A few notes: first, the "overpayments" provide extra benefits. The program is growing. And patient satisfaction between Medicare Advantage and Traditional Medicare is similar. Opponents argue that this means Medicare Advantage won't be missed. This is like saying that if you made happy Escalade owners switch cars with happy Prius owners, neither one would care, because hey, they're both happy with their current cars!
But mostly, I look to the history of Cat Care, aka the Medicare Catastrophic Coverage Act of 1988. Unlike killing Medicare Advantage, this enjoyed broad bipartisan support. Democrats liked expanding coverage for seniors and the disabled. Republicans were happy as long as you paid for it, and thought it would boost their image with seniors. The AARP gave it the big thumbs up. All sides had to stage a dramatic retreat a year later because seniors screamed bloody murder over the premiums. The benefits were actually pretty useful, but deficit neutrality was political suicide. The post mortem strikes some familiar notes:
Mr. Reagan stipulated that the program would be financed entirely by the elderly, who would pay a flat fee of $4.92 a month. ''We were forced to accept the premise that Reagan insisted upon: financing entirely by the elderly,'' recalled Representative Henry A, Waxman, the California Democrat who is chairman of the health subcommittee of the Energy and Commerce Committee.
Long-term nursing care was what the elderly wanted. But that was financially out of reach; the annual cost was estimated at $20 billion or more, doubling within a few years. The cost of the expanded hospital and doctor coverage proposed by Secretary Bowen was much more modest.
Indeed, the proposal was too modest for many. It was the first major health care bill to come before Congress in years, and advocates of health programs seized on it. ''The bill became the vehicle for the deferred agenda in health care,'' said John Rother, legislative director of the American Association of Retired Persons, the major lobbyist for the bill. ''It was the health policy community seeing this as a way to fix all their problems.'' Mr. Burke, now a health policy consultant, added, ''Congress went on a feeding frenzy.''
The late Representative Claude Pepper, the Florida Democrat who was chairman of the Committee on Aging, and Mr. Waxman were demanding protection for the cost of long-term care. To induce them to drop that demand, the House leadership agreed to support an expensive prescription drug benefit. Other additions followed. The Senate voted coverage for mammography screening and proctoscopic examinations for the elderly and disabled, as well as for certain drugs at home, hospice care and a program to provide help for those who cared for sick relatives at home. The House voted to extend nursing home benefits from 100 days to 150 days and eliminated the requirement that patients spend at least three days in a hospital before becoming entitled to the benefit. It added a program to protect a spouse from becoming bankrupt from the costs of a husband or wife in a nursing home, and a provision having nothing to do with the elderly: a requirement that states provide Medicaid benefits for poor pregnant women and infants under the age of 1.
''When the original Reagan proposal came to Congress,'' Mr. Waxman said, ''all elderly groups were united in opposition. But when other benefits were added, the elderly thought that on balance it was a step in the right direction. But it was a step with plenty of reservations.''
The total cost from 1989 through 1993 was initially estimated at $31 billion. The flat premium of $4.92 proposed by President Reagan became a fee that increased from $4 in the 1988 fiscal year to $10.20 in 1993. And Congressional leaders realized that the flat fee could not raise enough money to finance the program, so Congress enacted a surtax, to be added to the income tax bills of the wealthiest Americans aged 65 and older.
The Administration balked at the new benefits added by Congress. ''We wanted the President to veto this bill,'' recalled Mr. Burke, then Secretary Bowen's chief of staff. ''Unfortunately, this was not the President's strongest time. We didn't count on a guy named Ollie North and the Iran-contra scandal.''
President Reagan signed the bill on July 1, 1988, at the behest of Vice President George Bush, then in the middle of his Presidential campaign.
The end result?
At first, the Senate and House leaders minimized the protests and said they would not revise the program at all. But by spring, the flood of mail and phone calls became too much to ignore. Critics called the leadership arrogant and out of touch with their consituents.
To ease the protests of the elderly, Senator Lloyd Bentsen, the Texas Democrat who is chairman of the Finance Committee, said the surtax could be cut because revenue was going to be greater than needed to finance the program. But he quickly ate his words when the Congressional Budget Office increased the 1989-93 estimate from $31 billion to $48 billion.
Responding to constituents, the House Ways and Means Committee spent three weeks developing a compromise intended to end the protests and salvage the program. It would have cut the surtax in half, increased the flat fee and retained most of the benefits. But last week the House ignored the committee and the Democratic leadership, and voted to repeal the program.
