It's easy to get cynical about the process of the health care bills. At this point, I'd say that conservative and liberal health care analysts both know the score. Everyone knows that this bill won't work as advertised: it will not cover as many people as promised, and it will run into budget shortfalls, if for no other reason than because Congress is not going to enact the cuts as written--they will get lobbied into repealing many of them. Doug Elmendorf has done everything but hire a skywriter to make it clear that he doesn't think that any of the various bills will actually be deficit neutral--while doing his job, which is to score what's written, not his best guess at what will happen.
Liberals don't care, because they think it's worth it to cover more people. Conservatives care, but their kabuki complaints about what everyone in the wonkosphere knows go mostly unheeded. I find it hard to get too outraged about any of it; I'm against the bill, but I think that this part of the process is playing out about as well as you can expect.
But then you have moments like the one I experienced the other night, in which I sat in a room full of journalists from various sectors who are not quite as deep into the policy weeds as I am--they're political reporters, not wonks. Good political reporters. Very well informed political reporters. And some of the questions really frightened me.
In quick succession, they asked a prominent budget wonk questions like:
1) How come, if so much of the money that's available to be wrung out of the health care system is going to doctors and hospitals, Obama is attacking insurers?
2) How this could possibly provoke a fiscal crisis if the CBO was scoring the bills as deficit neutral?
. . . there were more, but I stopped writing in despair.
This stuff isn't even controversial. I don't think that Ezra Klein or Jon Cohn would have a problem admitting that we'll be in big fiscal trouble if Congress behaves in the future as it has behaved in the past, or that the insurance industry isn't really hoarding big stacks of cash, and other stakeholders will have to take big hits in order to make any reform work. They just think that it's worth it to cover more people, and also that this may provide a framework for future deliver services reform. But everyone pretty much understands that whatever bill we get will not work as written.
We're all off in the woods battling over the appropriate discount rate for dynamic tax effects. And we seem to have left a lot of more politically focused journalists behind.
I get the sense that this happens in administrations too. The wonks understand that they have to make compromises, so they let bad policies through without a fuss in order to secure some larger agreement. (cough/steeltarrifs/cough). The problem is, they sometimes forget to tell the political people that it's a compromise--and what the cost of that compromise is.
Copyright © 2009 by The Atlantic Monthly Group. All rights reserved.
But everyone pretty much understands that whatever bill we get will not work as written.
Considering nobody has read the bill, that seems kind of overconfident.
But everyone pretty much understands that whatever bill we get will not work as written.
That is absolutely correct, considering nobody has read the bill.
You have inadvertendly landed on the reason magazines and newspapers are dying. Many of the journalists have no idea what they are talking about. Polls in general highlight this... the public doesn't trust the media.
I mean you are the rare few that have the credientials to back up your articles. The run of the mill reporters comign from prestigious news organizations are more highly valued that their background and understanding of the topic.
Because such prominant reporters don't really know anything, they will need to rely on other factors to make people trust them. One of the factors is reporting a news story first. with the advent of online media and social networks, newpapers simply can't compete. an organization of thousands cannot compete with tens of millions of people interested in 1 subject. the internet is 1000x faster at reporting the event as it happens. And it turns out, anybody can report news without knowing more deeply the issues surrounding it. hmmmm, starts sounding like run of the mill journalist!
btw, i am also upenn + gsb. hurrah hurrah for the red and blue. now i should say booth
Newpapers started going downhill when "journalists" replaced reporters.
Reporters had some knowledge of the areas that they covered.
"Journalists" know how to write and thats about it. They do nothing but repeat what ever bullshit the "experts" tell them.
Can we dig a shallow grave and toss that in alongside "See [last name], [first name]" -- and then cover it up with dirt?
This sounds just like the parable of the vizier in The Myth of the Rational Voter:
You live in an Arabian Nights sort of country whose caliph, or sultan, or potentate has absolute power and is used to everyone doing what he says. You get appointed to be his vizier. You are a genuinely wise man who wants some combination of the good of the country and the survival of the ruler's regime. The ruler comes up with a proposed new law that you can see will obviously have ruinous consequences. What do you do?
You can say, "Blessed of Allah, your policy is ill-judged and will have ruinous consequences, and you must abandon it." And before you get to explain what those consequences are, you have been beheaded and someone more willing to go along with the ruler has your job.
You can say, "Of course, Your Omnipotence!" and carry out the policy. And then everything falls into ruin and you get the blame for it.
You can say, "O Splendor of the World, you are as ever wise and benevolent, and it shall be done as you say"—and then do as much as you can of what actually works, covered over with a thin whitewash of what you were told to do. And then things stumble along, a bit inefficiently, as long as you keep the balls in the air.
This, said Caplan, is the position of policy makers in a democratic society dealing with the electorate and with legislators. The current health policy debates seem compatible with this.
