I think it's pretty clear at this point that no bill from our Congress is going to meaningfully "bend the cost curve". Every time I argue that cost control seems unlikely, I hear that no, the Senate bill is going to make some serious inroads into delivery system reform. Well, according to the CBO, the savings achieved by Subtitle A, the main delivery system reform part of the bill, are trivial--not really distinguishable from zero, when you consider the uncertainties inherent in the estimates.
What passes for delivery reform consists mostly of slashing reimbursement rates to providers, and then putting Medicare Advantage on the same plan. There are two problems with this. The first is that there's no reason to believe that providers will find ways to efficiently provide care at the new, lower rates, rather than just stop serving Medicare patients. That was the core point of the recent report from the Centers for Medicare and Medicaid Services--and though a lot of bloggers developed sudden suspicions about the integrity of government reports, in fact, this pretty much jibes with the warnings that Doug Elmendorf has been issuing, and also, reality. There are already shortages of geriatricians which can be substantially attributed to the fact that Medicare has ensured it is one of the lowest-paid specialties. When the guy who oversees your provider payments says that your new payment scheme is probably going to lead to providers dropping out of your program, you need to take that seriously.
The second is that the treatment cuts--and any further cuts recommended by the cost effectiveness commission--can be undone by Congress. Not only can, but almost certainly will. There's some attempt to get around this by forcing Congress to do only an up or down vote on the recommendations. By bundling the really unpopular stuff with other reforms, the hope is that they'll be able to push them through.
Unfortunately, the commission's recommendations do not save much in any one year, which means it's not actually going to be all that difficult to vote "no" in any one year--and by the time it actually is hard to vote "no", we'll face the same problem we have with the Sustainable Growth Rate cuts for physicians--the cuts needed are so big that it has become impossible to vote "yes", because the providers can't deliver those kinds of cost savings.
So while the bundling might ease the passage of controversial cost-control measures, it might also ensure that no-brainers fail. There's also, as far as I can tell, nothing to stop Congress from passing the whole package--and then amending the health care bill in order to guarantee coverage of anything that gets voters excited.
The current brouhaha about the new mammogram treatment guidelines is very instructive. There are good reasons for doing as few mammograms as possible: they're uncomfortable; radiation causes cancer; and false positives take a huge toll on the patient with invasive procedures and emotional anguish. I follow this issue pretty closely, because I have a family history of breast cancer, and the new guidelines don't seem unreasonable to me.
But some of the criticisms of the guidelines are valid, particularly the fact that they don't take digital mammography into account. And they've activated a very real fear that people will die because they put off having a mammogram until they're fifty. It seems virtually certain either that the task force will revisit this decision, or that any agency or insurer actually acting upon their recommendation will be overridden by legislative action.
I expect that if we do get guidelines with teeth, we'll see this play out over and over.
I don't think it's any good to say, well, we have to hold down Medicare costs eventually, so we might as well hope. That's as fuzzy and dangerous as some of the thinking that got us into the Iraq war. If the mechanism for holding down costs is not realistic--and neither the head of CMS, nor the head of the CBO, seem to think that it is--then in all likelihood, you're planning to increase the budget deficit, whether you want to or not.
Aside from the panel recommendations, the only other substantial attempt at real delivery system reform is the excise tax on high cost plans, which the CBO and the Joint Committee on Taxation are projecting will reduce health care spending. In fact, it's projected to reduce health care spending so much that companies will save a bunch of money, pass that money onto their workers in the form of higher wages, and thereby generate a bunch of new tax revenue to help pay for reform. Maybe. Of course, if they're wrong, and it ends up just being a heavy tax on a random group of people who happen to have expensive health insurance, then it won't cut health care costs, and also, will probably end up being repealed.
Ultimately, the excise tax is just another version of the provider payment reductions: take some money out of the private sector, and hope that they figure out how to make do with less. If they can't, Congress probably decides to give them their money back.
None of these make any real changes to the incentives of either the providers of health care services, or the people who consume them. All they do is tinker with the level of the third party payments. That's not reform. It's wishful thinking.
Copyright © 2010 by The Atlantic Monthly Group. All rights reserved.