Taking anything at all from seniors is extraordinarily difficult. They have a lot of time on their hands, and they use it to vote. The AARP blessing is not the all-powerful talismanic protection that many seem to imagine. Even if you pass Medicare Advantage cuts, my sense is that this will survive just as long as it takes for an insurance company to mail out notices to its Medicare Advantage patients, regretfully explaining that the payment cuts mean they will no longer be able to offer the following benefits . . .
I don't think that, in the end, Congress is going to be able to take much money out of Medicare. This is not something I'm happy about--it's something I've been lamenting for a decade or so. But reforming senior entitlements has always looked difficult. In the wake of Social Security reform, it's starting to look damn near impossible.
As babyboomers join the ranks of the seniors, all you have to do is to have Medicare offer them free, legalised marijuana as a trade-off for dropping some other benefits. Problem solved!
Megan - I think your take on this is interesting, but i don't think I agree with you. Medicare Advantage has 10-11 million seniors enrolled, about 25% of the total population. Benefits in this program are better and costs for individual seniors are lower. But i'd also note that private plans in Medicare have been cut before, by Bill Clinton in 97-98.
But there's 2 other important points. 1) The reaction of companies that operate in this businees tells us a lot. By word and deed, the companies that sell Medicare Advantage plans all believe that they will be cut. These companies are exiting certain markets, shifting their focus to lower cost products, increasing cost sharing for seniors -- all in an effort to prepare for eventual payment cuts. They've always viewed the higher payments as "priming the pump" - a temporary measure to encourage companies to enter this market. Many companies believe that they are efficient enough to deliver the same benefits as the gov't (or slightly better benefits) and still make a 4-5% profit.
2) even if cuts aren't included in a reform bill (i still think they will be), there are other things that Obama can do administratevely through CMS (the fed agency that runs Medicare) to reduce payments. Such as, change the way risk adjusted payments are calculated, make assumptions about lower grwoth in medical costs, etc. These are all gray areas that are open to politics.
Lastly, I'd say that even Baucus, who has been a big supporter of Medicare Advantage, supports cuts to the program as they are included in his chairman's mark.
It's entirely possible that I'm wrong--though I'll also note that health insurance and other health companies made substantial moves in preparation for a Clinton health bill that never came. Better safe than sorry.
Those gray areas are theoretically open to politics. In practice, it is not enough to express an ardent belief that you can cut payments. You have to actually do it. It has been done before--but never on this broad a scale, and the history shows that the various interest groups often, even usually, manage to reclaim a substantial portion of the cuts by the simple expedient of making a credible threat to stop providing service.s This is already happening to some extent with GPs, which is why physician reimbursements keep getting uncut. At the other end of the scale, who doesn't enjoy the antics of the oxygen lobby?
Well, not to get to far into the weeds, but Medicare Advantage plans are already facing payment cuts of 4-5% in 2010 (vs cost growth of 4-5%) and it is being done administratively. CMS is re-basing health plans' risk scores because the plans do "too good" a job of capturing data on their members' health. So CMS simply reduces risk scores across the board, which reduces payments. This type of re-basing was never done under Bush - last year they planned to do it and decided not to at the last minute, which i think was a political move. CMS also calculates health plans' 2010 payments assuming that the doctors' payments are cut by 20% even though everyone knows Conggress will reverse the cut. So health plans will be paid at the lower level while being forced to pay docs at the higher level. Again, i don't think that CMS would have taken this path under Bush.
Clinton's health bill never came, but BBA 1997 did reduce payments to private sector Medicare health plans.
I agree that health insurers could be hedging themselves by reducing their capital allocation to Medicare. But the market firmly believes that cuts are coming - would be a big surprise to investors if they didn't come to pass.
My personal take on the history of Medicare is that these cuts get done, and then they actually start to bite, and then they get undone, a la 2002 SGR, Cat Care, etc. Some are more theatric than others, but long-term Medicare cost control has proven totally elusive. Maybe Congress will manage a substantial up-front cut to Medicare Advantage--as I say, I could well be wrong. But I don't see it in the history. These things always enjoy broad wonk support, and substantial political support, and then the optics suddenly look bad, and they go away again. But that's just one woman's opinion. And I can be convinced otherwise--by events, if nothing else.
As for Clinton cuts to private plans, not sure what you're talking about there. My knowledge of BBA 1997 is by no means encyclopedic, but I'm only aware of cuts to providers, not private plans, and a lot of those cuts have been clawed back.
The entire health care issue can be summed up as "everybody wanting somebody else to pay the bills". No program can be sustainable and make everyone happy.
