%, I wouldn't complain too hard.
And you do know that private employers are dropping health care coverage by leaps and bounds, right?
Your link does not support that argument. It just says unemployment is rising.
http://www.census.gov/prod/2006pubs/p60-231.pdf
And here's one to answer the inevitable assertion that the Republican Senator is citing fictitious statistics on his website.
Calvin,
"The recent turmoil in the job market is likely increasing the number of uninsured at the rate of 14,000 a day"
These are people being laid off, not employers dropping health insurance.
The part the incenses me about those "that's not what is on the table" arguments, is that no one actually knows what is on the table. Those bills are far longer than anyone can possibly read, far more complex than anyone could possibly understand. And they people voting on them ussually don't bother with either.
There isn't even a maniacal bad guy somewhere up above crafting devilishly tricky legislation in the hopes of passing one over on the rest of us. Instead, its just a collection of requests and desires of different interested parties, that do not know what the other parties are inserting, thus leading to something that often conflicts with itself.
"The part the incenses me about those "that's not what is on the table" arguments, is that no one actually knows what is on the table."
Exactly. If those pushing this plan had their way it would have been law before anyone knew. If you have the temerity to ask you're called a nazi. But somehow it's the objectors who are out of line.
I suppose a better way of saying it would be:
"My impression of what is on the table does not seem to match your impression of what is on the table"
but that would not make a rhetorically powerful argument.
Exactly. If those pushing this plan had their way it would have been law before anyone knew. If you have the temerity to ask you're called a nazi. But somehow it's the objectors who are out of line.
Proof? And it's the right-wing that's calling people Nazis. So get your facts straight.
Proof? Obama publicly stated he expected to have the bill voted on before the recess.
Whoops, you're called un-American.
I didn't realize Nancy Pelosi was a member of the right wing. Good blog you run here, Megan. I learn new things every day.
Proof?
Nazis, no. Un-American, yes.
MJ:
What's wrong with that? He campaigned on the health care issue. Are you telling me that you don't expect the House and Senate to walk and chew gum at the same time? Everyone knows what the stakes are. Everyone(unless you were willfully ignorant) knows what Obama campaigned on. So it should have been in the works for the past 9 months or so.
John Galt:
When are you "Going Galt"?
Calvin: I'll "Go Galt" as soon as I can nail you to a door in Germany. Deal?
Calvin,
Do you not keep up with your own assertions? You denied by implication that the legislation was intended to be passed before anyone could read it. When proven wrong you ignore your assertion and say "so what"?. Bizarre.
MJ:
I don't get something. Name me a Congresscritter who ever reads every single page of a bill they pass? No one does. When Republicans controlled the House and Senate, they were known to let lobbyists draft the legislation. I am not advocating for not reading it. I just recognize what reality is. Are you saying that it should take more than 9 months to write any bill that Congress passes?
Calvin,
By changing your argument to "this practice is acceptable and routine" you're now accepting that Obama intended for the legislation to be passed before anyone could read it, correct?
"When Republicans controlled the House and Senate, they were known to let lobbyists draft the legislation"
Is there any talking point from the crazed fever swamps you don't agree with?
Are you telling me that you don't expect the House and Senate to walk and chew gum at the same time?
Given past behavior, I can emphatically state that not only do I not expect them to do that, but I believe them to be incapable of same.
I don't get something. Name me a Congresscritter who ever reads every single page of a bill they pass? No one does.
Then they need to be replaced ASAP with people who can. I'm serious. We're paying them way too much money to sit around not doing their jobs (hmm, that sounds like many other government workers). These people are here to serve, and that doesn't mean serving their own interests, pocketbooks, egos, chances of reelection in perpetuity, etc.
Those bills are far longer than anyone can possibly read, far more complex than anyone could possibly understand.
Yet the Quittah from Wasilla takes a provision introduced by a Republican(Sen. Isakson of Georgia) and uses it to try and claim Obama wants to euthanize Trig. Go figure!! And Isakson is just as much a wing-nut as she is!!
If Trig had been conceived in Europe, she would have been advised to abort him. She might not even have been told birth was an option.
You see, when the taxpayer foots the bill, the government has an incentive to avoid expensive babies who require a lot of care.
And your proof of this is what?
Yeeah, but people choose to abort Down Syndrome at approximately the same rates (low 90%'s), here and there.
This is not to say that the doctors don't push the abortion option (or not). This is meant to say that both systems appear to end up at roughly the same place.
Hmm, I thought I had posted 'here and the UK', my mistake.
Dude...do you do anything other than demand science projects from people you disagree with?
A woman in Vancouver won a suit against a doctor when he didn't suggest prenatal screening and she gave birth to a Down's syndrome baby.
Derek
There was an article last year of doctors surveyed in Europe, and more than a third said they had told parents to abort and not told them it might be possible to deliver safely. I don't have a link handy.
There is a tremendous pressure in gov't-run systems to meet the numbers. Problem births mean problem budgets.
Many of the people who are showing up to counter the ignoramuses at the town halls are themselves waving signs saying "Single Payor Now" or some such. How many of these people know that the bills being pushed by the Democratic leadership don't create such a system? I'd say most. So why are they so strongly supporting this plan? Megan's provided the answer.
Another example--gun control. However one feels about the NRA, you really can't blame its members when they oppose "sensible gun control", and characterize it as a slippery slope toward gun prohibition. Because that's absolutely what most of the proponents of "sensible gun control" want--gun prohibition.
Because that's absolutely what most of the proponents of "sensible gun control" want--gun prohibition.
That's ridiculous -- I've met a lot of people who think gun control is a good thing and I can't recall ANY of them wanting to prohibit guns. Read the second amendment -- it doesn't in the NRA's wildest dreams imply that guns should not be controlled. In what does universe does 'A Well Regulated Militia' mean 'No regulations on militias or individuals -- go at it boys'.
I was not commenting on whether or not the efforts of the NRA or gun control groups were right, or on the constitutionality of their efforts. I was talking about the "camel's nose" theme of Megan's post, and how it applied in areas other than health care.
Perhaps I should have been more precise, but when I said "...most of the PROPONENTS of 'sensible gun control'...", I meant gun control activists and the national groups they belong to, and I think I'm on pretty safe ground when I say that those who really work and push to see more gun control laws enacted would like to go much further than the laws they propose.
Yet guns have been outlawed in many jurisdictions - DC & Chicago being two prime examples.
Just because not everyone wants to prohibit all firearms doesn't mean that there isn't a health constituency that wants just that.
"A well regulated militia being necessary to the security of a free State, the right of the People to keep and bear arms shall not be infringed."
A militia is composed of civilians and not part of any standing army. If you feel it relates to State's rights to maintain their own militia, or if you feel the passage is speaking of individuals, either way it's implicitly stating that People have the right to keep and bear arms.
Either side of this argument is a slippery slope, with Washington D.C. on one side and Texas on the other. The point is trying to find a middle ground that gives people personal freedom and doesn't infringe upon their rights, while maintaining a reasonable set of guidelines to personal ownership of arms.
Joe
P.s. I know ALOT of people, self-described as liberals, who want to prohibit guns as the endpoint. Their immediate aims are just wider controls
Because that's absolutely what most of the proponents of "sensible gun control" want--gun prohibition.
If by prohibition you mean background checks, sure. Or if you mean being prohibited from walking into a gun store and buying an AK-47, yes. No one is talking about prohibiting hunting rifles.
No one is talking about prohibiting hunting rifles. Yet.
Unless they are 0.50cal hunting rifles. Then people are talking about prohibiting them.
You already can't buy a real automatic version. You can buy semi-auto versions, which aren't substantially different than a regular semi-auto. BTW, 2A is not about hunting. That's just a convenient side benefit.
You omitted handguns from your discussion. Interesting.
What proponents of "health care reform" don't get is that they won't always be in power.
It is extremely easy to conceive of a time in the future when Republicans get into power, they'd outlaw abortion by government providers. How would Democrats feel about that? How would they feel about outlawing contraception should - in the future - political winds begin blowing that way?
Gay men represent a tremendous cost imposition on health care and have lifespans 20 years less than others who have less risky lifestyles. How would Democrats feel about some future government dictating in that area?
That is just a few examples of how a future government hostile to their lifestyles, once it gets its hands on our health care, could ration care and dictate to Democrats in ways I bet they wouldn't much care for.
I bet Democrats haven't thought that one through very well. It's not like they're very strategic thinkers.
It is extremely easy to conceive of a time in the future when Republicans get into power, they'd outlaw abortion by government providers.
So why didn't they outlaw abortion in the 4 years they controlled all three branches of government? It's easy. If it wasn't for abortion, they'd have nothing to get their base worked up over.
Dude...what DO you smoke in the mornings?
They did - in every way that they could.
The very first thing that George W. Bush did when he gained the Presidency was to outlaw, by fiat, government funding of abortions. He instituted by Presidential decree the Global Gag Rule requiring all non-governmental organizations (NGOs) that receive federal funding to refrain from performing or promoting abortion services, as a method of family planning, in other countries.
That you are ignorant of this history undercuts your argument and reveals the strength of your research.
America has a long and storied history of government provision of health care. The government, at one time in our history, ran lots of hospitals. In almost every single case it was a disaster. Because in almost every single case the government doctors in those hospitals abused their patients.
We don't have to speculate what will occur when government is in charge of health care. History shows that patients will suffer and be abused. There's no debate about it that can be had. The facts are there for any student of history to see.
There is a HUGE difference between banning individual purchase of an abortion and having government not pay for abortion. This is something that the Republicans have done in numerous ways on numerous occasions.
When government starts paying for medical procedures I'll put money on the table that they will try to de facto outlaw abortion by refusing to pay for it.
You are making my point: Once the government is providing health care to people, government can withhold that care. That's why we do not want the government providing health insurance. Once they do, that opens the door to partisans on both sides deciding what will and won't be provided.
Keeping health care insurance private ensures quality care and prevents partisan politicians from denying care based on political considerations.
Good post.
Another off-putting tack of advocates, aside from what you've mentioned above, is the false sense of urgency.
I think the sense of urgency is because people are dying that could be saved in the current system. It is morally abhorrent and costly to our society.
I think the reason the current bills are better than nothing, despite their problems, is that they will all pass a core set of regulations that will fix some of the broken parts of the health insurance market. Beyond that, making private insurance work well is probably the best way to stop a single payer system from happening.
People will argue regulation increases the cost of insurance, this is true. Many insurance companies will tell you they will insure your medical care, take your premiums for years, then dump your coverage when you get sick and it is time to pay up. Yes, it is costs more to pay what you promised to pay than to shirk your debt, but I tend to believe reasonable people would want to discourage this sort of fraud.
I think it is perfectly reasonable to ask someone to pay a 1-200 a month for the rest of their life (or until the balance is paid) for a major life saving or massive quality of life improving operation.
I don't understand why people feel that it should be someone else's responsibility to cover these costs (if you don't have insurance).
Health care reform I could believe in would include a combination of: actually creating a market for health insurance by decoupling it from employment and reducing certain unnecessary regulations so customers can choose what economical plan fits them best and a long term mortgage/student loan style payment plan for catastrophic care or necessary care that may not be covered by your plan (or if you just don't have insurance). I'd also like some consideration of a plan that avoids this messy concept of insurance (against severe accidents or sickness) with health maintenance that individuals should actually have to pay for. I don't know if this last one is possible, but I see no reason why we shouldn't pay for a trip to the doctors office just like we do for an oil change, buy food, buy plane tickets, etc.
Its reasonable, but it may not be enough. $200/mo for 50 years is $120K if the loan was made at zero interest. $120k is not a great deal of money for a massive quality of life improving operation. In addition, who is going to be giving 0% loans?