Yeah, well, only if you (the vizier) and the sultan are actually one and the same person, and you've put yourself in this ugly position.
No one forced the Democrats to bring up this whole issue, remember? There was no huge clamor from the voters in November of '06 or '08, people ululating in the streets: Reform health care! Do it now!. As I recall, the top concerns were the Iraq War (in '06) and the economy (in '08). While everyone agrees that health-care premiums are "too high," kind of like they agree baseball umps are blind, Wall Street financiers are greedy, and the younger generation is ruder than ever before, people in general were quite satisfied with their health care.
So Democrats could have left the whole shebang alone, and concentrated on, for example, helping the economy regrow, winding up the wars in Iraq and Afghanistan wisely, and on disciplining the growth of government spending they so bitterly condemned during the Bush Administration. They could even have tackled a few of their hobby-horses, like "Don't Ask Don't Tell" or gay marriage, or reform of No Child Left Behind, or some environmental legislation, tax credits for solar, whatever, and with their solid majorities have
rolled bill after bill down the aisle, giving a clear impression of a focussed, practical, efficient, businesslike Congress.
They could even have taken on some modest, sustainable, uncontroversial health care reform, like allowing insurance to be sold across state lines, or doing something to make it more likely it could be tied to the individual, hence portable, instead of tied to the job.
But no. They had to go for the biggest power grab in post-war history, and they had to do it in the middle of economic chaos and two foreign wars, and in an arrogant, hyperpartisan, hysterical, and absurdly rushed and clumsy Keystone Kops way.
They have very richly earned through staggering levels of stupidity the thorough contemptuous rejection they'll get next year. It's just sad the GOP benefits so undeservedly from these loony fools overreaching.
Spoken like someone with good health insurance. Of course, the system worked well for you, what could possibly be the problem?
Of course, for the uninsured, thousands of whom die every year because of lack of access to health care, things are a lot different:
http://www.reuters.com/article/healthNews/idUSTRE58G6W520090917
Money quote:
"For any doctor ... it's completely a no-brainer that people who can't get health care are going to die more from the kinds of things that health care is supposed to prevent," said Woolhandler, a professor of medicine at Harvard and a primary care physician in Cambridge, Massachusetts.
Some of those who die are children:
Nearly 17,000 deaths of hospitalized children might have been prevented by having insurance over a span of 18 years, researchers from Johns Hopkins in Baltimore estimate in a new study.
http://children.webmd.com/news/20091030/lack-of-insurance-puts-kids-in-peril
I suppose that someone like you WOULD think its loony to move quickly to help uninsured folks who are dying for lack of health care with measures more effective than the palliative non solutions that you Republicans push. Thankfully, the majority of the country disagrees.
If Democrats were sincere about making healthcare available to the poor, they'd have gone along with some kind of tort reform. But trial lawyers are a strong Democratic constituency. The issue is not that someone is trying to reform health care. That's been going on for some time, and both parties have their ideas. The issue is that this thing is so massive in scope, and is being rushed through before anyone can read it. Is that how policy should be made? How well did that work with the Iraq war?
Of course, dramatically increasing the money spent on healthcare will probably improve outcomes. That doesn't nessicarily mean that all plans which increase spending are equal, that the cost of that extra spending won't have a significant impact on things like job creation, or that any plan which decreased real costs (rather than simply trying to lower doctor's compensation, say, with more regulation) wouldn't have been more effective or a better first step.
than the palliative non solutions that you Republicans push.
The Democratic plans seem more palatative, since they don't actually reduce costs (which is, in my mind, analogous to a 'cure'.) Encouraging people to calculate cost benefit for their (non-emergency) care puts downward pressure on costs that doesn't now exist. Compensation charts encourage doctors to game the system. Gaming the system seems pretty palliative to me.
(Yes, this is simplistic, but any response less than a thesis paper would have to be.)
Yes, because as everyone knows, only those without good health insurance are allowed to point out flaws in Obamacare.
70% of the people are happy with their health insurance it's crazy to make 70% worse off to help make 30% better off.
Thankfully, the majority of the country disagrees.
The majority of the country is stocking up on tar and feathers at the moment. Grab your place near the middle of the rail to get some coverage from the incoming produce.
"if Congress behaves in the future as it has behaved in the past"
And what on earth makes anyone think they will act any differently? If anything I expect they'll act worse.
70% of the people are happy with their health insurance it's crazy to make 70% worse off to help make 30% better off.
JoshinHB: It's certainly not crazy. What it is is non-libertarian. You could argue that the 90% of the population that doesn't receive Social Security benefits is worse off (since their incomes are reduced via payroll taxes) in order to help the 10% who do receive such benefits. Similarly, you could argue people without children are worse off by having to fund schools for those who do.
This course of action, in fact, is what we do all the time. It's called civilization.