1. Universal Coverage
2. Unrationed Care
3. Not having every disastrous effect Ms. McArdle predicts (i.e. skyrocketing costs, national insolvency, stagnating innovation, etc...)
You Only Get To Pick Two.
Yup, Indy is correct.
Medicare Advantage programs are an example of transferring govt funds (ie, taxes) to a private industry. If Seniors are wealthy enough to buy additional coverage, then that coverage should not be subsidized by the federal govt.
Anecdotal stories from patients who have Medicare Advantage coverage shows the same trend as in all insurance: they do not understand what it covers nor what benefits they receive. They are *sold* a plan that is based more what they can afford versus what is in their best interest. Healthy wealthy seniors likely do not need any further coverage, yet they are the ones with the loftiest coverage. Again, this is anecdotal, but it fits a pattern seen with all other health insurance.
This is exactly why physicians support single payer. We are delusional to think that any lay person can know what is the appropriate amount of health care. Call it rationing, but it's really following guidelines for things like mammography and colonoscopies and PSA's, when to perform a cholecystectomy or heart surgery, etc. If you're inclined to be sold additional coverage for whatever weird reason, for godssakes don't use tax revenue to subsidize it.
The entire health care issue can be summed up as "everybody wanting somebody else to pay the bills".
I've been saying that for what, the last decade or so? Nobody thinks you should get to live in a mansion if you don't pay for it, and nobody objects to you going bankrupt if your house burns down and it turns out you didn't pay your insurance premiums. But heath care is different: everyone is entitled to Cadillac Care and nobody should be expected to either pay for it or plan ahead by buying appropriate insurance.
This mentality is the death of both freedom and democracy. A slow death, to be sure, but a death even so.
Aren't we cheery today?
Rob, I don't understand how you can possibly believe that even a much more radical move than what we're contemplating now (like single-payer, for instance) would be "the [slow] death of both freedom and democracy".
I suspect your usually solid reasoning has fallen victim to a giant slippery slope fallacy.
Either that, or you're suffering some sort of early Autumn blues.
It's not health care "reform" that is dangerous, it is the mentality of something for nothing--heavily indulged and encouraged, especially by the pro-reform side--which is dangerous.
Once that notion takes firm root, and most especially when handouts start getting called "rights," then elections degenerate into a competition to see who can take the most from whom, with inevitable consequences for liberty.
Oh, and I would add that some slopes really are slippery, even if not all of them are. I don't think that, say, single payer health care leads to Communism (although, logically, there's no reason not to support single-payer housing or single-payer wages if you support single-payer health care, it's just that politicians don't follow things to their logical conclusions). I do think that free stuff from the government corrodes work ethic and makes people more amenable to restrictions on their freedom as a price for free stuff.
It may be another nail in the coffin of freedom, but it's exactly what one would expect from a democracy.
Of course it's different. Every human being needs and ought to have meaningful access to health care (AKA health insurance). It's a necessity of life by any reasonable definition in 2009. But not everybody needs a mansion, or even a house (though they do need shelter). Tax money shouldn't be used to provide luxuries for people, but it should be used to provide necessities for life for those who can't afford them.
Everyone in the United States has meaningful access to health care.
You're ignoring the tough questions. It's silly to pretend that there's always a "right" treatment. The tough cases are where
treatment A works faster/better than treatment B but is (much) more expensive. Is treatment A a luxury or a necessity? To use the President's example, is a hip replacement a luxury if you could live with painkillers? As soon as something is invented, does it become a necessity, even if it's still outrageously expensive?
Every health care system requires making these decisions, and deciding what health care is an unaffordable luxury. It is absolutely impossible to pay for every theoretical procedure that might help every condition. Some countries have government make the decisions; some countries like the US have insurance companies make the decisions. Singapore comes closest to having the individual make the decision.
Tax money shouldn't be used to provide luxuries for people, but it should be used to provide necessities for life for those who can't afford them.
Fine. Just explain which treatments are a "necessity" (even if you couldn't get it 10 or 20 years ago because it wasn't invented) and what is a "luxury," and we'll be good to go.
We can easily provide basic vaccines and antibiotics, and set broken bones, for everyone, and do it very cheaply. To coin a phrase, no serious proposal on the table does that. Everyone expects Cadillac Care (AKA McMansion equivalent). If not, the "rationing" and "death panels" charges wouldn't be so damnably effective.