I really like the idea of emergency loans for procedures like this, but one has to face the music and realize that most will not be repaid in full.
What about private charity? Is it conceivable that private charities could provide those at loss loans?
For most emergency care it is plenty enough. For the massive 500k+ bills there can be something else that kicks in, but as far as I'm concerned if you (I) have a terrible accident and no insurance and live to tell the tale I'm the luckiest guy in the world. I should be happy to forefit $500 a month or more if I earn more to pay for it. At the end of my life, which was prolonged by the generosity of my neighbors tax dollars (assuming I'm uninsured) if I own any assets they will go to pay my debts.
I don't see how this is unreasonable.
At the very least it would push people toward buying insurance for themselves. And it provides some level of safety net with the combination of personal responsibility to pay it back.
Chronic conditions.
People keep focussing on single-event expenses. The real money is in all the people coming down with expensive chronic conditions like heart failure, diabetes, Alzheimers, MS, Parkinsons, whatever.
Care for a diabetic with no complications runs over $5,000 per year, more in expensive cities. Every year. Forever. 100% certain. As the disease you get complications requireing hospitalizations and surgeries, figure there will be multiple years where it's more like $20,000 to $100,000.
Yeah like duh. Of course this bill would be a first step towards universal health care. That's the whole point.
Megan, do you understand how medical care prices are determined in the current system? Why are you charged X dollars for Y surgery and not 10*X or 100*X or 1000*X? Seems like a pretty crucial thing to know before deciding whether the free market or some government run system will be advantageous.
combining health care reform WITH the abortion issue: very ambitious and I predict at least 250 comments.
I cant tell if its deliberate obtuseness or naivete on the part of those that assert that the various proposals in Congress dont "create" a single payer system. I suppose that is technically correct, but the system created irreversably leads to that result.
Alright, I was thinking about this back during the community-rating post, but here goes:
Health care follows roughly an 80-20 rule. The sickest 20% of patients account for about 80% of the costs (or something close to those numbers). This 20% basically involves people with one or more chronic conditions, which are practically uninsurable on an individual basis. Chronic illness is the main cost source (about 75%), and they're very hard to insure against; once you get a chronic illness, you're no longer a risk, you're a definite cost, hence the whole pre-existing condition thing. I guess you could have a fixed payout upon diagnosis, but that's currently not done. Anyways, we have several options in setting up health insurance.
1) We charge everyone their individual risk premium. This causes people to be excluded for preexisting conditions, and soforth, probably leaving a lot of people uninsured.
2) We pool people together in groups by employer and charge a group rate. Healthy members of the pool are effectively subsidizing unhealthier members, since both pay about the same premium.
3) We pool people by community rating and charge a group rate; similar to #2.
4) We put the high-risk people in their own pool, then subsidize the pool with taxpayer money. Some states currently have risk-pools, also Medicare is arguably this, given that old people are generally high risk.
5) We implement single-payer, or the more extreme version, some sort of NHS, where taxpayer money pays for all medical expenses. Effectively, all the healthy people in the country subsidize all the sick people.
Our current system is a combination of mainly 2, with some 1,3 and 4 thrown in. And we still have 40 million uninsured. The current plans can mainly be viewed as altering 4; arguably a public option is equivalent to a state-subsidized risk pool. Note that also, unless you want the entire system to look like #1, you're going to have healthy people subsidizing sick people, so if this bothers you, the current system should also bother you. Barring #1, it's all really comes down to finding the most efficient way to have the healthy people subsidize the sick people. So while there are certainly criticisms to be leveled at current proposals, it's hardly any more "socialism" than we currently have, merely in a different form.
5) We implement single-payer, or the more extreme version, some sort of NHS, where taxpayer money pays for all medical expenses. Effectively, all the healthy people in the country subsidize all the sick people.
Yes and no. Everyone gets old eventually.
So, it's okay because when we get old then it's our turn to leech off the young?
Bob,
I think you miss the important points. Current seniors tend not to worry about consequences because they expect to be dead before:
A. we bankrupt the country,
B. the difference in technology is enough to matter more than getting the currently available level of care.
Yep. Other than you attaching a pejorative to that by asserting that its leeching why is it wrong to have the young subsidize the old as part of a social contract that they to will be subsidizing when they get old (as the great majority will). Also as for BobW, yes, just like Social Security - which in fact has worked great! Virtually eliminating elder poverty which was a much more serious problem before. And SS's financial problems stem almost entirely from our decision to spend the surplus on general fund budget priorities, so, morally its a general fund problem not a SS problem. SS would be solvent for years to come and forever with small adjustments if we did not require its surplus to cover the general spending deficit.
TomO,
It would be fine to "leech" off the young provided that the old either had enough offspring to support them in their old age or built up enough of a surplus to prevent placing a greater burden on the young than the older generation had to bear.
The current situation has been caused by the older generation (really starting with baby boomers) not having enough children to support them and not saving enough to pay for other people's children to support them. On top of that, they've voted themselves benefits that increase faster than inflation. So now the younger generation is being crushed by the burden of having to pay to care for the older generation while they are saving for their own care and/or trying to have children of their own.
Not sure that's a social contract that many younger people would voluntarily sign up for.
Correct. Bernie Madoff runs a Ponzi scheme and he's evil incarnate who lights puppies on fire for entertainment. If the government does it, they can just tax us all at higher rates to get more money and "How dare you question Social Security!?"
There is a vast difference.
Taxpayers want low taxes, and are the majority. Sick people are a minority. Taxpayers will force a starving of resources to health care. No malice here. Think Laffer curve. Right now health services are being cut in most Canadian jurisdictions as they attempt to minimize deficit spending in the face of declining revenues. Again, taxpayers like that. Sick people suffer.
In the US, payment for health services is a constant concern. If you don't pay insurance, quit your job and have none, etc. There are hard learned lessons of low insurance premiums, catastrophic insurance, HMO's, etc. Paying good money for bad service. Any holes or injustices are quickly and vociferously brought to the fore, for the simple reason that it is a constant concern. Healthy people make the decision to pay as much as necessary to get good health care.
Unsustainable increases in medical care costs are a worldwide problem. The solutions that government run systems propose is cutting services and extending wait times, and costs still are increasing. Government run systems have not been able to contain costs. The only hope for an improvement in this situation is the US. A relatively free system responding to market forces will produce solutions to the problem. The US consumer has been demanding excellent service at no matter what the cost, and the industry has been providing it. If the US consumer demands something different, the industry will provide it.
Derek
Excellent explanation.
We'd probably have a lot more agreement if everyone understood this with your level of clarity.
Barring #1, it's all really comes down to finding the most efficient way to have the healthy people subsidize the sick people.
I'm not sure this is always a good idea; it depends on how the sick people got sick. Suppose it could be proven that the diabetic acquired that condition by making poor dietary choices? Or the person who contracted an STD by having unprotected sex? Or the three-pack-a-day smoker who gets lung cancer? I'm perfectly OK with helping to subsidize people who get sick through no fault of their own; with people whose conditions are direct results of their own poor choices? Not so much. Why should I have to pay to subsidize someone else's poor choices? Whatever happened to individual responsibility in this country?
Isn't it a little ridiculous to divide abortion-seeking teenage girls who don't want their parents to know into only two groups? Apparently the first group is "girls who want abortions just so they can get out of the awkwardness and embarrassment of discussing sex and abortion with their understanding parents." The second, of course, is "girls whose parents will beat the leaving crap out of them as soon as they find out they're pregnant."
I think it's possible that there are girls out there who would like to avoid telling their parents for another reason: because while their parents might not beat them, their parents will regard them as sinners for the rest of their lives, and/or disown them as soon as they turn 18.
But I guess it's easier to pretend that so long as physical abuse isn't in store for her, the only reason a teenage girl might want to withhold such information from her parents is because the little princess might find it embarrassing to have that discussion.
That's a great big red fish you just bit into there. Where did you catch it?
?????
Herring, Publius. Red Herring. Delicious, nutritious, and highly distracting.
Publius is confused because herring aren't all that big.
Thank you. When I have pickled herring, they're white. The "red fish" comment seemed too ... obscure.
And hard to cut with.
Oh, I see, I was under the impression that if Megan says something really misleading about abortion that completely minimizes the issues involved, we could actually call her on it. Instead of just ignoring it because it really doesn't matter, because the "real issue" is health care.
Of course, if the points she's trying to make about abortion are completely irrelevant, one has to wonder why she felt like including them.
(really replying to Publius' reply to me.)
I like the sill in mustard. It's yellow.
Presumably, a judge can grant waivers in those cases. But they aren't really all that common. Evangelical parents aren't monsters--they love their children just like the rest of us.
So you support judicial waivers for teens whose parents will judge them harshly for it, not just those whose parents will beat them? That makes more sense to me.
Re: your second sentence, though - considering that it's not unusual for evangelical parents to disown their children for being gay, I have a hard time believing that it's rare for evangelicals to disown a child for committing (or attempting to commit) what they see as murder.
I have to chime in:
I am an evangelical with a 16 y.o and 18 y.o. daughter. We have regular and substantive discussions on sex, abortion, homosexuality, Proust, and Derrida. If either of them becomes pregnant, my wife and I will encourage her to bring the baby to term. If either of them terminate her pregnancy, we would weep.
We would never disown one of our children. Yes, I see abortion as murder. If one of my children became a drug trafficker, I would weep. I might even (for the child's good, under counsel) cut off contact. (In fact, when an older child became addicted to online computer gaming we came close do doing that.) But I would never disown my child.
I would not support an abortion. Ever. My daughter would have to go outside of our family to procure one. If she utilized a "friend" who facilitated this I would support that friend's prosecution as contributing to the delinquency of a minor. But I would never disown my child.
I don't know where Jake437 finds it "not unusual" for evangelical parents to disown their children for being gay. I suppose he's referring to the monster Dick Cheney, yes?
The only person here who seems to have an overtly revealed capability for heartlessly writing off people based on his irrationally-derived prejudices is, in fact, yourself.
I mean, maybe you are reasoning from anecodte here based on a couple bad experiences in your personal life, but I hope the irony of what you are doing isn't completely lost on you.
Megan,
It's cute that you're so optimistic, but you need to get out more if you think it's so rare for kids to have parents who are less than loving.
To the liberals proclaiming that, unlike those of us in the conservative or libertarian camps, they are practical people just seeking the best way to make us all better off, I say: I think your utilitarian calculus is badly wrong.
I think this assumption of moral superiority is what bothers me most about leftist thought. As if the free market hasn't done more to help more people than any act of government!
Most evil gets done in the name of good, and billions of people have been impoverished by promises of equality.
But assuming that they aren't funning me
Wow, is that a Tombstone reference? Never heard that phrase anywhere else.
Wait, after that post your accusing the left of assuming moral superiority?
Myself, I am fond of quite a few acts of government; the British slave trade embargo, the 13th, 14th, and 16th Amendments, Allied victory in World War II, and the Apollo Program to name a few.
Also of course evil gets done in the name of good -- almost no one thinks of themselves of evil. Plenty of people have been impoverished by private enterprises as well; e.g. East India Company and United Fruit. Plenty of people are just straight up impoverished - it seems to be the default state that we have to work hard to get out of.
Anyways, all red herrings. Brass tacks, are you willing to let sick middle class people die and or go bankrupt because given their risk profile, as a pure business decision, they should not be insured at anything less than ruinous rates or can we let the government intervene. (Note, our current system in which the government bribes and threatens employers into having their healthy employees subsidize their sick employees is a pretty serious government intervention.) If not we do agree in principle and we are just arguing about the most efficient way to do it. And I think that bundling employment to health care and leaving millions of people uninsured and thus only able to receive emergency care is a pretty big problem for the idea that the current system is better than universal healthcare.
the British slave trade embargo,
... that rescinded an earlier act that allowed slavery? That doesn't strike me as an example of how great gov't is, especially since it was only the prosperity brought about by the free market that eventually made it economically reasonable to abolish slavery.