I think you're right, Megan, at least when you throw in the modifier "meaningfully."
But I also think our political system as currently constituted isn't remotely capable of comprehensive reform that A) moves us toward universal coverage and B) bends the curve in a major way. I think the best we can do is accomplish "A" and hopefully set the stage to make "B" easier in the future.
I think the key question for liberals, at least, is: when the time comes when we have no choice but to bend the curve (and that day will surely come) do we want everybody on board (universal coverage) or not?
When we do take substantive steps to slow down the growth in healthcare costs, I'd much rather have 97 or 98 percent of Americans covered than 85 percent. From a financial and political perspective, putting the necessary pieces together to expand* government's role to cover more and people is going to get tougher, not easier, the longer we put it off, given the increasingly grim arithmetic with respect to medical costs, demographics, etc (unless of course the system's viability simply begins to suffer widespread collapse, and the number of people without coverage skyrockets, or wages get crunched into oblivion, and this situation creates widespread outcry and increased political pressure for HCR).
*And no, as the Swiss and Japanese and Germans will tell you, this does not require a huge expansion in government spending as such, as long as you're willing to regulate the hell out of insurers and providers.
as long as you're willing to regulate the hell out of insurers and providers.
And accept rationing. And worse care. And suffocate medical R&D.
But sure, let's give up the best health care in the world so we can cover people who are already getting medical care anyway.
We already accept rationing. The vast majority of Americans with private healthcare insurance face rationing of one sort or another. I just think if we're going to have rationing we might as well get everybody meaningfully covered, as those commie-bastard Swiss and Japanese manage to do (both of whom have smaller public sectors than the US last time I looked). And needless to say we don't have "the best healthcare in the word" if amenable mortality, or cost, or comprehensiveness, or justice are taken into the equation. But sure, if you want to ignore those factors, it's awesome. Finally, we manage to refrain from "suffocating" medical R&D now, despite engaging in lots of rationing and using the government's purse to pay half our medical bills. Decreasing the scope of rationing and spending yet more public money -- which is what ObamaCare does -- seems likely to help, not hinder, medical innovation.
Government rationing will be far worse than private rationing.
Purely in terms of healthcare, we have the best amenable mortality in the world -- best cancer survival rates, best access to new drugs, most transplants done, best preemie survival rates, best geriatric care, best access to MRIs and other advanced medicine. Cost, comprehensiveness, amd justice are not measures of medical care. If you want to go by cost-effectiveness the best healthcare systems are the ones that only use vaccines and antibiotics.
Decreasing the scope of rationing and spending yet more public money -- which is what ObamaCare does -- seems likely to help, not hinder, medical innovation.
It will increase rationing and stifle innovation. There is no reason to think otherwise.
And please tell me we're not going to see that godawful Nolte McKee "amenable mortality" study again.
1) They don't adjust for lifestyle differences, which could account for the entire measured difference.
2) They don't account for better diagnostics. When you have twice as many MRIs you can diagnose more diseases.
3) The WHO data is not comparable between countries. The WHO itself says so. What we call a live birth is considered a stillbirth in other countries. Perversely, countries let these babies die but still get credit for "better" healthcare because the death isn't counted against them.
http://www.coyoteblog.com/coyote_blog/2008/01/uncovering-some.html
I agree with Jasper about us already facing rationing in health care and join in demanding a more equitable form of rationing -- one that is guaranteed to be equitable by careful government oversight and wise, socially-just allocation of scarce resources by well-informed bureaucrats.
I wonder, as I often do, though, why we are limiting ourselves to ending this insidious & inequitable 'private' rationing only in the health care arena? Is it because health care is so much more important than other forms of rationing? Is it because we can only do one thing at a time and health care is it right now?
Why, just in the past month I was informed by Peter Luger's that I could not have a steak I felt I needed, by Apple that I could not have a computer without which my personal productivity will remain stunted, and by Mercedes that an appropriate mode of transportation was to be kept out of my hands. I was, frankly, apalled.
Researching further, I learned that there are almost countless people who do not face these limitations, who gladly eat all the steak they want, obtain state-of-the-art computers that in many cases they do not even come close to fully utilizing & have in some cases more cars than they can even drive. At the other end of the spectrum, there are many people who have no access to steak or even simple food, no access to even obsolete computers & the net, and have no car at all and are forced to deal with the burdens of public transportation -- no treat, I can assure you.