Fine. Just explain which treatments are a "necessity" (even if you couldn't get it 10 or 20 years ago because it wasn't invented) and what is a "luxury," and we'll be good to go.
Somebody needs to determine what is a *necessity* and what is a *luxury*. I trust the medical community in cooperation with the government to do this... as is NOW DONE WITH MEDICARE!!!! I do NOT trust private insurance companies, but that's just me.
Ah. But President Obama feels that what is "now done with Medicare" is too generous, and treats some luxuries as necessities, like perhaps hip replacements. He believes that we need to set up a board to scale back what Medicare considers a necessity. Do you agree with him, or do you feel that Medicare gets it right now?
Absolutely I agree with him, and I do not remember anything said about Medicare being too generous. Standards of care evolve and there is no better mechanism than a panel of experts to determine these standards. Medicare, vis CMS, is actually very progressive and proactive in establishing such standards... and it seems that most private insurers follow their lead. You can call it death panels if you like, but it's going on now.
Well, hopefully Megan won't mind a bit of thread hijacking.
Rob Lyman:
But do you really believe the majority, or even a large plurality, of the country feels it will get something for nothing? An argument can be made that our health care system has certain inefficiencies and, in that sense, you can get something for nothing. But, besides that, I'm sure most people realize we're giving up something to get something better.
Every positive right is, in some sense, a "handout". Many people consider basic health care should be right, in the same sense that a basic education is a right - everybody should get it, regardless of their income. The difference is, a basic education is much better defined than "basic health care". Some people think we already have "basic health care" - you have access to emergency care even if you can't afford it. Other people believe that basic health care should be more than that - it should probably cover some sort of regular checkups and treatment of some diseases outside the emergency room.
But, just because the boundaries of basic health care are not well defined, this doesn't mean that people are completely unreasonable about it. My guess is that most people agree that subsidies for Type-1 diabetes fall within the boundaries of basic health care, while dental implants don't.
In this particular discussion, I think the "look at Europe" argument is warranted. Look at (Western) Europe! They have had universal health care for a while. How come people there aren't asking their governments to pay for their cars, houses, restaurant dinners and movie tickets?
There's a key difference between what you can logically derive from first principles and what most people feel it's reasonable. So, for instance, it's difficult to argue from first principles that the ideal age to start voting should be 18. Why not 16 or 21? Still, most people would find it preposterous to move voting age to 3 or 65.
That's the gist of the slippery-slope fallacy. Incidentally, that also why I believe the main thesis of The Road to Serfdom has failed. Hayek gave a disproportionate importance to positive feedback mechanisms. At some point in a democratic system, "We the people" will feel that we've moved too much in a particular direction, and there's some unreasonable stuff going on. So that will tend to get corrected in the next election cycle.
Yup. When a little old lady comes in with Medicare for her Pap smear, I look in her chart and see that she had a normal one two years ago. I say, "Medicare only pays for one every three years."
And she says, "Fine. See you next year."
She does not go off half-cocked about rationing and death panels. The three-year recommendation comes from the Amer College of Ob/Gyn and the CMS. This is science, folks, but it's not that difficult to understand.
I'm not sure what Aetna and United Health have to offer to the conversation (except, of course, taking their 20% fee.)
I'm not sure it's a good political move to try to cut Medicare Advantage. The people I know who are on it are terrified they won't be able to see Dr. Soandso any more after 30 years of building a relationship. Older people tend to be on a lot of drugs for conditions that sometimes overlap, so it's not an unreasonable fear, IMO.
Fear-based medicine. Nice.
Oh, I'm with you - screw those old people. They'll just have to be happy with the doctor the state provides.
But do you really believe the majority, or even a large plurality, of the country feels it will get something for nothing?
I believe that the entire basis of almost all complaints about the health care system in this country flow from either 1) getting insufficient something for your nothing, or 2) having to give something instead of nothing to get something.
The entire theme of the debate is twofold: 1) That, unlike with all other scarce (in the economic sense) goods, medical care should be allocated without any regard to (economic) cost, and 2) it is unreasonable for ordinary people to be expected to provide for themselves, so they need the government to do it for them. (These are, by the way, rephrasings of that Facebook meme from a few days ago).
The first flies in the face of even the crudest and most basic of economic principles: we cannot consume what we do not produce to begin with. The second is directly contrary to self-reliance, personal responsibility, and what might be called the "protestant work ethic" (most frequently observed nowadays among nominally Catholic illegal immigrants), the three of which are essential preconditions to successful self-government.