Also of course evil gets done in the name of good -- almost no one thinks of themselves of evil.
Capitalism works the opposite way: good gets done in the name of greed.
I'm reminded of an old U of Chicago joke: the student, when hearing some policy plan, ask the presenter, "That's all very well in practice, but how does it work in theory."
Megan's public-choice objections comport with some of the good-government libertarian concerns: if a party can abuse IRS audits or FBI wiretapping, *imagine* what it can do with health-care decisions. Didn't Rahm send a dead fish to a reporter once? And didn't Cheney advocate using the US Army to round up the Buffalo al-Quaeda gang?
We ought to address the public-choice arguments here. Leave the abortion debate about sinners and beating for another day. Megan, I'm glad you didn't get pregnant as a teenager.
So it really doesn't matter what we talk about, because Megan's going to sit in the corner with her fingers in her ears shouting, "I don't want any of it."
Nice debate.
But she doesn't want any of it.
You're trying to beg the question by saying, "So, what kind of bridge are you going to buy today?" Then, when she says she doesn't want a bridge you complain that she won't discuss it.
Inappropriate analogy. More like - you are trapped in the basement with a broken water pipe and the water is rising. It was ankle deep in 1993, and is now up to chest height. You could say "I don't believe in plumbers, they are a drain on society (sorry) and I will ignore the problem, as the water is only up to my chest and I can still breathe ok."
Why that would be taken to be a serious or thoughtful argument is beyond me. Why anyone would take that seriously and "debate" it is beyond me. These arguments are not worth the candle. Sure some people are in upper floors and will not be bothered by the flooded basement. Maybe I read too many comic books, but I would think and hope that this would not be the official policy of this country. Are we really back to the very first national anthem as cited by the 2000 year man: Let them all go to hell, except cave 76!
Perhaps we need a little less "self-interest" in the rational self-interest mantra and a bit more "rational." Everyone reads Ayn Rand and thinks they are Howard Roark, when in truth, they are more like Peter Keating.
Talk about an inappropriate analogy! No one is claiming that the health system isn't a mess. Your presumption is that government is the only solution. Megan and others are saying that there other - much more effective - solutions.
Smilerz:
Ah yes, it is a well thought program, with only three steps:
(1) Get rid of government program
(2) .......
(3) Profit!
Much more effective. As I mentioned in a comment to the last post - the LAST thing you want is unfettered markets. Care to eat uninspected meat? Complaining about attempts to fix things by slamming aspects that the bill does not contain, under the notion that it might in the future, is not far removed from complaining about Death Camps (its not in the bill, but whose to say - slippery slope - etc.) and in the meantime the band continues to play on the deck of the Titanic.
We lead the world in medical advances AND infant mortality. By all means - lets make sure the government does not get involved. It might be philosophically impure.
Jim: We have ample examples of...
1. Problem
2. Add government
3. ....
4. Problem gets worse.
What makes you think that these attempt would be different?
Derek
Epic fail. Either Angola or Sierra Leone lead the world with infant mortality (with 160-180 deaths/1000 live births), depending on who's statistics you believe. By contrast, the US has about 6.3/1000, and a few world leaders have 2.3-2.9/1000.
http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate
To plagiarize from myself down thread:
"At what point does the fact that the U.S. leads the world in infant mortality for developed nations become an issue we do something about? I really don't care public/private - I want to improve the system. Those who say the public option will make matters worse - I say, compared to what has worked so well up till now?"
I left off 'Developed Nation' when I said that we lead the world in Infant Mortality. Obviously, Ninja Zombie (if that IS your real name) that is an Epic Fail - I think we should be really proud that we are doing better than either Angola or Sierra Leone, don't you?
Derek: The second part of the point I quote above addresses your question. I have no idea that additional government intervention won't make things worse. Maybe it will be a disaster. But I personally know too many people directly harmed by the current system. A relative of mine could have built a space elevator to the moon during the time she devoted to getting charges authorized for her daughter, who has type I diabetes. Why do no libertarians factor in the lost man hours spent on both sides of the phone as the insurance companies attempt to deny payment and their customer tries to get reimbursement for a service that they paid for? Is this an example of the free market at its finest?
Could the government make this situation worse? Sure, possibly. But not definitely - as there are many circumstances of the government doing things for the common good that the private sector decides is not cost effective (such as delivering mail to remote rural locations).
An imaginary plan will always be better than a real one. And as the man said, don't make the perfect the enemy of the good.
Jim Kakalios - RE: "We lead the world in medical advances AND infant mortality."
See
--
"...First, it's shaky ground to compare U.S. infant mortality with reports from other countries. The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don't reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates. For this very reason, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country.
Infant mortality in developed countries is not about healthy babies dying of treatable conditions as in the past. Most of the infants we lose today are born critically ill, and 40 percent die within the first day of life. The major causes are low birth weight and prematurity, and congenital malformations. As Nicholas Eberstadt, a scholar at the American Enterprise Institute, points out, Norway, which has one of the lowest infant mortality rates, shows no better infant survival than the United States when you factor in weight at birth..."
http://health.usnews.com/usnews/health/articles/060924/2healy.htm
---
Infant mortality rates also reflect broader social trends, including the prevalence of infants with low birth weight. The health system in the United States gives low birth-weight babies slightly better survival chances than does Canada’s, but the more pronounced difference is the frequency of these cases. In the United States, 7.5 percent of babies are born weighing less than 2,500 grams (about 5.5 pounds), compared with 5.7 percent in Canada. In both nations, these infants have more than 10 times the mortality rate of larger babies. Low birth weights are in turn correlated with teenage motherhood. (One theory is that a teenage mother is still growing and thus competing with the fetus for nutrients.) The rate of teenage motherhood, according to the O’Neill study, is almost three times higher in the United States than it is in Canada.
http://www.nytimes.com/2007/11/04/business/04view.html?_r=2&oref=slogin&ref=business&pagewanted=print
Clearly zic, you fail at understanding the nature of MOST debate. If you hold an opinion strongly enough to debate it well from a certain viewpoint, the probability that someone on will be able to convince you otherwise in any given situation approaches zero. Lightning bolt epiphanies which radically change a person's worldview don't occur very often after all. Debate is about presenting information and attempting to deconstruct the opposing side's argument. You do this for the benefit of those watching, or those without strongly held opinions, so as to sway them to your viewpoint. Now, occasionally someone's strongly held viewpoints will change, but that is generally the endpoint of a much longer process.
you're a smart, witty, and above-all confident writer/arguer -- i'm often left with a gut sense that i disagree with you, but without the sufficient knowledge and/or rhetorical tactics to articulate exactly why. nevertheless, i do occasionally reread your 2004 endorsement of bush (linked below), and it reminds me that someone can be intelligent, logical, impassioned, convincing... and terribly wrong.
http://www.janegalt.net/blog/archives/004974.html
Why was Kerry the better choice again? Oh yes, he would never have encouraged the surge. He would have "sold at the bottom."
Meh. I don't think this post does nearly the amount of work you want it to do.
Your critics, by and large, aren't saying you've got some minor provision of the bill wrong, but (despite your protest to the contrary) that you are mainly arguing against a Canadian style system in which private insurance is illegal. And this just isn't going to happen. Very few liberals want it even if they could get it.
And whether you are making pragmatic or principled arguments against more government health care makes a big difference. As you will pretty much lose the principles argument in the U.S. because our shared ethics revolt against the idea that a middle class person can get sick (or have their kid get sick) through no fault of their own and by virtue of being sick find that their medical bills and/or health insurance are far larger than they could possibly pay.
Currently we solve this for most people by arranging our taxes and regulations so that the healthy are coerced into subsidizing the sick through grouping them by employer. Thus our current "private" insurance is very substantially government controlled. You generally tend ignore this when talking about why a larger(really more different rather than larger) government role would be bad. Also you don't propose any non-government way to deal with people don't fit under the employer grouping system we have now.
McArdle is mainly arguing against passing a 1000+ page monstrosity that most congress-critters admit haven't read. You call this transparency in government? You should be ashamed of yourself if you think this is how government should operate!
Actually, I was arguing for health care reform, not transparency in government. I am not Obama, as cool as that would be, and I have not adopted all of his talking points.
But, anyways, yes, I do think this is pretty much how government should work, because its pretty much how government has to work.
I don't know how you expect to pass any major legislation that doesn't start getting up to some very hefty page counts. I suppose you could if you wanted to either set a clear simple and draconian rule that applies inflexibly in all situations whether it makes sense or not. Or you could pass a simple but vague rule and leave it up to judges and executive agencies to develop and articulate the thousand pages of interpreting it to fit specific situations and articulating necessary common sense exceptions. And sometimes I even want to do these things (usually the later), but its hardly unreasonable to want elected officials to do the work of applying general goals to specific situations, which means high page counts. Congress critters are not usually experts and they have a lot to do, so they rely on committee reports, outside think tank analysis, and their legislative assistants -- all of whom are likely to have more expertise and time to go over the bill. So, no, I don't think Congress is making an uninformed decision. This talking point is just silly. It was silly when it was used by liberals to critique the Patriot Act, and its silly now.
Government doesn't work that way. It hasn't in a long time. Outside of libertarian fantasies, or ceding every real decision to executive agencies, it can't. So, no, I am not ashamed for thinking this is how government should operate.
Specifying and clarifying rules is much different than creating new entitlements, oversight committees, processes, advisory counsels, reporting requirements, and exchanges. The current bill also gives the Secretary of HHS a fair amount of discretion to prescribe regulations over prices, coverage, reporting, fines, qualifications, etc.
Also, how is this for a short statute that would constitute major legislation:
All carbon emissions shall be subject to taxation at a rate of $14 per ton or as otherwise set by the EPA.
Does the Army pay that tax? Do nonprofits? Do churches?
Who is charged with measuring the emission? What tools do you give to get them to go about doing it? How do you pay for that? What employment rules apply to the employees of this new agency? How do you even measure some types of emissions - e.g. forest destruction? What heuristics will you use when the method of carbon emission necessitates fuzzy measurement? What is the penalty for failure to pay the tax? Is the tax indexed for inflation? Who determines that? How often is the tax paid? Who do you collect the tax from - note its pretty impossible to collect the tax from end users of consumer goods so you have to impose taxes somewhere up the production line? Do you tax imports where carbon was emitted in the creation of the imported good? How do you estimate that tax (I doubt foreign countries are going to let you go over there and measure their emissions directly)? Do you give any relief to poorer families that are just about to be hit with what, by itself, is a fairly regressive tax?
Thats just off the top of my head - I am sure there is a lot more.
While I feel I could add a few sentences to fix the holes you pointed out, I am sure my new statute would be arguably vague as well. Since so much of this thread is off topic, I will concede this point to you for now. And plus, for all practical purposes you are right - most bills probably need to be long.
And congresspeople don't have time to read every word of every bill. But they do need time to have their staff to prepare summaries. And for important laws, the public should have time to analyze the bill and have a debate over it.
What is the career track of a health-care HHS policy maker? It is in his interest to expand his role. That means more administrative rules, and more costs. Not unlike financial regulation.
I used to work for a regional banks. Everyone knows that the FDIC examiners (at least of smaller banks) were mostly kids with clipboards who couldn't land an auditing job with a big-3(or 4?) accounting firm. It was in their interest to punch their tickets and not leave a mess behind. If they were involved in a big case, great. But that was for the suits to decide.