And of course, it's highly debatable whether or not the 70% you cite actually will be be "worse off." I'd say for most Americans, the fact that -- just like the citizens of all other rich countries -- they'll always be covered by comprehensive medical insurance constitutes a substantial increase in economic security. That's a real, tangible benefit.
Yeah, until the music stops. Next Republican Congress will be well advised to look into structural changes in spending on higher education as well as the regulations governing the use of the broadcast spectrum, among other things. Not to mention the application of anti-cartel laws to unions.
Drew,
It's amazing that "progressives" worship at the alter of democracy (majority rule uber alle) until a majority thinks the progressive are lazy jack offs that are full of shit. Then the "progressives" are some kind of vanguard that must force a better way on the majority.
M is right: Newspapers are dying because newspaper reporters, with a few exceptions, don't know anything about substance, so everything gets reported as a political story. Why anybody thought it was a good idea to establish journalism schools is a mystery. Those people don't even write very well.
Everyone who wants to reform healthcare always starts off by saying "Americans spend much too much on healthcare ..." and then goes on to advocate only solutions that require much, much more spending on healthcare.
You don't need to be a wonk to ask why the solution to too much spending on healthcare is to double down on healtchare spending.
I don't know who those political reporters are, but the fact that none have ever thought to ask that question means that whatever they're good at, it's not journalism.
Sorry, but I don't share your faith in Klein and Cohn.
@ William H Stoddard: Parable of the Vizier
Tell them the one about the Caliph, the
Mathematician, the chessboard, and the
grains of wheat: 1 2 4 8 16...:)
Afterwards, the Caliph had a head for math. :)
2) How this could possibly provoke a fiscal crisis if the CBO was scoring the bills as deficit neutral?
I LOLed.
But everyone pretty much understands that whatever bill we get will not work as written.
Is Krugman lying, then? Because he seems to think this is all going to work just great.
Of course, he's also on record claiming all those complaints about the British health care system are, quote, "false."
Krugman's position is much closer to being skeptically optimistic. He has voiced many concerns and criticisms, but in the end feels there is enough good in it to support it. He is definitely a supporter of health care reform in general, but to say he thinks these bills will work out "just great" is more than just a tad disingenuous.
And what are "all those complaints"? Many of the ridiculous claims that have been made about the British, French, and Canadian health care systems were outright false. Not 100% of the criticisms were false, but the falsehoods outnumbered the truths by quite a bit. I can personally vouch for most of the crap about Canada being false, having lived there myself.
As for the NHS, it often ranks as one the proudest achievements in Britain in national polls. There would be a revolt in England if you tried to scrap the NHS, and the same could be said for Canadians and their system.
I disbelieve this. Cite?
Most of the claims I've seen include links to newspapers in Great Britain and Canada reporting the basis of the claims. Are these
papers lying too?
If the British health system is so bad, why didn't Margaret Thatcher abolish it and go over to a system like ours? Why doesn't David Cameron, almost certainly the next British prime minister, make abolishing the National Health part of the Tory platform? Can you name any political party in any democratic country other than ours which wants to institute an American style "free enterprise" health system? Closer to home, why don't the Massachusetts and Hawaiian Republicans pledge to end their health insurance systems? And do you ever question the propaganda you hear on Fox News?
Wow, there's a persuasive argument. If Soviet Communism was so disastrous, how come the people didn't rise up and put a stop to it sometime between the famines of 1933 and the final debacle in 1991? If it wasn't a good idea to send all those Jews to the ovens and make war on the entire world, how come the German people didn't rise up and toss the Nazis out in 1943? Or 1944?! Geez, what were they thinking?
If it isn't a good idea to rush over the cliff, how come all the lemmings in front of us aren't turning around? Forward! There's no need to think for ourselves, comrades!
There is a BIIG difference between the totalitarian Soviet system and British parliamentary democracy. If You think they are one and the same, there is no point in further discussion.
Stonetools: It's much more difficult to change third rail issues in democratic systems than totalitarian systems. We know that Social Security is a looming disaster but our politicians will not fix it. The NHS is a much more dangerous rail than SS, no matter how good or bad you think it is.
Stan -- Having recently visited some close friends in the U.K., I can answer your first two questions with one word: inertia. Healthcare was a prominent topic of discussion abroad, as our English friends have been watching the debate unfold across the pond. It is not hyperbole to suggest that complaints about NHS in the U.K. are incessant, and seemingly every daily newspaper features some anecdotal horror story about the system.
But while these articles were relating tales of woe about complete strangers, it happened that one of our friends was in very poor condition throughout our stay. She was on massive doses of pain killers to alleviate a crippling abdominal pain, while awaiting a simple CT scan to diagnose the problem. It turned out for the best in the end (pinched nerve that was causing radiated pain -- easily corrected with minor surgery). But - and I am not making this up - it took 5 weeks for her to get a CT scan. Think about that for a second -- 5 weeks of awful pain to the point of tears, out of work, on narcotic painkillers, etc. b/c there are not enough resources in the NHS to get people seen in anything resembling a timely manner, not even for a simple imaging scan that you could get in 5 minutes here regardless of insurance status.