By all means, let's look to Europe (or hell, even New York): I see higher taxes (despite tiny defense budgets) and less personal freedom, both economic and in the "civil liberties" sense. And I see those problems worsening as we speak. Lovely place to visit, don't want to live there.
A little stronger than I'd put it. I'd put the fundamental root of the problem as that everyone wants to get back more benefits than what they pay in, and that's impossible. The United States of America cannot collectively subsidize itself.
I won't pursue your first points because I'm more interested in the "mentality [that may lead to] the death of both freedom and democracy"
So, Rob
It's certainly true that Western European countries pay more taxes and have heavier market regulation. Except for Ireland, they are behind the U.S. in the 2009 Index of Economic Freedom. But the all countries that are ahead of the U.S. have UHC (except, possibly, for Hong Kong. I don't know what's the deal over there).
OTOH, we kind of suck in one of the most important measures of a healthy democracy, freedom of the press.
There's an index of civil liberties here. The U.S. is on par with Western Europe. Civil liberties are a hard thing to rate. I have seen some other measures, and will link them if necessary. In none of them are most Western European countries worse rated than our country in civil liberties.
I don't see why. I lived in Portugal for half of my life, plus one year in Spain and some months in France and the UK. In these countries, I paid higher taxes but I also had access to more government services. Other than that, I can't say I felt a difference in civil liberties.
Again, I don't see how. Tax burden in the countries I mentioned above (don't know very well the situation in other countries) has been pretty stable in the last 10 years. And you would be hard-pressed to find a bigger threat to civil liberties than our own warrantless surveillance and preventive detention programs.
I am interested in knowing the specifics of your gloomy prediction - what are the mechanisms that will lead us to the slow death of freedom and democracy, and why are countries in Western Europe closer to said death than the U.S.
I'd put the fundamental root of the problem as that everyone wants to get back more benefits than what they pay in
Given the way people freak out at the very thought of buying health insurance in the individual market (even when it costs them less than what their employer would pay), I'm inclined to believe that most people object to the very concept of paying in.
Yes, we see this in all the people who want their premiums to be 50/month, but pay for any care they need, expensive or cheap. People don't seem to want to understand that you can't pay 500-1000/year and actually be paying for the bulk of your own care if you are remotely expensive.
It's like when it comes to health insurance, they believe you have to have something called 'insurance', but it's supposed to pay out constantly in excess multiples of any money you pay in premiums. That's not insurance-- that's subsidy and it is completely unsustainable.
I was surprised by the massive deficits and constant politicking over cost overruns in the UK, France, Germany and especially Canada. Those countries are reducing services and access because it is completely unsustainable under their divers systems, but all we hear on this side of the pond from pro-reformers is that all those countries work great and nobody is ever denied care and OMG YU HAET POOR PEEPUL.
There is a lot of lying on the pro-reform side about how health care really works. Using the one-time (one time only! completely questionable source of data) WHO study. Using another study that covered a single year and EXTRAPOLATED WITHOUT EVIDENCE that '20,000 americans die from lack of healthcare access each year'. Not admitting the flaws in the Western European and Canadian systems of healthcare provision. The list, sadly, goes on.
I think it's just about Obamacare supporters talking themselves into believing that more health care will eventually give them eternal life on earth and they'll never have to die. I can't think of any other reason for the shrill insistence that it's a right.
No "shrill insistence" about anything. You decide which dying sack of protoplasm doesn't deserve to live. The answer is that you can't, you won't... nobody will.
Health care is a de facto right since there aren't any security guards keeping the unwashed masses out of the ER's, and in fact your representative democracy has decreed that, by law, nobody can be turned away. Unless you can convince the indigent to have the common courtesy to die quietly without bothering the rest of us, then I suggest you figure out a way to pay for their health care.
http://www.pnhp.org/physiciansproposal/proposal/Physicians%20ProposalJAMA.pdf
OTOH, we kind of suck in one of the most important measures of a healthy democracy, freedom of the press.
I note that the page you link indicates that freedom of the press is measured by polling journalists, and apparently there can be wide variations from year to year. Neither the method (which, being a self-diagnosis, is prone to hypochondria, self-delusion, and jingoism) nor the year-to-year variations are particularly encouraging. I would be curious to know if you have any instances of government actions against the press in the US comparable to the the (higher rated!) Canada's actions against Mark Steyn, Ezra Levant, and McLean's magazine.
There's an index of civil liberties here. The U.S. is on par with Western Europe. Civil liberties are a hard thing to rate. I have seen some other measures, and will link them if necessary. In none of them are most Western European countries worse rated than our country in civil liberties.