Move over to health care. The processors who review claims and allocate are following orders from the suits who have political masters to attend. It's in everyone's interest to punch tickets and not leave a mess or embarrass a superior. Incentives for innovation? I don't think so. Call it the "utility model" of health care. Health care as effective as the water company. Which operates basically with 1950s technology right now.
Like all of Ms. McArdle's previous writings on health care, this one is deeply flawed by ideological fervor. Arguing that the US under its present system is the world's leader in basic medical research has nothing to do with our system of health insurance. We do well in scientific research because of excellent research universities and generous government financing through the NIH, not because Blue Cross makes x megabucks per year. Arguing that the pharmaceutical industry and hence applied pharmaceutical research would suffer if the administration passes its bill is similarly foolish, as shown by the fact that the industry supports the administration, not opposes it, because the it covets an increased customer base. For the same reason, the AMA supports the House version of the bill, and the health insurance industry will certainly do so if the public plan is defeated. And finally, arguing that we do well in treating prostate cancer, thus showing that our health system is really better than the systems used in all the "cool" countries (i.e. every industrial democracy but ours) is another red herring because prostate cancer is a disease of the elderly, and its treatment is financed by Medicare.
Regarding McArdle's statement that to most people on the left feel that her opposition to any government role in providing health care is akin to declaring that she would like to take up killing orphans in her spare time, no, I don't feel that. What I feel instead is a feeling of sadness that somebody so well intentioned should be so lacking in common sense .
you may be right that access to health care is a separate issue from the level of health care available to those with money. i don't know enough about healthcare in particular, so i won't guess. i do, however, know enough about economics to say that innovation in any industry tends to come from competition and it tends to be led and financed by luxuries.
when you write a comment aimed at another person's ability to make logical and reasonable arguments, make sure your own arguments are the same. your understanding of these things seems to be the exact opposite of how these things actually are. established industries regularly support government intervention in markets precisely because it protects their market share from competition. do a little studying up on the behavior of monopolies and cartels.
You're the one with the ideological blinders on. McArdle is simply saying we should slow down, read the DAMN bill and do a true cost-benefit analysis. YOUR side is the one that wants to ram this thing down our collective throats.
Actually, no. McArdle is arguing against any bill along these general lines and not the specific bill (or proposed bills) in question. Thats kind of the main theme of the post.
And ramming? Really? Liberals have been proposing something along these lines since the 1970s if not the 1940s. Your side has had plenty of time to learn about what the proposals are and what effects they might have and to either agree or come up with alternatives. The slow down mantra is just a tactic to ensure we don't do anything along these lines, not now, not later, not ever.
McArdle is being far more honest than you and the current GOP talking points.
Oh so you admit you want to ram it down our throats? Good. You're on record now. You can NEVER take it back.
Wait? WTF? How does "ramming? Really?" translate into that admission.
"What I feel instead is a feeling of sadness that somebody so well intentioned should be so lacking in common sense."
Funny, that's just what I thought reading your post, beginning at "this one is deeply flawed by ideological fervor."
Megan's post isn't ideological fervor. It's a pragmatist recognition of how human systems work best over the long term. Sadly liberal ideologues refuse to engage such issues and prefer to simply level the "ideologue" canard.
I feel sad when I hear someone state that they think that the institution that has been responsible for the Katrina response, runaway military spending, and the post office can provide everyone with better, cheaper, more efficient health care. Not to mention the work of that institutions subsidiaries, which include public schools, the dmv, and the state of California. The belief that government provided health care will somehow be better than private health care shows a lack of common sense.
If you want your kid to have the best education, do you send her to public school or private school? If you have a package that MUST be delivered tomorrow, do you use FedEx or the Post Office? If you want to provide event security, do you let the police do it or do you hire a private security company? If there is another hurricane would you prefer FEMA or Walmart to be in charge? (for those unfamiliar with Walmart's response: http://articles.moneycentral.msn.com/Insurance/InsureYourHome/RealKatrinaHeroWalMartStudySays.aspx)
Why should the answer change for health care?
Because I am not just trying to buy the best health care for me, but to ensure that everyone in the U.S. can get reasonably good health care. And I do expect, and given that we actually have data on this, know that private insurance will be too expensive for a lot of people. Its very nice when private corporations do charity/pr like WalMart did during Katrina, but I don't expect them to insure sick people for a loss. And they don't. So just like with the post office and schools I would like there to be a public option such that people who can't afford better aren't screwed. And like the post office and most public schools I would like that public option to be pretty decent such that you would expect middle class people to use and support the program.
If there were any evidence showing that the public option would be both pretty decent and affordable, then I might support it. Given the other services that the government has delivered, I would expect otherwise.
I wouldn't have a problem with public schools if so many of them weren't bad. The problem is that public institutions come with the typical public problems: a lack of incentives for improvement, government hours and holidays, direct political manipulation, difficulty in firing bad employees, and inverted budgeting (you are rewarded for spending all of your funds rather than for delivering the most value per dollar).
Ah so then we have a disagreement about data. I think your pretty obviously wrong here though. Most public schools are pretty good. There are some serious problems with some inner city schools that get a lot more attention, but that is in large part because they serve a population that for a variety of reasons faces more difficult problems. Nonetheless, approximately 85% of kids go to public school in this country. Your average middle class public school just isn't that bad.
As for the post office, really what is the big problem with it? It provides very cheap service for staggering tons of mail that is usually delivered within 2 to 4 days of being sent. What on earth is wrong with it.
Both public schools and the post office aren't prohibitively expensive. Our tax rates aren't as low as we'd like, but we aren't even remotely overtaxed to the point where it seriously hurts economic growth.
My standard is decent enough for middle class people to use regularly. With 85% of the country using public schools and nearly everyone using the post office, I think thats pretty obviously met. You are letting your anti-government ideology prejudice your evaluation of government performance.
First, the post office. It is losing money and cutting services. It is also unreliable, and a pain to deal with. Going to the post office is a miserable experience. Ever been to a UPS store? Or a Fed Ex? Or a private mailbox company? The service is faster and better. Sure, service seems adequate. But how much better would it be if the Postal Service didn't have a monopoly for the past 100 years or so?
Second, public schools. I went to one. But private ones are better, and they may even be cheaper. Tuition at private schools often is on par with the amount spent per student at public schools. Private schools seem significantly more expensive, but that is only because you don't get your tax money back.
I am not anti-government per se. I am anti-monopoly where there are no incentives for improvements. Government _could_ work. Sadly experience has shown that it doesn't work; it leads to stagnation and inefficiency.
UPS and FedEx are faster for much more money, but 2-4 days is fine for most things and the post office comes to my house daily without an appointment. They are in fact very reliable -- pretty much never had a problem with them. And very cheap.
And yeah some private schools probably are the best in the country, although a lot of that is getting to select only the brightest students. And cheaper, well, maybe some of the Catholic schools, but the Daltons and Exeters of the world I think not. And like with health care a reason why private schools can be cheaper is they don't have to deal with the hard cases. Not many seriously disabled or discipline problems at Andover.
These institutions serve everyone and most people perfectly adequately without breaking the bank. They may not be the best -- but you haven't got any evidence that you can make the best available to everyone; thats the problem with the private sector it discriminates by price.
I am not anti-government per se. I am anti-monopoly where there are no incentives for improvements. Government _could_ work. Sadly experience has shown that it doesn't work; it leads to stagnation and inefficiency.
That's because government has one thing that private enterprise almost never has--a ridiculously thick level of bureaucracy, the members of which are almost impossible to fire no matter how incompetent they are. (The only place I really want to see a bureaucrat is either in the unemployment line or headed back to school to learn a marketable skill that would help him/her land a job in the productive class.)
Sure, there are useless layers of middle management in private enterprise as well (and it would be a good idea to get rid of them as well, in the name of efficiency), but they can't hold a candle to the amount of government bloat.
Actually, I sent my kids to public schools. One's now at Chicago and the other is at Emory. So I guess they got pretty good educations.
And if a package HAD to be somewhere tomorrow - I'd use FedEx. If I needed to send something across the country for under half a buck, I'd use the Post Office.
To assume that the private sector will ALWAYS trump the public is to ignore too much counter evidence, and the cost/benefit question. Insurance companies are spending $400,000 per day to affect the debate on health care reform. They spend billions on NOT paying insurance claims. At what point does the fact that the U.S. leads the world in infant mortality for developed nations become an issue we do something about? I really don't care public/private - I want to improve the system. Those who say the public option will make matters worse - I say, compared to what has worked so well up till now?
Your facts are grossly incorrect. The US spends 3 times as much, per capita than anyone else in the world and develops more advances than all of Western Europe combined.
In the US alone private industry spends about twice what the government does on R&D.
No, it spends about 35-40% more than the next highest spenders. Sine those are the systems people want to emulate, like France and Switzerland, that's the right benchmark.
As someone who does university basic science research I can tell you (and Megan has said in the past) that figuring out how a certain receptor and cell pathway work and making a drug that targets this pathway/receptor are entirely separate enterprises. Since about 1/1,000 to 1/10,000 drugs make it from the bench to the market, the drugs that make it there must be extremely profitable/homeruns to cover the costs of the ones that didn't. Therefore, moving that huge profit incentive for patented drugs would in fact kill innovation.
For the record, I know a lot of docs who are LIVID at the AMA and don't feel well represented by their lobby at this time. As for the pharmas, they may be thinking "Let's put in a good impression with Obama in case it passes, and if it doesn't then we'll be fine as things stand."
should be
"Therefore, REmoving that huge profit incentive for patented drugs would in fact kill innovation."
Sum entire post up as:
"Did you mean Overton Window?"
The problem, Megan, that you probably very well know is that your opinion on this health care proposals is just drowned out by others that are against it for no other reason than it is proposed by Obama. Most of the detractors don't have a clue what is in the bill as evidenced by all these colorful discussions around the internet. You might raise legitimate concerns, but even the Republican party will not pay attention to them because they most worried about scoring political points, not fixing any problem.
Anyways, I think the overall fallacy of your beliefs on this issue is that the you make a error in assumptions based on the free market. You can assume that the free market will solve a great majority of issues but not all. Can you name a situation in which the free market operated beneficially for 100% of a people? In fact the free market guarantees that 100% of a people can not operate in it. And in the issue of health care, it is moral obligation that 100% of people get that benefit.
Can you name a situation in which the government acted beneficially for 100% of the people? That's a ludicrous benchmark.
Show me when the government operated beneficially for the benefit of 100% of the people?
Jinx!
And in the issue of health care, it is moral obligation that 100% of people get that benefit.
Presumably you would also agree that it's a moral obligation that 100% of people have sufficient food. Does that imply that the government should take over all food distribution, or even run "public option" grocery stores?
"[Y]our opinion on this health care proposals is just drowned out by others that are against it for no other reason than it is proposed by Obama. Most of the detractors don't have a clue what is in the bill."
Disagree. The opponents know what's in these proposals and it scares the hell out of them.
We can't win with people like you. One group of supporters tells us we don't understand the proposals, so there's nothing to talk about. When we queston or criticize a specific proposal, we're told that particular proposal may not be in the final bill, so there's nothing to talk about or worry about.
Even if the proponents honestly believe that they are not advocating single payer, we can legitimately ask if that's what we will end up with.
When Hubert Humphrey advocated the Civil Rights Act of 1964, critics voiced their concern that it would lead to hiring quotas. HHH said that he would eat the bill page by page if it had any mention of quotas. I think he honestly believed that the bill did not mandate quotas.
Five years later, the EEOC, created in part the implement the Civil Rights Act, adopted a policy of testing for 'disparate impact'. Employers were left with no defense against disparate imapct suits except to have statistical hiring practices, i.e. quotas.