Never mind the other niceties of the system, like the fact that our friends don't get to choose their physician, or that they can't make appointments for diagnostic tests (instead you wait for a letter to arrive in the post, telling you when and where to appear for your test). The waiting times and doctor shortages alone would be enough to spark mutiny here in the States. When I asked our English friends why the country has not abandoned NHS, they said, in essence, that it's what the populace is used to, they've all paid into it, and they keep hoping for some incremental improvement rather than wholesale change. So be it. But having been to England many times, and knowing well many people who live there, I can only conclude that the system is, as the English eloquently put it, "absolute rubbish." This does not mean that our healthcare system is necessarily a gem by any means, but if given only a choice between existing U.K. or existing U.S. options, it's not even close.
Of course, if she was in the United States and uninsured, she would still be waiting for that cat scan.
not even for a simple imaging scan that you could get in 5 minutes here regardless of insurance status.
This statement is proof positive that you have never been to an emergency room or clinic in a big city in the US. Your vision of prompt treatment of an elective condition is pure fantasy, based on what you think the US system is like . If you have no insurance, there is no instant CAT scan. I can assure you of that as one who has been in the US system without insurance. I too had to wait for weeks to be treated for a painful condition-rheumatoid arthritis. I was hospitalized and presented with a $4800 bill after I left the hospital. Thankfully, no "minor surgery" was needed or the bill would have been double that.
I also have anecdotal evidence of people who have been treated in the NHS and who have actually worked in the system. They tell me they give quality care.
The reason that the British persist with NHS is that on the whole, it works well for them.
See http://twitter.com/search?q=%23welovetheNHS
See the right wing Daily Mail's defense of the NHS here:
http://www.dailymail.co.uk/news/article-1205953/NHS-branded-evil-Orwellian-high-level-US-politicians.html
Note their characterization of right wing attacks on NHS as "Orwellian". Indeed.
Excuse me, stonetools, but your comment is at best an overgeneralization. I live in the United States. I have no health insurance. A couple of years ago, my doctor recommended that if I wanted to be sure my enlarged thyroid was goiter and not thyroid cancer, I could undergo an aspiration biopsy to confirm the results of an ultrasound. So I called up the medical lab he used, which is where I had had the ultrasound done. Not only did they agree to accept payment in cash, and offer me a discount, but they helped me negotiate a discount with the lab that would actually do the pathological study.
I can give you anecdotal evidence, every bit as good as yours, that I was given quality care in the United States for my cash.
Now, I'm sure that just as rpott001 says that "It is not hyperbole to suggest that complaints about NHS in the U.K. are incessant, and seemingly every daily newspaper features some anecdotal horror story about the system," one could also say "It is not hyperbole to suggest that complaints about privately funded medical care in the U.S. are incessant, and seemingly every daily newspaper features some anecdotal horror story about the system." But if you're going to discount the British horror stories as (a) anecdotal and (b) exaggerated, it's just as legitimate to do the same about the American horror stories. And if you take the resistance of the British to any thought of changing the NHS to show that it must be working, it's just as legitimate to say that the widespread American anticipation that Congressional proposals to "reform" American health care show that our system must be working. If you don't accept that mode of inference for American health care, it's intellectually dishonest for you to accept it for British health care . . . that is, when it leads to a conclusion you want to endorse, but not to one you want to reject.
Stonetools -- Try to ease up a bit. You are entirely incorrect that I "have never been to an emergency room or clinic in a big city in the US" -- it happens that I was in one such facility just today, and yesterday, and the day before that...etc. I am in over my head on many subjects, but on this one, I do have a good deal of concrete, real-world experience. It is quite possible to identify very serious problems with the U.K. system without also necessarily being a crazy right wing ideologue -- and I don't think you'd find that label fits me appropriately if you knew me at all. My only point was that the NHS is very dramatically broken, and if you've spent any extended time in England, it seems to me almost impossible to argue otherwise. That is not an inherently partisan opinion. And holding that opinion does not, as I noted above, mean that we don't need meaningful healthcare reform here at home, or that we don't have our own massive problems. But it's utter foolishness to suggest that the Brits have it right, and just as soon as anyone chooses to live in Birmingham, or York, or Luton, or almost anywhere else in England outside of London, they tend to agree.
As for my English friend's anecdote (she's a strong supporter of the English Labor party by the way, if that somehow helps your thought process): After 5 full weeks in pain and thus out of work while waiting for a simple CT scan, she did, as mentioned, at least have her corrective surgery scheduled promptly. In Denmark. Through a series of connections, she arranged to pay out of pocket to have a Danish surgeon handle the task, since she couldn't abide various further delays at home, even though she'd paid into the NHS system throughout her working life.