I agree that civil liberties are hard to rate. Permit me to observe that I own a somewhat strange historical military curio from a Seattle-area pawn shop: 8mm Mauser ammunition manufactured in 1938. I will also observe that the possession of this ammunition is forbidden in numerous European countries, and not for any reason of gun control, but rather because their headstamps constitute a thought crime. Relatedly: at the Anne Frank House, there is (or was) a display in which a government official of some sort commented that the internet had made the banning of neo-Nazi literature much harder, because it could cross borders so easily, and that international cooperation was essential to stamping it out. Moving right along, Michael Savage is (or was, maybe they reversed it) banned from entering the United Kingdom because of his political views. Finally: see the Steyn/Levant affair under "press freedom", or Fallaci's persecution in Italy. And of course, most European countries are somewhat more relaxed about internal spying and illegal police searches than is the US; we're still the only country I know of with the exclusionary rule.
So I hope you'll forgive me if I persist in my suspicion of European-style "civil rights."
Back (sort of) on topic, what I fear, and oppose, is the transfer of adult responsibility to the state, and the corresponding infantilization of the populace. Children who don't understand that things cost money whine and wheedle and nag and cry when their parents refuse to buy them a plastic toy, and whey they get it, they lose interest in it in short order. Nominal adults will do exactly the same thing when things are given to them for free. Witness student protests in Germany over proposals to charge exeedingly nominal tuition in exchange for a very valuable good. Witness student obsession with drunkenness and hookups at US colleges where mom and dad typically foot the bill. My own recently deceased--and dearly loved--grandfather, the EVP of a major public utility at the time of his retirement, declared that he could not get by without his Social Security. In some sense that was true; his lifestyle as he lived it depended on it. But although he retired before the age of wild salary inflation we are now seeing, there can be little doubt that he was at least top 5%. If the top 5% of income earners really, truly, can't survive without government subsidy, then we're all totally screwed. What he should have said was, he would have to cut way back on his expenses if he didn't have Social Security (or he would have had to save more, but that's a slightly different issue). But he--a financially sophisticated and old-fashioned guy--didn't see it that way.
A successful and self-governing society depends on self-reliance and work ethic. Insulating people from the direct costs of their decisions (even if they wind up paying the costs indirectly in taxes or premiums) breeds dependence and an entitlement mentality. And as I said above, it turns elections in to a contest to see who can steal what from whom.
I hasten to add that our current system is a disaster in this respect also, and indeed is responsible for much of the something-for-nothing mentality which drives the debate.
I should amplify my previous comments a bit.
Big government also tends to poison discourse. Witness the "death panels" comment and ponder its implications for how Americans think about health care.
First, this is a very personal issue: we aren't talking about some vague generality of improving outcomes or reducing spending or whatever, we're talking about killing grandma.
When people start taking politics personally, things can get very ugly. One's opponents are no longer wrong; they're evil for trying to hurt you. Obama isn't trying to allocate scarce resources in a prudent way; he hates old people and retarded kids. Making government bigger just magnifies how personal each and every election is, and deepens divisions. Deep divisions stress the fabric of democracy and tempt both those who would dismantle it and those who would use it to bludgeon their "enemies." After all, if they're evil and want to hurt us, why shouldn't we do something bad to them?
Obviously I don't expect Zimbabwe-style electoral starvation, but is it so nuts to imagine that (for instance), somebody might decide to support "hate speech" restrictions, or gun control, or some kind of punitive taxation (on tobacco, say), on the grounds that the people who it will most affect deserve to suffer because they're racist and trying to hurt you, personally? I think such sentiments already exist.
Better that government should be small so that we can express our disagreements and hatred by ignoring one another pointedly.
"Death panels" also supports my thesis that people--including "conservatives"--really, truly do think themselves entitled to free health care. The putative "death panels" weren't going to force people to die, they were going to refuse to pay for certain treatments, and presumably permit people to buy them with their own funds if they wished. Yet the possibility that government might not pay for certain treatments was regarded as being equivalent to compelling death. That is the mentality of an entitled brat, not a self-reliant citizen.
OK, let's say I agree with this premise and govt needs to be smaller in regards to critical issues. The more critical the issue to individuals, the less govt involvement will be tolerated. Never mind that the economics of health care have interstate commerce considerations in regard to the efficient movement of labor.
Following your premise, I assume that you are fighting for the rights of doctors and hospitals to refuse care to indigent who cannot pay. Acute appendicitis? Show me your insurance card or stay in the ambulance. Brown Spanish-speaking girl shows up in labor? Sorry, can't deliver here.