So those who cry foul today, saying that no one is advocating a particular outcome, like single payer or `death panels', and try to label any such concerns as illegitimate, lying, fishy, or fear-mongering, need to look back at the lesson provided by Hubert Humphrey: an honest man who hated quotas, yet ended up making them the law of the land.
Megan, just because you write more words does not mean it has any more significance.
bedmondson translation
My mind is made up. Don't confuse me with facts.
I never read Brad Delong, he writes way too many meaningless essays.
Bottom line is McArdle says "Halt! Let's not just pass some monstrosity for the sake of passing something!". And watch the flood of lefties condemn her as "anti-reform". This is what passes for "reasoned debate" among the left. They get to demonize whoever they want, and if anyone strikes back they cry foul.
There seems to be a great deal of "~A, therefore B" thinking on the left these days. I wonder when they'll figure out this is only true when the universe consists of A & B.
I have a friend who says never, but I'm taking the over.
Refreshing to see camel slapping somewhere other than Urban Dictionary.
I just think, going back to first principles on this, but putting the same people in charge of health care who espouse and live by a creed where the ends justify the means, who still idolize such people as Sanger and the eugenicists (who advocate aborting black babies for the sake of the 'common good'), is like putting Mengele in charge of Jewish child care.
And the Nazi analogy seems particularly apt considering the astroturf campaign supporting these bills is being largely funded by Nazi collaborator George Soros.
The burden of proof is on the lefties pushing HR 3200, not on the rest of us to prove it's bad. Currently it's a stalemate, who will break through first? No doubt RahmBo is busily preparing bribes and threats to peel off 15-20 Blue Dogs so they can get a headline soon and declare victory.
Regarding the analogy of the health care situation as being like rising water in a basement, and equating those who oppose the proposed health care bill with those who refuse to hire a plumber:
If the plumber you're talking about is the one who caused the problem in the first place, darned straight we don't want to call him!
I don't know of any thinking conservative (I know, for most of you on the Left that's an oxymoron) who does not want health care reform. It's just that we believe in reform in a different direction: allowing people control over their own health care, and the money they spend on it. Decouple it from employment, and eliminate its peculiarly tax-favored status (the single largest factor in driving up costs). Use insurance for catastrophic loss, as it is when one insures a home or a car, instead of for routine maintenance (another factor in driving up demand, and hence costs). Vouchers for the poor, so they can make their own choices.
From my (and many others) point of view, the current proposed reform will simply exacerbate those problems which bedevil our health care system as it stands now.
Wow two people proposing vouchers. Maybe if we got another one we'd be a movement.
Third!
"Decouple it from employment, and eliminate its peculiarly tax-favored status (the single largest factor in driving up costs). Use insurance for catastrophic loss, as it is when one insures a home or a car, instead of for routine maintenance (another factor in driving up demand, and hence costs). Vouchers for the poor, so they can make their own choices."
Second. So many benefits, comparatively little cost.
Additional thought. Anyone who makes the claim that further government involvement is justified partly because we've already accepted some degree of government involvement is unintentionally validating the slippery slope argument. After all, if only people who advocate no government involvement can give "principled" arguments against more government involvement, then Bearded Spock may be the only principled person on this website. Otherwise, its perfectly legitimate to argue that some government involvement helps but eventually the marginally utility of government involvement turns negative. Furthermore, its legitimate to argue that the current bill is likely to head us down this path.
If I were in charge of health care reform, I'd do away with the laws requiring emergency rooms to treat anyone regardless of ability to pay, I'd liberalize the requirements to become an MD and let the free market sort the rest out. I will NOT be party to big government programs.
Actually, I believe the laws only apply to hospitals that accept federal funds. Of course, that turns out to be most hospitals in the country.
The only reason we will not see positive health care and insurance reform is because the current House bill with government option is the only vialble way to begin to get the camel's nose under the tent.
Otherwise, there are obvious middle of the road options that would pass with large majorities - 1) Mandatory individual policies with government supplements for the poor(the food stamp or McCain method) this could be done with tax credits funded by the revenue from removing the tax deduction for employer provided health insurance. No pre-existing condition refusal of covereage until one year after passage.
2) Mandatory Health Savings Accounts of $2500.00 (indexed for inflation) and minimum deductions of $2500.00 for all policies with no co-payments. The poor could apply for grants to fund the HSA. All others would have them through work. All doctor visits and procedures would be paid out of this fund that would increase each year. Those who become chronically ill would be eligible for a government assistance for medicine and other excessive out of pocket expenses.
These would require the elimination of all state regulation of health insurance and reasonable tort reform to hold costs down.
Both of these ideas would improve over the current systema and would reduce costs and increase competition. Why not put them up for a vote in Congress? The reason is neither one leads to single payer.
Well 1) is too vague to really critique. How are the prices for the policies set? Is there a minimum policy? What does it have to cover? Why can you be dismissed for pre-existing conditions after a year? But assuming you had community rating, at least as to the minimum policy, to prevent sick people from being priced out and there was a minimum policy with decent coverage ... well that sounds pretty much like what Edwards and Clinton proposed in their campaigns (Obama was similar but tried to pretend you didn't need a mandate), and it sounds a lot like what Democrats are proposing currently via the exchanges. I'll grant you that some Democrats are pushing for a public option on top of this because they really do want a French style system, but if there were actually a significant number of Republican votes for this the Democrats would take that deal in a second.
As to 2) depending on where you set excessive out of pocket expense, well that pretty much is single payer. Now if you set it high, I don't think you'd get many takers because most Democrats generally do believe in a sort of Rawlsian system where we share the burden of being sick rather than let it all fall on the unlucky. But if your setting it low, I don't think Democrats would have any problem - hell it sounds pretty much like the first two planks what Brad DeLong proposes here: http://delong.typepad.com/sdj/2007/06/dealing_with_th.html
I think you seriously overestimate what Democrats want and what Republicans would accept.
I think you seriously overestimate what Democrats would accept. The reason decoupling insurance from employement is off the table is not that Republicans won't go for it. Regardless of how good an idea it may be, a majority of voters have employer provided insurance and there are too many politicians on both sides of the aisle that are unwilling to mess with that constituency. I doubt Democrat politicians would even be willing to try a backdoor method to get rid of it except they apparently believe killing employer provided health care gradually will shields them from some of the political fallout.
The main difference between Basil's proposal as I read it is that individuals make the choice about what kind of insurance they buy and what kind of care they get within the scope of the money available in the vouchers. Under single payer, unless your using the term differently, the government pays directly for your care and thus has final say in what you get. I think the difference between that and voucher type systems is huge.
Johnson_85:
Well of course Democrats won't propose it without Republicans going along for the ride. Decoupling employment and health care is, politically, very risky. But my argument is that Democrats would jump on such a compromise if Republicans were actually ready to vote for it in significant numbers. My supporting argument is that this is very similar to what Democrats are proposing grafting on as a parallel to the employer system. In what significant ways - other than being less national health care by not simply eliminating the current system - do you think the Democrats' proposals differ from Basil's 1.
bombloader:
Different from single payer yes, but different from what Democrats are currently proposing and would gladly take, I don't think so. Possibly, as I pointed out - the proposals are vague at a lot of points but lets look closer.
There is a mandate - so you are ordered to buy some health care not just given a cash voucher/tax credit which you are free to spend however you like. Presumably you have to buy some set minimum of coverage that the government determines. Now assuming you get that government determined minimum of care and there is still money in the voucher, yes, I think you would be free to purchase whatever additional health care you wanted. But I seriously doubt the government is really going to provide a voucher/credit that is worth more than the set minimum.
So with single payer the government is going to buy you a set amount of health care, where the government has set what that amount is, and the government will then tax you to provide funds to cover the health care.
With the Basil plan the government is going to give you money and require you to use that money to buy a set amount of health care, where the government has set what that amount is, from a third party private inurer, and the government will then tax you to provide funds to cover the health care voucher/credit.
In either case the government has the final say in what you get out of the money/health care that the government is paying for. In either case you are perfectly free to use your own additional money to buy more health care in whatever amount you choose. I don't see those two programs as that meaningfully different.
I assure you that Democrats would gladly give up the nudge toward single payer of the public option (which is having difficulty getting support from even enough Democrats) to get Republican support for an individual mandate, community rating, and a voucher sufficient to cover the individual mandate. It is pretty much what they campaigned on.
Thats a pretty small nit to pick (also I seriously doubt that you can't get insurance to insure you for one thing -- in a world where thats the market why wouldn't they? You can get all kinds of tiny insurance now, renter's, id theft, various gap insurances, etc., anything that can be price risked out). But for the sake of argument, fine -- Democrats would be thrilled to take that compromise (hell a significant number don't even want public option so its not even a compromise). Bet you can't find 5 Republican votes in the Senate for it.
Couldn't reply to your reply to my reply so here it is. I still maintain the difference is meaningful because cash or a voucher is more fungible than a good or service provided in kind. Under a voucher system, I may decide that the minimum the government sets is good except for 1 particular item. So I look for a complete policy that includes everything required plus the extra I want. If I'm under the government policy, its probably much less likely that I'll find an insurance policy that will cover nothing but the one item the government doesn't. Instead, I'll have to buy a policy that probably double covers me on something, probably costing more than simply buying the next higher policy option. However, I'd prefer to keep the government required policy to a minimum. Probably some type of catastrophic plan would suffice.
sorry -- post above should have gone here.
Anybody who has argued that we need to enact 'something' (other than targeted reforms) to fix Medicare/Medicaid has conceded that Megan's argument in this post is correct.
That's because they really really want single-payer. They are not interested in targeted fixes.
Those in support of the administration-propped current healthcare reform:
There isn't even a final bill being debated. You can't claim "the left" has been pushing these ideas for generations, because "the left" is arguing over them right now and no formal bill has been put forth for debate.
To those who are against what the administration is trying to do:
Remember not to just put down the concepts, but to offer alternative ideas.
Also....it's important to remember that, as Tom O has pointed out, "the left has been pushing these ideas since 1940" which has yielded MediCare & Medicaid and other such services.
History repeats itself unless we learn from it. So far, I see no learning from the mistakes of Medicare (and, similarly Social Security) in the advent of new, broad-range massive government subsidization programs.
Joe
It seems that there is a significant push for some type of voucher system going on in these comments. Now if only Congressman were reading it.
It's interesting how persistent health care inflation is. In the past 60 years, it has outpaced regular CPI 54 of those years. Now, in the past 30 years it has outpaced CPI 29 of those years, so that may be an argument that its special tax status has contributed to price hikes, but I'm skeptical. From 1950 through 1980 it grew more expensive too.
I have not seen convincing studies that tell me why this is so. I haven't seen convincing theory that tells me why this should be so. The only thing that I can come up with is that an affluent society may choose to allocate an increasing share of its wealth on health care to improve the length and quality of life.
I also do not thing, absent policy errors, that health care will bankrupt us. Stein's law almost assures us of that: "If something cannot continue it will stop." Unsustainable trends are unsustainable. Markets self-correct.
The issue that many libertarians and conservatives have with health care reform is the "absent policy errors" clause. Now, it is a problem that there are ~10mm unwillingly uninsured people in our republic. It would seem to me that we can deal with 3% of our population without restructuriing 18% of our economy.
And incurring an insoluble public choice problem in the process. I have yet to hear a substantive argument re: Megan's public choice objection or regulatory capture issues other than "the pharma/AMA/insurers support it." Rent-seeking, anyone?
Please, a substantive answer?