Probably for the same reason that crappy school district throuhgout this country(LA, Detroit, Memphis, etc.) never get reformed, even though they only produce worse and worse results.
Most of the comments about the British NHS are part of the REpublican propoganda offensive against health care reform. Essentially, it's beern a giant floopd of misinformation. Thje EConomist, Megan's former employer and a right wing British newspaper, said it best:
in America there seems to be a silly notion that having a state-funded health system such as the NHS is somehow tantamount to socialism.
Britain is not a socialist nation. It is much less left-wing, in terms of economic philosophy and welfare provision, than many other European countries. But it does have a deep attachment to the NHS, deriving in part from a folk memory of what it was like, for many people, to fall sick in Britain before the service was introduced in 1948. This attachment is an anomaly in Britain's political consciousness rather than evidence of some more pervasive ideology.
And, as it happens, it is turning out to be a rather sensible quirk. As all developed countries struggle to contain health-care costs, the single-payer system is regarded by many as one of the most plausible ways to control them. The British reliance on GPs, who keep most patients away from the more expensive hospitals, is an important strength. Universal provision is also a good answer to some of the problems likely to arise from advanced genetic testing, which in some places may create a rump of uninsurable malcontents.
http://www.economist.com/blogs/bagehot/2009/08/god_save_the_nhs.cfm
THe Economist statement here should demolish once and for all the idea that NHC is "socialism". It also vaporises the false notion that private systems are naturally more cost effective than government systems. The actual experience of universal health insurance around the world proves that government systems are cheaper. Conservatives who claim that cost is ptheir primary concern in resisting health care reform, are either lying, misinformed or stupid.
While this may seem a harsh judment, it is based on the many posts and comments of Megan and others, who unwittingly seem tto be a real life version of the Monty Pyhon parody " What have the Romans ever done for us"
http://www.youtube.com/watch?v=ExWfh6sGyso
THe Economist statement here should demolish once and for all the idea that NHC is "socialism".
But it didn't say that national health care is not socialist. It argued that Britain was not a socialist nation and that NHC was an anomaly which could not accurately be used to judge the whole of Britain.
Genetic testing, incidentally, has not been nearly as predictive as it was once expected to be. Perhaps a better understanding of epigenetics will change that. Or perhaps not. But such an understanding, if it comes to pass, would bring with it a sizable capacity to change our genetic destinies.
The actual experience of universal health insurance around the world proves that government systems are cheaper.
What does 'cheaper' mean? Can you make cars 'cheaper' by Eliminating Hummers and forcing those who might have bought them to pay pedestrians to buy Saturns? Where do you believe this cost reduction is coming from?
'Cheaper' means that you pay less money and get the same or better results. The UK gets better overall health results than the US and pays less than half as much for health care on a per capita basis. France's single payer system is a little more expensive the Great Britain's, but still vastly better than ours in terms of outcomes and per capita expenditures. Ditto for the systems in Germany, the Netherlands, and Switzerland, which use health insurance systems similar to the one Congress will pass later this year, with the exception that their equivalents of our health insurance companies are tightly regulated.
'Where do you believe this cost reduction is coming from?' In an honest country, it would come from lowering administrative costs in the insurance industry, which are much higher here than abroad:
http://tinyurl.com/5s7ko7
Does this answer your questions?
Stan: You can lower administrative costs by removing barriers to competition in the medical insurance industry, so that insurance firms compete on price. Parkinson's Second Law, "Expenditure rises to meet income," applies to private businesses just as much as to government bureaucracies; if you give them a guaranteed revenue stream, they'll find ways to spend it. Not least on lobbying politicians to maintain their guaranteed revenue stream! But a business that has no guarantee, and that faces competition from other businesses that offer better prices, has an incentive to shed the excess weight.
The medical insurance industry in the United States is shielded from competition by laws against buying insurance across state lines; in many states by laws that mandate inclusion of certain types of coverage, denying people the choice to do without coverage they don't expect to use in return for lower rates; by the simple fact that most people get their insurance from a short list of choices offered by an employer, and not by shopping on the open market; and by the fact that most people are insulated from a large part of the cost of their medical insurance by its being treated as a tax free benefit of employment. Obviously under those conditions insurers have little incentive to become more efficient.
Now, we can deal with this by taking away those anticompetitive shields, and create conditions where the insurance market itself rewards firms that are more efficiently run. Or we can keep the current setup, and have the government step in and try to regulate the industry . . . actively working against the interests of insurance firms under the unchanged anticompetitive conditions. I'd prefer the former.
Stan -
'Cheaper' means that you pay less money and get the same or better results.
I hope you're not using lifespan as a proxy for healthcare effectiveness here. Lifestyle factors (exposure to violence, drug use, diet and lifestyle), not to mention how stillbirths vs. live births are calculated have so much more of an influence on lifespan than access to healthcare. Japanese-American lifespan is similar to the lifespan of Japanese in Japan, not the national American average. Also, the effectiveness of a healthcare system is supposed to be measured by the portion of the population which is exposed to the system. I'm concerned because many NHC advocates don't run their numbers that way.