Emergency Medical Active Labor Transfer Act (EMTALA) prohibits the refusal of care in such situations. Maybe this occurred insidiously, but the fact is that Republican and Democrat alike have signed onto this legislation and added onto it over the years and it is a fabric of the way we treat people. As such, the libertarian principles to which you subscribe are quaint, outdated, and frankly, dangerous if they were ever instituted.
We don't let people die here in the USA if we can avoid it. So find a way to allocate the resources to pay for this mandated care. The current model of private insurance is inadequate. This is why most physicians are in favor of single payer.
Following your premise, I assume that you are fighting for the rights of doctors and hospitals to refuse care to indigent who cannot pay.
I'm not sure what this has to do with anything (perhaps you could elaborate), but with regard to ER care and EMTALA, I have said, in these very comments, that our system is haphazard, irrational, and inefficient, and I have proposed various solutions, such as mandatory catastrophic insurance tied to drivers' licenses, government single payer for expenses above a given amount in a single year, or a government guarantee to hospitals, with garnishment completed by the IRS. So your purported challenge to me was mooted before you wrote it.
Rolling right along, I can't see how EMTALA should be considered constitutional, given that 1) it has nothing to do with interstate commerce, post roads, or import duties, 2) it would seem to constitute an uncompensated taking of medical consumables, and 3) it would seem to require the involuntary servitude of a doctor who genuinely would prefer not to treat dying patients, assuming such a doctor can actually be found. Not everything that we like is constitutional, nor is everything we dislike unconstitutional.
Also, as a matter of simple justice and quite divorced from the medical context, it seems to me that if someone is to be forced to do something, the forcing entity (in this case, the government) ought to pay a reasonable rate for the required service. If the feds want to conscript doctors, it ought to at least make them O-3s and enroll their families in TriCare.
Even if we conceive of charity care as a duty of those granted the august privilege to practice medicine, it makes no sense to impose that requirement by law on ER docs but not, say, dermatologists. Perhaps a tax on doctors who don't to charity care should be used to partially compensate those who do.
I assume the courts disagree with my assessment, but its also possible that it hasn't been challenged because nobody wants to sign onto the complaint. I sure as hell wouldn't if I were an ER doc.
You're not sure what EMTALA has to do with the health care debate? It IS the health care debate! We are talking about people gaining access to the health care apparatus without any ability or intention of paying... this is one of the drivers of higher costs within the system, which leads to higher premiums for those who pay, which leads to more people opting out of insurance, and the viscious cycle continues.
Earlier you said some inanity about there being no "basic health care" standard (in comparison to education.) Please. If you get nothing else from this discussion, please understand that nothing could be further from the truth. We can argue on the margins about particulars, but "basic (comprehensive) health care" is fairly well-agreed upon: screening for health conditions (mammography, Pap Smears, prenatal care, etc); management of chronic conditions (hypertension, diabetes, COPD, etc); treatment of acute and subacute illness (pneumonias, cancers, heart attacks, etc); indications for surgeries (hysterectomies, heart bypass, GB surgery). Period. These are by and large not controversial topics and manuals are filled with guidelines for management, diagnosis codes and management codes. The manuals were written my CMS along with medical specialty organizations and by-and-large co-opted by private insurance companies.
You say that you agree to "solutions ...such as mandatory catastrophic insurance tied to drivers' licenses, government single payer for expenses above a given amount in a single year, or a government guarantee to hospitals, with garnishment completed by the IRS."
This pretty much describes single-payer, especially the part about govt guarantees to hospitals (I guess doctors still work for free? And taxing only doctors who don't do charity work seems pretty arbitrary-- why not tax only dry cleaners or ice cream vendors?). Basically you are agreeing with PNHP [ http://www.pnhp.org ]. Everyone is covered and the standard for payment is uniform.
I'm guessing you're not writing your Congressman to withdraw EMTALA servitude-- even the most die-hard libertarian doesn't want to take the heat for someone's life yet they are strangely okay with doctors working for free. Constitutional or not, these policies that promote inefficient ER usage are the drivers of health care costs to a large extent.
We can cut costs by either 1) letting people die in the streets for completely treatable conditions (very cost-effective), or 2) treat the conditions more expeditiously with prevention and comprehensive care (somewhat cost-effective.)
Nelson wrote "The entire health care issue can be summed up as "everybody wanting somebody else to pay the bills"." You can delete "The entire health care issue" and insert "democracy".