Not very substantive, but the explanation I've always heard for the health care inflation is that healthcare (1) is labor intensive and (2) requires specialized/educated labor. Healthcare may have gotten better over the last 50 years, but it hasn't really been able to achieve efficiency gains with respect to how long it takes a doctor and/or nurse to diagnose a problem. And specialized/educated labor is one of the few things that hasn't gotten cheaper in the past 50 years. On top of the wage increases of health professionals (which like other educated labor has generally far outpaced inflation?), we also have much better technology that doesn't replace labor, and actually requires (costly) training of more labor to operate it. So we have the same amount of labor getting more expensive, and new and improved technology that is getting more expensive, plus gov't policies that mute price signals that might otherwise drive down demand (and eventually price?).
The only reason that healthcare inflation has outpaced regular inflation for so long is that we've become rich enough to afford it (and also probably in part because our policy decisions have been so poor). It will stop outpacing inflation when it becomes unaffordable.
It would seem like one area that technology would decrease costs is where it allows less invasive procedures to be substituted for more invasive ones. For example, antibiotics instead of removing tonsils. Or laparascopic surgery in place of conventional. The new technology may have a cost of its own, but if it allows recovery to be faster, we can have shorter hospital stays, which consume less of the expensive skilled labor. Might take a while before the cost savings become evident.
The bit about labor inputs makes sense. It applies to the entire time series, not just the last 30 years. Also about technology. Most technology increases productivity. In health care, it improves outcomes but doesn't make delivery of services more efficient. In that sense, it is almost identical to higher-ed inflation
Until now. Health consultations across the web, radiologists in Mumbai reading x-ray images, computerized records available for professional consultation make service delivery via broadband much more efficient.
That kind of innovation can drive down costs, as it delivers services more efficiently.
Health care inflation will outpace regular inflation even after it is unaffordable. Look at college costs. No one is arguing that they aren't unaffordable. And they continue to outpace regular and core inflation.
"The only reason that healthcare inflation has outpaced regular inflation for so long is that we've become rich enough to afford it (and also probably in part because our policy decisions have been so poor). It will stop outpacing inflation when it becomes unaffordable."
I'd add that it's also one area in which the technological advances don't become orders of magnitude cheaper every few years. MRI's have advanced tremendously in resolution/contract and capability, but they still cost anywhere from $1.5 million to $4 million to build, staff, house, and maintain (upfront costs). And they don't have permanent shelf-lives....a new, better, faster machine is brought forth and replaces the old one.
Furthermore, you have physical limitations behind that technology. You can only run so many people through it per day, and most of those people are going to be willing to go through it between 6am-8pm. Building a 2nd one might not be worthwhile. You need to keep salaried staff on hand to work and analyze the results.
So you've got only maybe 5-10 years to put this machine out there, pay for itself, and make a reasonable profit off of the investment you put into it. Even if you are a non-profit, you can't operate it at a loss and each exam might only be 4-5% cheaper.
In the meantime, over the past 2 decades, demand for MRIs have gone up dramatically....but you are still faced with the same model. You can't supply it any more cheaply to the individual.
Using this analogy to apply to the broad healthcare strata - You've got great technological advances being made that aren't getting any cheaper every few years (in some areas that's not true), you've got rising demand for the technology, and you don't have any way to make that higher demand into a cheaper supply beyond what was done with the technology within the first year or two.
Sounds to me like the total amount of money going towards those technologies would increase linearly with demand for their services.
I'm curious-why wouldn't MRI's get cheaper? Powerful magnets may not decrease in price, but isn't the image created basically by computers interpreting the signals created? Computing power does keep getting cheaper. Or is it just that it is getting cheaper per unit of resolution, we just keep increasing resolution instead of decreasing price.
Bombloader -
Let me put it this way: if you went to a computer show 10 years ago to buy a mid-to-high level desktop computer, fully equipped, you'd spend $1000-3000 depending on where you wanted your money to go.
If you do the same thing today, you'll still spend $1000-3000. You'll just get alot more computing power for your money.
MRIs have become substantially faster as a procedure, with alot better resolution, contrast, options, and even less claustrophobic environs for the patient.
None of that made it cheaper to build.
And the demand for MRIs during that timeframe only increased dramatically....so our healthcare costs became far greater because the demand increased far more than the decrease in cost or time of the procedure.
Joe
Point: The FDA requires most healthcare machines to be manufactured in the US or Canada. So part of the reason healthcare machines do not get cheaper to build is that the cost of the machine and its constituent components has pay for North American wages and benefits, and many of those machines and their constituent components, especially larger equipment such as MRIs, are in low-volume production.
This is the most amusing thing since the
Monty Python bit about the Philosophers
playing Rugby.
Most of you have good intentions, but that
is no substitute for being willing to admit
how the political sausage grinder works.
No, that is wrong: you are unwilling to admit
that the economic downturn continues, and will
eventually reach a level where TPTB are willing
to feed the useless eaters into the grinder,
along with anyone who objects to their tactics.
The current sloppy, sort-of-private system has
an ~80% success rate; That means it is not broke,
so don't try to fix it, by giving the State a tool
which can double as a weapon.
"A little kindness is the beginning of great cruelty."
See also King Log vs. King Stork
Assuming we will eventually get government health care, I'm certain the "moral obligations" will not end there. In fact, the state will continue to expand into many other areas that have nothing to do with morality. Look at politics in any European country. The various socialist parties, now that they have various levels of state health care, buy votes left and right.
- Free day care for babies 18 months and up (and free kindergarten beyond)
- 500 to 1000euros a month in cash for anyone with a kid
- Free public transportation passes for the "needy"
- Public transportation expansion and continual "upgrading" (I can't count the number of perfectly fine train stations that are 100% better than anything we have in America that are constantly being completely rebuilt so it's newer and 10% faster - with no costs passed onto the travellers)
I've even seen some political signs now buying votes by promising to run the trains and buses around the clock on the weekend -- again at no additional cost to people using public transit.
The list can really keep going on and on. Someone should compile all the various "gimmees" that get handed out to a group of people to keep them voting for select parties.
Whatever happens to health care in America, we can be sure of one thing, it will most certainly not end there and it will continue to expand. And once that battle has been won it will most certainly move into many other areas deemed "necessary".
It's almost as if congressman/women and senators need term limits...
Wow now I know your a crazy radical:)
It's almost as if congressman/women and senators need term limits...
Agreed. And bureaucrats too; nobody should feed at the public trough for more than a decade. The expansion of the productive class (at the expense of the non-productive class, and its seamy subset, the parasite class) is the best hope we have as a nation.
To whoever said I was wrong about medical research because industry does the majority of such research, I say so what? Most basic medical research is supported by the NIH, which has nothing to do with health insurance. Most applied research is supported by private industry, in particular the pharmaceutical industry. The industry backs the administration on this bill because its passage would mean more customers. Therefore, I don't see why passing a health reform bill would have a downward impact on their research budgets.
Most of the rest of the posts I see here argue for the status quo or for private purchase of health insurance, perhaps with government help, as in the Wyden-Bennett proposal. Apart from the fact that most individuals would do an awful job of buying their own insurance, there is no conceivable chance of Wyden-Bennett passing in the foreseeable future. It would mean the end of employer-provided health insurance, and the demonstrations we're seeing now at Congressional townhalls would be replaced by full-scale riots. If you reject the administration approach, you're arguing for the status quo. This is not sustainable.
As a last point, I think the Libertarian party needs a new patron saint. Ayn Rand just doesn't quite hack it. My nominee is Charles Trevelyan. His actions during the Irish potato famine are an inspiration to all Libertarians.
Hah! I had to google him - that's funny! As I said upthread - its taking the national anthem from the 2000 year old man literally!
So why are the people fighting Wyden-Bennett not the ones arguing for the status quo?
One group is arguing for a proposal that (1) is at least supported by sound economics and (2) with some tweaks, could more or less achieve the stated goals of each party. With the main drawback being that it forces people to recognize costs.
Another group is arguing for a proposal with major benefits of (1) being warm and fuzzy, (2) having an opportunity for lots of give aways during the legislative/political process, and (3) allowing supporters to hope that they can use the political process to stick the costs to some group to which they don't belong.
And the first group is the problem?
Maybe the LP loves Ayn Rand, but I consider myself fairly libertarian(small l), and I'm not a fan of hers. I find Hayek a lot more interesting and practical.
"If you reject the administration approach, you're arguing for the status quo. This is not sustainable."
More ~A, therefore B. Just isn't true. Wasn't true last week. Won't be true next week either.
In answer to a question about why liberals don't support Wyden-Bennett, I can speak only for myself and my two brothers. We'd all support Wyden-Bennett if we thought it was the only way of achieving universal health insurance coverage and if we were sure that individuals buying their own health insurance under some variant of Wyden-Bennett had adequate guidance and adequate subsidies based on their income level. We want to see universal coverage AND cost containment, and Wyden-Bennett is one way of achieving this. So is single-payer, though few people reading this would agree. The problem is that the Wyden-Bennett plan is politically unachievable. The majority of Democrats in Congress are more statist than I am (I can't speak for my brothers), and I can't see them slapping their heads and saying oops, I was wrong, I don't support the administration plan after all. And I can't see many Republicans supporting it either, because the Joe the Plumber crowd would see financial support for people buying their own insurance as rank socialism.
Right now, the only two alternatives are the administration plan, possibly without a public alternative, or the status quo. The proprietor of this blog prefers the status quo, and I'm really, really afraid that that's what we'll get.
Possibly more moderate reforms like this can occur if Republicans pull Clintonesque triangulation. But, like you said, you'd probably have to still get enough Blue Dogs on board to make it work. Then, would it survive Obama's veto pen? So, yeah the political incentives are lining up for probably nothing happening.
Right now, the only two alternatives are the administration plan, possibly without a public alternative, or the status quo.
Again, that's patently false. Not passing this bill doesn't mean that others can't come up with a better one down the road. It's not an either-or, and it's enough a major issue that it doesn't have to (and shouldn't) be done NOW!!! before there's a chance for reasoned debate on all sides.
And yes, Congress should come up with a bill that they can, and will, actually read.
One of the things we can always be sure of in an American Health Care debate is the vast amount of "supposed facts" about others systems that are simply not true. Megan stated stated that she saw Obama's Health Insurance Reform Program and the the three bills currently in Congress as the noise of the single payer camel trying to get under the American tent, like "Canada" where private health insurance is "illegaI." Except of course its not. From Wikipedia:
"About 30% of Canadians' health care is paid for through the private sector. This mostly goes towards services not covered or only partially covered by Medicare, such as prescription drugs, dentistry and optometry. Some 65% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers.[15] There are also large private entities that can buy priority access to medical services in Canada, such as WCB in BC.
The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises. Most doctors do not receive an annual salary, but receive a fee per visit or service.[1] According to Dr. Albert Schumacher, former president of the Canadian Medical Association, an estimated 75 percent of Canadian health care services are delivered privately, but funded publicly."
Further, most of the universal systems in Europe allow a mixture of private and public coverage. Insurance companies even still make a good profit, maybe to good of one, in Switzerland, Austria, and Germany. I lived in Europe for 17 years and what I saw of the care it was least equal, if not better, than the care in best hospitals in the United States. So we are not talking about Soviet Russia if we were to enact a mix system like Obama is proposing.