Also, we need to account for free rider effects. Megan has done a good job of pointing out that Europe is basically free-riding on American innovation. We could fix that in the way of pharmaceuticals by just allowing drug reimportation, so that the US gets the same deal that other countries get and fast-tracking drugs approved in Europe. At the very least, this would help make the statistics more honest about cost of care relative to other countries. (Though I WOULD like to see more naturopathic medicine used, as in Germany. But in the US that isn't even on the table for a NHC system. So anyone who wants that, as I do, has to pay twice.) Eliminating innovation by killing the higher-end services for the sake of overall cost savings has long-term effects, though, that most analyses don't seem to even try to address.
France's single payer system is a little more expensive the Great Britain's, but still vastly better than ours in terms of outcomes and per capita expenditures.
Again, to what extent is this a matter of taking people's hummers and using the money to buy other people compact cars? Or would you be in favor of that?
And are you sure you're accounting only for outcomes which are determined by exposure to the healthcare system? I question that. A car that runs at 55MPH but can only be afforded by half the population may cost more per person than a vehicle that runs at 30MPH but can be afforded by everyone.
In an honest country, it would come from lowering administrative costs in the insurance industry, which are much higher here than abroad:
It's my understanding that some of the administrative costs for government systems are shoved off onto other areas of government. Perhaps it would be possible to get actual savings this way. I don't know well enough to say. But it seems to me that government regulation usually ads an aspect of rigidity to a system. Buckminster Fuller's ideas about architectural engineering, for instance, were difficult to implement because there was strict regulation on how houses should be built. I'm concerned that a US NHC system will be less focused on providing effective care and more on providing a 'standard of care.' Something which the unusually high threat of lawsuits compared to other nations has already made a feature of our system. I'm curious what malpractice insurance is in other countries...
I suspect that many — maybe most — Americans, if they were suddenly dropped into an average British city (e.g., Manchester), would consider the U.K. to be a socialist nation.
And I suspect they would perceive many of the "other European countries" to be communist nations if similarly familiarized.
And before someone goes on another rant about how the U.S. is actually a left-of-center nation, please review in detail the latest findings of the well-publicized Gallup Poll here: http://www.gallup.com/poll/123854/Conservatives-Maintain-Edge-Top-Ideological-Group.aspx
I suspect that many — maybe most — Americans, if they were suddenly dropped into an average British city (e.g., Manchester), would consider the U.K. to be a socialist nation.
And I suspect you've never visited the United Kingdom. Simply walk down any High Street in Britain -- and certainly any major metropolis like Manchester -- and you'll see ample evidence of a thriving free enterprise system: zillions of shops, restaurants, myriad advertisements pushing this or that sale, commercial vehicles, etc. You'll see, in other words, a lively and competitive commercial culture similar to what's on offer in the USA. I mean, if your argument is that government guaranteed, universal health insurance obviates the free market bonafides of a polity, then you're saying the US is the rich world's only free market system. Which is nuts. The US doesn't even have the smallest public sector among rich countries.
Stonetools
see these fine examples of britains non socialist healthcare
http://www.dailymail.co.uk/news/article-1211950/Premature-baby-left-die-doctors-mother-gives-birth-just-days-22-week-care-limit.html
http://www.dailymail.co.uk/news/article-1218689/Grandmother-dies-ovarian-cancer-sent-home-FIVE-times-trapped-wind.html
This is well-said and astute. Credit where due.
I'd like to see a sunset clause in this type of massive legislation.
Doesn't work in 10 years? It gets killed off like Bush tax cuts.
Exceeds budget claims in 10 years? Its gets killed off like Bush tax cuts.
No savings found in Medicare? The entire bill gets killed of in 10 years.
Hell, the GOP should insert something (oh, yeah, they can't sorry) that says if they don't pony up the "waste and fraud in 2 years = X amount, then its game over.
Let's see some metrics and benchmarking.
Never happen because the dems real goal is simply to make their constituents feel better (for a while) and also grab a whole bunch of shiny new government worker union members as voters.
"I don't think that Ezra Klein or Jon Cohn would have a problem admitting that we'll be in big fiscal trouble if Congress behaves in the future as it has behaved in the past...."
But has Ezra said so in clear terms on his blog? I toil on his blog endlessly and I do not see that, or at least not in a bold type.
This is why many common folks get frustrated - there are experts who know that things are not right and Congress is driving a 'freight train' off the cliff; but they do not bother to come forward and say so in clear terms.
Most people are content to see the politicians "doing something" for the sake of it. That wins elections. Heaven help us.