Tony, I would appreciate it if you were to actually read what I write. You brought up EMTALA as a reply to a post about my expectations of the probable moral and political effects of health care "reform." Specifically, my thesis is that "free" health care--and the nanny state more generally--is the death of freedom and democracy (albeit a slow death) because it is the death of adulthood in favor of perpetual adolescence. EMTALA has nothing to do with that. At least, you haven't explained the connection yet.
But hey, as long as you're throwing out factual claims that have nothing to do with anything I'm saying, how about a source for the notion that EMTALA is a major cost driver in the system at large(as opposed to a major one in ER care but a minor one overall), or that preventive care will save lots of money (as opposed to saving lives, which is a good thing but not what you're claiming).
As for the notion of taxing doctors, I raised it in the context of charity care as a price of the privilege of a medical license, which is one way to get around (some of) the constitutional problems with EMTALA I raised immediately before. The proposed tax would simply be a way of distributing that burden more evenly among specialties. Dry cleaners and ice cream vendors do not possess medical licenses (for the most part) and therefore cannot be said to have any particular duty to perform charity medical care.
Two of my three proposed solutions do not look anything like single-payer. One of them is an insurance mandate, one of them is indeed single-payer but with a really hefty deductible, and one of them is just the government essentially serving as a collections department and payor of last resort. I doubt PNHP would agree with any of those solutions.
No, I have not written my Congressman, because constitutional objections not addressed to the courts are a waste of time, and 99% of them are insincere anyway (Lawrence Tribe and Alan Dershowitz get props for making constitutional objections to policies they otherwise support). And while I can't speak for "most libertarians," I have already stated right in this very thread that I'm not OK with doctors working for free, at least involuntarily.
Oh, and speaking of actually reading what I wrote, there's this:
Earlier you said some inanity about there being no "basic health care" standard (in comparison to education.) Please. If you get nothing else from this discussion, please understand that nothing could be further from the truth. We can argue on the margins about particulars, but "basic (comprehensive) health care" is fairly well-agreed upon...
1) I didn't say that, Nimed did.
2) Just because doctors agree on something which is oxymoronically called "basic (comprehensive) health care" doesn't mean that there is nothing up for discussion. The list you outline is broad and likely to be pretty expensive, so it's fair to ask if everything in the doctors' definition of "basic" should be paid for by the government health plan.
Nimed's (quite correct) point is that there is no public consensus on what constitutes "basic" care, and indeed whenever anyone of the "health care is a human right" school of thought is challenged to list which medicines and procedures are human rights and which are frivolous luxuries (usually with the accompanying point that many fairly inexpensive interventions today were wildly expensive or simply unavailable 20 or 30 years ago), the answer is always silence.
Accept my apology for the misallocation of the quote... but apparently you agree with him, so I feel somewhat vindicated in my error.
Sure the list I provide is "pretty" expensive, but not relative to the massive expense of not providing it... as we are learning. But while you may not agree with these ideas of basic care, it's a decent place to start the conversation.
If we are calling for a free market, then let's hear the loud arguments calling for moral hazard for those who eschew insurance... I don't hear that. It's accepted even by the purest of free marketeers that freeloaders still have access, or at least we hear silence on this issue.
Sorry again for the misquote.
If we are calling for a free market, then let's hear the loud arguments calling for moral hazard for those who eschew insurance... I don't hear that.
Yes, moral hazard is a huge problem. As is its cousin, adverse selection, that our employer-based system defeats to some extent but which a purely individual market would face in spades.
Both of these problems, incidentally, tie in nicely with my moral argument. Fundamentally, we, as a society, can't have what we, as a society, don't pay for, because we can't consume more than we produce. But thanks to the structure of our health care system, we, as individuals, feel fully entitled to demand what we, as individuals, won't or can't pay for, and even make sniffy blog posts about how health care is a "right," and nobody should go bankrupt trying to pay for health care. That's just another way of saying that you should get what you don't pay for. It's an idiotic argument which nobody would accept in any other context, proving that our gracious hostess is correct to say that we all seem to be wearing magic glasses that make stupid things seem sensible in the health care context.
At bottom, my health care plan is simple: you should pay for your own damn health care. If you don't buy insurance but get sick, then you get a "Chicago projects" level of health care on the taxpayer's dime. If you get free treatment off the (lousy) government plan, then either you hope your doctor considers you a charity case, or you get hounded into bankruptcy the same way you would be if you got a flat-screen TV and refused to pay for it.