As for most people being happy with their insurance, I expect that most people are not sick at the time this question is asked. This woman was happy with her health insurance, until she go sick and they told her to drop dead.
http://www.pbs.org/wgbh/pages/frontline/story/2009/07/you-next-on-rescinded-list.html
What do you think might happen if the President endorsed Wyden-Bennett, said that he will sign it and only it and strongly suggested that the Senate take it up, without amendment, as its first order of business after the recess? I would predict 75 votes in favor and the House being forced into following suit. This is what used to be called leadership, See, Reagan, Ronald. For a contrary example, see McCain, John
Nope, because Republican support for Wyden-Bennett is a mirage.
http://voices.washingtonpost.com/ezra-klein/2009/06/is_the_healthy_americans_act_a.htmlhttp://voices.washingtonpost.com/ezra-klein/2009/06/is_the_healthy_americans_act_a.html
The GOP has been crystal clear that they want to defeat any health care reform proposal. Period. Democrats aren't going to compromise for zero votes.
The thoughts of Ezra Klein count as "crystal clear" proof of Republican intentions? A new low.
I think when the Republican sponsors when asked about the bill say that they oppose what the bill actually does that shows they aren't serious about supporting the bill if it ever actually got voted on.
TomO,
"they oppose what the bill actually does"
This is false. The quotes given say they have reservations about certain aspects. These are the areas they have compromised on but accept. To say they don't support the bill generally because they have reservations about some is just wrong.
"shows they aren't serious about supporting the bill if it ever actually got voted on."
Logically unsupported. Let's say Obama says he will pay for this in part by raising middle class taxes by and expresses regret that he has to do so. Would you claim this means he won't sign the bill?
I think Deomcratic talking points need some work. This is the disadvantage of living in the liberal cocoon, where everyone seems to accept any silly conclusion regardless of whether or not it can be supported. In any reasonable world anyone making the above assertion would be laughed out of a job.
I thank TomO for the reference. It's clear that the Republicans in Congress have zero interest in reforming our health system. Instead, they cling to the idea of terrifying the country with tales of how Obama is going to kill Trig Palin and let granny's breast cancer go untreated. It's really sad, and it's also sad that intelligent people like the proprietor of this blog support their aims if not their methods.
What's sad is that we've attracted two more Klein sycophants who have no interest in discussing the issues, but rather are simply here to cast aspersions on anyone who disagrees with them.
In reply to mj, what you regard as aspersions are simply facts.
Fact 1: The per capita medical expenditure in the US is twice as large as in the Netherlands, France, Germany, and Canada.
Fact 2: These countries have almost universal health insurance coverage and we do not.
Fact 3: These countries have life expectancies at birth at least as long as ours, and a similar advantage in infant mortality rates.
Fact 4: The wonderful role played by the US in basic medical research is due to NIH funding of research and excellent US research facilities, and has nothing to do with our health insurance system.
Fact 5: American pharmaceutical companies support the administration plan, showing that Megan's charge that the plan will hurt the industry is spurious.
Fact 6: The health insurance systems in the countries I cited are popular with their publics, and ours is not popular with ours.
One could go on. I'm presenting facts, and you are relying on ad hominem arguments. If you feel my facts are wrong, refute them if you can.
So your genious insight is that everyone else is doing it so we should too. Leftism has certainly come a long way now that they've reached third grade levels of argumentation.
Explain how any of your list (#s 4, 5 and 6 are not facts) supports your assertion that "It's clear that the Republicans in Congress have zero interest in reforming our health system".
Then please explain how the above is simply a "fact", as you claim you have only presented.
And last, why would I refute "facts"? We refute conclusions. But not knowing what a fact is explains why you can't tell the difference between fact and opinion.
Fact 2: These countries have almost universal health insurance coverage and we do not.
Fact 3: These countries have life expectancies at birth at least as long as ours, and a similar advantage in infant mortality rates.
I fail to see the correlation here. Why do we assume the amount of money, or the design of a healthcare systems, has anything to do with life expectancy?
There is no way you can prove (or even suggest) this without a very detailed, thorough, randomized study. Which would cost millions if not billions of dollars, and decades of follow-up.
In short, your facts are unrelated.
mj, with regard to my "ingenious conclusion" that, since everyone else attempts to achieve universal health insurance we should also, that's not my argument. I'd like to see universal health insurance in the US because I believe our democracy functions best when all of our citizens can lead a decent life if they work hard and follow the rules. To me, Social Security, Medicare, public schooling, and universal health insurance are means to that end. I mentioned the experience of other countries to show that
we can achieve universal health insurance if we summon the will, and that the results will be good for us and for our economy. I cited health outcomes in other countries because I'm pragmatic. I try to learn from experience. What do you do?
Re Fact 4, most basic scientific research in the US is federally funded and carried out at universities. I don't see how this is affected by our health insurance system. If you feel that most basic scientific research in the US is not carried out in the manner I stated, or that implementing a Massachusetts type health insurance system on a nationwide basis would cause our research program in medical science to collaps, please explain why you feel this way.
Re Fact 5, it's indisputable that the pharmaceutical industry supports the administration. There have been several stories about this in the press, and the Obama administration is under attack from some liberals for making a deal with the industry. If you feel this is not a fact, please give your source.
Re Fact 6, every public opinion poll on the attitudes toward health insurance in Europe supports my contention. Furthermore, the countries I mentioned are all democracies and they all have conservative parties. Yet not one conservative party in ANY of the countries I mentioned includes in its platform a promise to go over to an American style health insurance system. Furthermore, in the two US states that presently have near-universal health insurance, Hawaii and Massachusetts, the state Republican parties are not promising to revoke their states' health plans. I infer that programs aimed at achieving universal health insurance are popular. To me, that shows that the people in the best position to judge programs of this type feel that they're effective. Do you really disagree with this?
The conclusion I draw from my list of facts is that health insurance plans of the type used by every industrial democracy but ours work - they provide good results at costs much less than ours, and in a manner consistent with democratic values. As regards the Republicans in Congress, they have presented no plan to deal with the problems of ever increasing health costs and steadily declining percentage of those with health insurance. I could be mistaken. If you think I am, please refer me to official Republican party proposals concerning our health system.
"that, since everyone else attempts to achieve universal health insurance we should also, that's not my argument."
Really? If you don't believe Europe's choice of system supports our choosing the same why did you include it in your your list of "facts" supporting your concusion?
"Fact" 4: Limiting the discussion to the "insurance industry" is a debating trick designed to obscure the relevant effects. The issue is how changes effect the healthcare system. Obama's stated goal is to drive money out of the health care system. By citing the cost difference as a reason to change you have supported this as well. Reducing either the number of uses or the reimbursement per use for new treatments drives down the potential return for any project under consideration. Since these are essentially cost / benefit comparisons, anything which reduces the benefit side without reducing the cost (when applied to a sufficiently large population) will result in projects declined which would otherwise have been approved.
So in general the change you support will make development companies set a much higher standard for new treatment development. I define an excellent basic research system as one that leads to better treatments. When you make that less likely you reduce effectiveness of the basic research as well. This would be true even if the government continues to fund the same projects they otherwise would. But they won't. Part of the grant and project approval process includes a marketing evaluation. NIH is less likely to fund projects where the economics don't encourage development. So this will effect the basic research system you so admire.
"Fact" 5: There are actually two errors in this. (1) Megan did not claim this would hurt the pharma industry, she claimed it would hurt medical service delivery to future customers. (2) Pharma's opinion is about them, not medical service delivery generally. There are several other reasons they might support this plan even if they believe it is not beneficial, so your conclusion is unwarranted even if you assume it's relevant, which it is not.
"Fact" 6: First, let me say that not one of your supporting comments supports the "fact" that you alleged earlier. I take this as an admission you know this isn't a fact. Both America and Europe show similar levels of support when asked the same questions. Both groups are overwhelmingly satisfied with both their own health insurance and health care, but also support reforms as they recognize neither system works for everyone.
It is true that Europeans don't want the American system, so what? Most Americans don't want their system either. Everyone likes the systems they are currently under, and you conclude one system is better than the other. Interesting.
Republicans have other proposals, including one indirectly referenced in a post you commented on. It's quite hard to understand how you can claim something you referenced doesn't exist.
Heh,Stan, don't keep citing facts. You'll just confuse 'em.
Listen, folks- the government is already heavily involved in health care-and that's a good thing.
The law requiring that emergency rooms treat people first-Good.Prevents people dying in the streets.
Medicare? Good. All seniors get health care. No seniors , anywhere, want to give up Medicare-even if, a few believe, somehow, that it's not provided by the government.
Medicaid-Good. See (1).
NIH-Good. The greatest engine of innovation in health care, IMO, and THE reason why the US leads in medical innovation.
CDC- Good, for reasons even the most benighted libertarian can agree with.
FDA- Good. Let's see if Megan serves non-FDA approved food at her wedding reception , or if any libertarian goes with no FDA approved drugs when their life is on the line. No takers? Didn't think so.
Government regulations requiring fluoridation of water-Good.
I could go on -and I think I will.
Truth-in-labeling laws? Good. I want the contents of my bottle of drugs to match the descriptions on my label.
State funding for medical and nursing schools? Good. I want the supply of doctors and nurses to be as high as possible.Most teaching hospitals are also state supported
VA and military hospitals-Good. The government should be responsible for the medical care of those who serve or have served in the military. That system which is entirely government run and financed,
Provides excellent care and leads the world for its innovative treatment of injuries due to trauma, which should lay to rest those arguments about government involvement ALWAYS stifling innovation.
http://www.washingtonmonthly.com/features/2005/0501.longman.html
OK,
I'll stop there.
SO government involvement in health care is good, on the whole. Where, then, does that leave the argument that there should be less government involvement in health care provision because government involvement is always bad? Nowhere, I'm afraid.
Its an argument that makes for a nice slogan, but it falls apart when you look at it.
When MM says, There should be no expansion in the government provision of health care, because more government involvement is innately bad, well, frankly, that's just stupid on the merits. She needs to come up with better arguments than than that.
What's astonishing is that so many commenters agree with her. But then, they have their libertarian biases confirmed, so they are happy.
The argument that other countries can do health care more cheaply than we do, therefore, we should copy them is disingenuos at best.
First, just like in defense spending, these other countries benefit from living under the American umbrella - this time the umbrella of scientific advances made by Americans. If we become like them, these advancements (driven by the profit motive) will decline. If you disagree with this assertion, please explain why American medical researchers are superior to British, Dutch, German or other "cheaper" countries in a way that excludes the profit motive as a possible reason.
Second, these countries are mostly filled with people who make healthier lifestyle choices. They are also smaller populations, are more homogenious and are naturally healthier populations.
Third, many of these countries do not have a government run system. Those of us who object to a government run sytem both on efficiency grounds and on philosphical grounds (the loss of freedom) do not object to reasonable insurance reforms as I discussed above.
My earlier point is that the Democrats could call Republicans bluff (if it is a bluff, which it is not) by going all in on Wyden-Bennett. Democrats do not need any Republicans to adopt a plan, but Wyden-Bennett will get 50% of Republican votes, in my opinion.
The ONLY reason we do not have a vote on Wyden-Bennett is becasue teh left wing of the Dems wants to start the process toward single payer. Their objection to Wyden-Bennett is that it will work, not that it will not work.
What evidence do you have that its not a bluff? Wyden-Bennett is very politically risky and there is no way to take that option without cover. I am pretty sure that if Republicans would vote for Wyden-Bennett in 50% like numbers they would have announced so more clearly by now. Instead you have seven GOP co-sponsors who when asked about the bills main provisions say they oppose them.
This is absolutely correct and it has the added bonus of being very easy to verify with the mountains of data available from the many developed economies that deliver universal healthcare to their people, while retaining both private and public insurance options, without reducing the standard of care. Try Australia, for example. It has a public plan (called Medicare) that covers the basics but individuals can purchase private care if they wish to. Many do. Like every health system, there are occasional cases of poor decision making but the mistake rate is no higher in public hospitals and nobody ever goes broke because they get sick. Care is every bit as good as the US. There is no intervention by government bureaucrats. The system has been in place for decades and despite more than 10 years of conservative government from 1996 to 2007, nobody ever seriously proposed removing the public insurance option. Ask anyone who lives in Australia, the Netherlands, the UK or anywhere in Europe - they all think American conservatives are crazy for the fuss over what is, in every other developed economy, a moral and political no-brainer.