I'm no fan of the NHS - everyone I've met who has used the French system, for instance, seems to prefer it. But "...our friends don't get to choose their physician.." is simply untrue in general. You choose your GP's practice from all the local ones that have room on their lists, so anyone having no choice must be very unlucky. When your GP arranges an appointment for you at the hospital, you will use "choose and book", which means you do have choice about which hospital you use. And when you recieve notification of your appointment at the hospital, you are free to phone to alter the appointment to some day and time that suits you better. Usually that will have to be a later time and date, but you might get an earlier one if they've had a cancellation or postponement from another patient. And, of course, you are free to "go private" if you wish, typically either at your own expense, or at the expense of any private insurance scheme that you, or your employer, has paid for.
My own guess as to why the NHS has become the state religion in Britain is that it has next-to-nothing to do with the pre-NHS sytem, about which almost no-one knows anything factual, but rather it's all due to the enormous fluke that the introduction of the NHS coincided with the wide availability of penicillin and other antibiotics, which meant that for the first time in history physicians were able to cure huge numbers of people. Penicillin had, of course, come out of the pre-NHS British medical system.
We are getting the "Romney Plan" from Massachusetts, with mandates on the young and healthy while kicking the cost-containment can down the road for the next Administration. Since Romney is the only credible Republican on the scene this takes the issue off the table in the next election. Medical spending as a share of national spending will continue to climb at 8% Wages will continue to stagnate as all of the still impressive US productivity gains are sucked into the health system. Since the industry is the most generous to Washington DC the Northern Virginia economy will continue to outperform all other regions. (Major reason to discount anything Lacker says about interest rates.) With mandates on small businesses or offsetting fines, the cost advantage from non-unionized labor across the South will be mitigated somewhat. Sounds like a political win-win-win for BHO.
William H. Stoddard, the Congressional Budget Office and a study at Rutgers University found that allowing insurance companies to sell across state lines would have a negligible effect on insurance prices. For what it's worth, my personal opinion is that a proposal like this would also weaken regulation of the industry. If you can find some independent study that supports your point of view, please provide a link.
Stan-
It isn't a "study", bur it seems independent...
Stan: Not having seen either of those studies, I'm not prepared to take them as authoritative. I don't feel able to judge whether their methodology is sound. Do you have links to provide?
It seems to me that given that there are substantial differences between the states in how much a basic health insurance policy costs, letting people buy from out of state would have to cut costs . . . at least for people in outrageously expensive states like Massachusetts and New York.
As to weakening regulation of the industry, I think that would be a good thing. The current medical insurance industry is a prize example of regulatory capture. Note that Massachusetts and New York, which have high costs, also have highly regulated medical insurance industries. This is not an accident. The whole theory that regulation serves the public interest is an appealing fantasy; regulation largely serves the interests of the dominant firms in the regulated industry, with a little sprinkling of concessions to popular resentments.
William H Stoddard,
For the Congressional Budget office report, see
http://www.cbo.gov/ftpdocs/66xx/doc6639/hr2355.pdf
and for the Rutgers study, see
http://www.cshp.rutgers.edu/Downloads/7130.pdf
Regarding your view of regulation, I think you overlook Adam Smith's observation that
"People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices."
Stan,
Thanks for the links. I'll take a look in a day or two when I have a little more free time.
As to Adam Smith, that asserts that people in business WANT to raise prices. Of course they do. But there is nothing whatever in Smith's comment that specifies that they use any particular method of doing so. My view of regulation is that regulation itself creates greater opportunities for businesses to raise prices, through well-understood processes called rent-seeking and regulatory capture; and that in fact raising prices with the connivance of government is so much more efficient than purely private agreements that it is overwhelmingly the preferred route to monopoly power.
A classic study of this process is Gabriel Kolko's "Railroads and Regulation."
One of the characteristic misunderstandings of libertarianism from people further to the left is to suppose that libertarians are enthusiasts for the free market because we love big business and think the free market will give it unchecked power. In fact, most libertarians are profoundly mistrustful of big business, and favor the free market precisely because we see it as the most effective check on the power of big business . . . a judgment that most businesses agree in, as can be seen by their mobilizing to oppose any proposal to do away with the subsidies, regulations, systems of licensure, and other government interventions that protect their monopoly rents. The reaction of all the medical industries over the past year has not been to oppose health "reform": It has been in the spirit of "We've already found out what you are; now we're haggling over the price."
I don't question your motives, but I think your philosophy benefits the rich way too much, regardless of your intentions. During the past thirty years of Republican dominance we have become a nation of haves and have-nots. I think this is bad for the economy and for social stability, and it affronts my sense of decency. So we're going to differ, I hope in a civil way.
During the past thirty years of Republican dominance we have become a nation of haves and have-nots.
You poor naif. It will just be a different set of 'haves' for a while.
"I don't question your motives, but I think your philosophy benefits the rich way too much, regardless of your intentions. During the past thirty years of Republican dominance we have become a nation of haves and have-nots."
There hasn't been a free market in health care for the last 70 years.
The system of pre-paid health care that we call health insurance, was a direct result of government wage-price controls during WWII.
When the war ended, the employer based "health insurance" system was maintained by giving it preferential tax treatment, when top income tax rates were 90% this was a siginificant subsidy by the governement.
The Insurance industry monopolies were enabled by government action, namely, allowing states to regulate insurance coverage within each state. This is clearly a violation of the Interstate Commerce clause in the constitution.
Cost were driven up by the states mandating what procedures had to be covered. By All0wing the tort system to go crazy in medical cases.
By using regulations, supposedly to protect the public, to restrict the supply of healthcare.
Insurance industry irresponisblity, denying legitimate claims, was enabled by government not allowing people to sue their insurance providers.
The current fucked up health insurance system was created, every step of the way, by govenment action.
More government involvement will only make things worse.
That conservative news magazine called "Sixty minutes" last weekend [10/25] described how perhaps 10% or 15% of Medicare was spent on outright fraud.
Nothing soft; blatantly billing Medicare for services to patients who never receive the services.
So Medicare supposedly has lower administrative costs than insurance companies. What do we get for that administrative money? Perhaps they greatly underspend for fraud prevention?
-dk
A day or so ago I gave a link showing that administrative costs for American insurance companies are much higher than those for insurance companies in countries that use a Bismark style health insurance system, e. g. Switzerland, Germany, and the Netherlands. For some reason Megan or whoever administers this blog wouldn't accept my post, and I don't feel like looking my link up again.
You may be right that Medicare doesn't spend as much as it should on fraud protection, and it may also be true that Americans are more crooked than the Swiss, the Germans, and the Dutch. It's also true, and this time it's not a maybe, that American insurance companies pay a lot more than their European competitors to upper management and they spend a lot more than the Europeans on advertising, lobbying, and political contributions. I expect that all three factors, more checking of claims by American companies, the usual American practice of paying sky high salaries to the people who decide the salary structure, and promotion in the broadest sense, contribute to high American administrative costs. Apparently you view this as a good thing. I don't.
Stan,
Jeffrey H. Anderson had an eye-opening post over at the Weekly Standard about this issue. He writes:
"As 60 Minutes reported last week, Medicare fraud is rampant and has now replaced the cocaine (ahem) business as the major criminal activity in South Florida. Both 60 Minutes and the Washington Post report that Medicare fraud now costs American taxpayers roughly $60 billion a year. That may sound like a lot of money, but surely it pales next to the extraordinary profits of private insurance companies, right?
Well, let's see.... Last year, the profits of the ten largest insurance companies in America were just over $8 billion -- combined. No single insurance company made even five percent of what Medicare reportedly loses in fraud.
While we're making comparisons, in its real first ten years (2014-23), the Senate Finance Committee bill would cost $1.7 trillion. At the rate of last year's profits, the combined ten-year profits of America's ten largest insurance companies would be $83 billion -- five percent of the costs of the Senate Finance Committee bill. Eighty-three billion dollars may not buy you much in comparison with BaucusCare, but -- on the bright side -- that ten-year tally is somewhat more than what Medicare loses each year in fraud.
So, the next time someone alleges that government-run health care is cheaper because of "lower administrative costs" -- a truly preposterous claim on its surface -- these numbers would be good ones to have at the ready: $60 billion in annual Medicare fraud, $8 billion in combined annual profits for America's ten largest insurance companies."
I'm unaware of estimates of how much fraud occurs in payments by the private medical insurance industry. Until I see this amount, I can't accept your reasoning. Certainly, any amount of dishonesty is unacceptable, and I support having Medicare and Medicaid check more extensively for fraud. But taking the American insurance industry with its bloated salary structure and heavy costs for promotion as a model strikes me as absurd.
Salaries are a drop in the bucket on health insurance fees--you will not generate any significant cost savings by forcing every health care CEO to work for a dollar a year. The much maligned "administrative costs" are one of the reasons that Medicare and Medicaid are the most vulnerable to fraud:
http://www.fbi.gov/publications/financial/fcs_report2007/financial_crime_2007.htm#health
The insurance industry spends a great deal of money rooting out fraud. That is expensive, but not as expensive as the fraud . . .
If this article
http://content.nejm.org/cgi/content/short/349/8/768
from the New England Journal of Medicine comparing medical insurance administrative costs in Canada and the US is right, Megan is talking through her hat.
See the surprising connection between Obama's push for nationalized medicine, NY-23, and the question:
WHO WOULD STALIN PURGE?
http://naturalfake.wordpress.com/2009/11/02/who-would-stalin-purge
Just watched the bloggingheads.tv episode w Matt Lewis and Tim Fernholz. Fernholz started right off by saying that the public option will save money, as if everyone knew it. He also mentioned that people are saying that the bills cost a trillion dollars, and of course that isn't true at all. Lewis did not object. Frustrating. Megan, we need you on bloggingheads, I think.