Somebody needs to explain to me why basic medical research, the type carried out at our major research universities and funded by the NIH, would collapse if Congress passes the administration plan. Basic medical research is supported by the government because the public would like to find treatments and cures for coronary artery disease, cancer, and other ailments. Congress funds the NIH because the public is interested in perserving its own health and because there exists a big commercial market for medicine and medical technology. Do the libertarians posting in this thread feel that this market would disappear if more people were insured? How could they conceivably believe something so foolish?
If passage of the administration plan would have a negative impact on the pharmaceutical industry and would therefore adversely affect the industry's development of new medications, as alleged by many people posting in this thread, why is the industry supporting the administration? I refer everybody to this article: http://www.slate.com/id/2224621/ Do companies producing medicines and medical technology abhor the idea of increasing their customer base? How could anybody believe something this dumb?
On the question of examining the experience of other countries, let's turn the question around. At present the Netherlands spends a little over $3000 on a per capita basis for its health care, as compared to our $6000 per capita spending, and the health outcomes in terms of longevity and infant mortality are similar to ours, though a little better. If things were reversed - if we, with our present medical system spent half what the Dutch do, we would see hundreds of articles comparing the two systems in the right-wing press, and there would be nothing wrong in my opinion in printing such articles. We're supposed to learn from experience. It's one of the things that humans do when they're not blinded by ideology.
And finally, if the Republicans in Congress came out for Wyden-Bennett, it would show that they do want to contain medical costs and help people in need. Does anybody think this will happen? I don't.
"Do the libertarians posting in this thread feel that this market would disappear if more people were insured? How could they conceivably believe something so foolish?"
I can't tell if this is disingenuous or just foolish. Increasing the number of insured is not the only variable. It's quite easy to see the market can be reduced since the entire public discussion is how this plan is going to drive costs down by (1) using government negotiations to reduce payments, and (2) using IMAC to reduce the instances of use.
I cannot figure out how anyone espousing a plan whose merits include reducing both the price per unit and number of units cannot figure out that this can reduce the market for treatments.
The pharmaceutical industry supports the plan because they aren't the ones hurt by it. Future consumers are. Since I expect to be one of those future consumers, I care.
"We're supposed to learn from experience. It's one of the things that humans do when they're not blinded by ideology."
There are thousands of years of economic history showing they central control reduces innovation. Those with ideological blinders on ignore this and claim central control will work if we just have the right people in charge this time.
"I cannot figure out how anyone espousing a plan whose merits include reducing both the price per unit and number of units cannot figure out that this can reduce the market for treatments."
mj, what do you mean by "price per unit and number of units"? Units of what? You seem to be accusing the administration of wanting a more efficient health care system. Is this bad in your eyes? Does more efficiency in the health care industry hurt you as a consumer? If so, how? Explain the mechanism by which more efficient health care is bad for the country. I'm all ears.
Stan,
On the one hand you claim market size cannot possibly be reduced. In fact, you claim "How could they conceivably believe something so foolish?" At this point you accept the idea that market size effects development, you just deny market size is reduced. Then when proven wrong you move the goalpost by claiming the issue is efficiency.
We've been claiming all along there is trade off between cost and innovation. A larger return encourages solutions. Leftists have claimed this is crazy (unpersuasively). But you implicitly accept it is true by changing to a cost argument and abandoning your earlier assertion that the market size won't drop. Do you not understand this completely refutes your point about innovation? Or do you simply hold contradictory beliefs by refusing to examine the implications of each?
Government controlled healthcare has the negative effect of increasing the return required by treatment developers before a project will be greenlit. This quite obviously results in fewer grweenlit projects. Over time this fewer projects means fewer successful new treatmetns.
Megan's contention has been elegantly and convincingly refuted here:
McArdle vs. National Health Care — Crooked Timber
http://crookedtimber.org/2009/08/12/mcardle-vs-national-health-care/#comment-285953
Read especially comments 24 & 25.
Exactly. I can't see how anyone who has actually studied the healthcare systems in other countries could possibly agree with Megan on this. There are lots of long-standing universal healthcare systems with co-existent public and private insurance options. ALL of them are cheaper than the US model. Why would anyone choose to ignore this? I can see some reason in libertarian approaches to some issues but health insurance is the wrong fight for them to pick. It is one of the few really clear examples of where the balance of the social contract favours State involvement.
I think we need to get the right verbiage in use. Insurance is something you pay for at a rate based on the risk you present. What we are doing is separating cost from potential risk, so we are no longer talking about insurance. We are talking about welfare. So the question is, if someone cannot afford insurance based on their level of risk, should we give them welfare? And who pays for that welfare?
Also many people citing lower costs in other countries neglect to mention the reason: The US basically subsidizes their care by paying more for the drugs invented here, more for the procedures invented here and more for the results of the R&D we do here that is far more productive and innovative than that done elsewhere. Not that Europe never comes up with anything, but most medical advances come from the US health system.
The big reason for our greater innovation is most likely because we spend more on basic research than other countries. Who is doing most of the basic research spending in the USA? The Government, through NIH and state level spending programs. Megan herself admitted that this is the case on an earlier thread.
Stan's question remains unanswered. How the hell does reforming health insurance affect R&D spending-either private or public? And No, waving your hands and saying that it MUST decrease such spending because the gumint will be more involved isn't a worthwhile response.
Sorry, Megan. You've just confessed to thought crime.
Hey, I had this idea and I don't know if it's a good one and this seems a good message board to float it on.
Principles for health care/insurance reform:
1. Maintain patient and physician autonomy.
2. Encourage responsible behavior by patients (they should take their meds) and physicians (order only useful diagnostic tests; prescribe generics whenever possible, etc).
3. Enable affordable health care, via out-of-pocket, insurance, etc, for a maximum number of people (preferably 100%).
Plan (only point 4 is the new idea):
1. Transfer tax credits for insurance purchase from employers to employees (we need to uncouple insurance coverage from employment.)
2. Loosen requirements for insurance packages, and enable people to choose among plans that may or may not cover things. (Like fertility treatments. Young women in their 20s on their way to medical school or other high-powered careers who know they will be delaying childbearing should be able to buy a cheap "fertility" insurance plan, so if they need fertility treatment in their 40s they have it. We should not require young 20-year old males to subsidize lifestyle choices of 40-year old women. Unless, well, no need to go there.)
3. Vouchers/government subsidies provided to low-income people so they can purchase catastrophic health insurance (like food stamps).
4. For chronic conditions, which is where the long-term costs are highest, and which all healthy people currently subsidize either through insurance premiums or taxes, set up privately operated, non-government organizations that each focus on a specific chronic illness. Most illnesses have one of these already--like the American Diabetes Association--and they focus on advocacy and funding research. Establish several of these for each disease (like an American League and a National League) because there needs to be a little competition and choice. These organizations become responsible for contracting for and paying for care for people diagnosed with that disease. Funding comes from catastrophic insurance coverage--if you have a child who develops juvenile diabetes, then your insurance company pays the Juvenile Diabetes foundation of your choice a set amount ($100,000 or $200,000 or whatever works out for about 5-10 yrs/care). The insurance company is done paying for treatment associated with the diabetes of your child. The foundation takes that money and invests it for the care of your child. The foundation contracts with hospitals, providers, etc to establish care. So one hospital in your area may provide care through the American Juvenile Diabetes foundation and another through the National Juvenile Diabetes foundation, and you pick the foundation based on which hospital you want to go to. Or which doctor participates in which foundation, or whatever.
These foundations also receive funding through government grants (preferably something along the lines of the NIH granting system, where foundations are rewarded for productivity, and not subsidized for failure--i.e. the Natl Juv Diabetes foundation gets more per patient enrolled if they've done a better job keeping diabetes under control, because their patients will then be living longer) and through private donations (tax breaks on donations to medical foundations).
Foundations could also serve as a mechanism for tracking best clinical practices, and maintaining centralized databases on patients. It would make clinical trials much easier.
Foundations for an illness can't turn away patients with that diagnosed illness, so anyone with a particular disease would receive needed care.
If patients were dissatisfied with their care and wanted to switch foundations, they should be able to, and their money should go with them. So if the American JD foundation discovered its patients lived on average 5 years longer than those in the National JD fonundation, I would hope most patients would want to "move" to the American JD foundation. The Natl JD foundation would then hopefully attract patients back by adopting whatever clinical practices enabled the longer life span of the American JD foundation and things would equalize again.
Since each foundation would focus on an individual illness, the foundation would have incentives to fund raise and focus on that illness and be strong advocates for their patients. No patient with juvenile diabetes would have care "rationed" because politicians suddenly decided that pediatric HIV was more important--the diabetes foundations would continue to have money through the insurance payouts and donations and investments.
Oh, and patients would be required to contribute some financial sum to their care--preferably some form of sliding scale, from a minimum of $1/visit to whatever. Patients are more likely to take their meds and look after themselves when they have made at least some minimal financial contribution to their care.
Physicians would want to attract the contracts of these foundations, and would have incentives to provide best quality care (if they offer lower quality, they lose the business) at a sustainable price.
Foundations should be sustainable, competitive non-profits, thus removing the "evil" capitalist profit factor, but have enough ardor to survive in a competitive environment (I'm thinking of the Sierra Club).
I wouldn't recommend suddenly switching to this kind of thing--I would pick one or two chronic, expensive illnesses that are easy to clearly diagnosis (sickle cell, cystic fibrosis, etc) and try it out.
I don't know how this would function with aging. It wouldn't really make sense to have a foundation for "aging" because everyone does it. Elderly patients could be split up into their relative diagnostic categories (foundation for Alzheimer's; foundation for prostate cancer; foundation for Type II diabetes; etc). But really I would try it out with diseases with smaller populations and see how it went.
Viable idea? Or not viable?
"I think most of the people demanding that I discuss nothing but current legislation understand this very well. That's because they feel exactly the same way about pro-lifers advocating for bans on partial-birth abortion, various sorts of counseling, waiting periods, and parental consent."
It’s a perfect example for a reason you don't list.
Some people in the pro choice movement just deny third trimester abortion is even legal because it is not spelled out anywhere in a law or court decision (it is due the interplay of medical privacy laws with a couple decisions).
That’s quite similar to insisting you not talk about single payer since this bill 'is not for that'*... while it will intentionally loophole / backdoor it in via the public option.
* I've been at tables where furious lefties go on how ads about late term abortion are deceptive and should not be allowed as they're all lies...
Some people can't afford food.
We, as a compassionate society, have implemented food stamps to provide for those people. Although it was originally passed as an agricultural subsidy, it's worked out reasonably satisfactorally as a food subsidy and it satisfies most people and it has wide public support. There are agricultural subsidies, but by and large hunger hasn't served as a wedge to socialize the food industry.
Some people can't afford housing.
This has worked out reasonably well, although not as well as food. We have Section XIII housing and rent subsidies. We also have rent control in a few large cities. As I said, this one was almost a win.
The difference in degree that rises to a difference in kind is that most people need to spend about the same amount on food, and most people living in a particular zip code need to spend the same amount on housing, so the means tests are simple. People differ vastly in how much they need to spend on health care.
We are already handling even that reasonably well in some cases. I understand that almost all hemodialysis [kidney machine] treatments are paid for by the government. I think we can solve the affordability problem, even for those middle class people with cancer or with a history that makes insurance unaffordable even for the middle class, without socializing an entire industry.
-dk