This state of affairs, it seems to me, would benefit every bit as much as the health care sector would by, as Jasper puts it, "decreasing the scope of rationing and spending more public money."
We would see an end to these unnecessary nutritional, computational & transportational disparities and, in all liklihood, an increase in innovation in all three sectors due to the injection of governmnet cash & wise guidance.
Why are we not talking about these vital issues too? Hopefully once we get health care established on a more equitable footing we can proceed to other, more neglected areas of inequality.
blighter - It's because healthcare is the most important that it must be destroyed first. If software were found to be just as significant it would be subject to the same litigation creating the same waste. The high price of software could then be blamed on a failure of the free market. The government, being more resistant to lawsuits, could then move in to software production. And as the money spent wastefully on innovation and defense against lawsuits consequently disappeared, we would see clearly just how greedy and inefficient the free market really was.
That's as fuzzy and dangerous as some of the thinking that got us into the Iraq war.
Except there were good reasons to think the second Iraq war might not be that expensive, such as the first Iraq war. Our experience with Medicare argues ObamaCare will be horrifyingly expensive. This is more like claiming, in 2009, that an invasion and occupation of Iran will be easy.
That's not reform. It's wishful thinking.
Hey, hey, watch it there. I believe the preferred term is "Hope."
And please tell me we're not going to see that godawful Nolte McKee "amenable mortality" study again.
Shorter TallDave: studies that undercut my worldview are "godawful".
I suppose the new Harvard study on ER mortality is also "godawful":
http://www.wbur.org/2009/11/16/trauma-study
Sure, ignore all the methodology problems I just pointed out.
It's just my worldview, not the WHO warnings on comparability or the failure to adjust for lifestyle or the failure to measure actual disease outcomes or the varying standards.
Riiiiight.
Sure, ignore all the methodology problems I just pointed out.
Citing an anonymous science skeptic's blog post to counter a serious study by real scientists in a peer-reviewed journal is your idea of a counterargument?
Um, okaaaaay......
The thing is, in addition to the dearth of findings to the contrary, America's poorer results WRT to amenable mortality are intuitive, right? I mean, I'm sure you're aware US ERs are only required by law to stabilize patients. There's no requirement to provide ongoing treatment for serious ailments, nor preventative care. Now, given A) the high cost of medicine in all rich countries, and especially in the US and B) the very large number of Americans without coverage, it stands to reason Americans are going to die from treatable ailments in greater numbers, earlier, than the citizens of other rich countries, where at least a basic insurance package is granted without regard to ability to pay. In short, it's easier (and cheaper) to save and extend life when you treat a medical before it becomes an emergency.
Shrug. Appeals to authority don't prove anything.
Address the actual issues raised, or you concede the argument.
The thing is, in addition to the dearth of findings to the contrary, America's poorer results WRT to amenable mortality are intuitive, right?
No, they aren't. They make no sense considering we have far superior care in actual measured outcomes. When comparing a specific to a general, the specific is always more trustworthy.
B) the very large number of Americans without coverage,
The number of people who can't afford treatment is far smaller.
Purely in terms of healthcare, we have the best amenable mortality in the world
No we don't.
It will increase rationing and stifle innovation. There is no reason to think otherwise.
There's plenty of reason to think otherwise, because spending a hundred billion extra bucks a year on medicine hardly equates to rationing.
No we don't.
Yes we do. Don't make me go through the list again.
There's plenty of reason to think otherwise, because spending a hundred billion extra bucks a year on medicine hardly equates to rationing.
Do you know why the U.S. gets new drugs a year earlier than Europe?
Don't make me go through the list again.
Nobody's making you do anything.
Do you know why the U.S. gets new drugs a year earlier than Europe?
It doesn't. It's too broad a claim to say the US gets "new drugs a year earlier than Europe." It depends on the drugs. And on the European country in question. It may be that on average the higher margins of the US market mean Americans get new drugs more quickly. But what of it? Are you seriously contending that the US market won't continue to offer higher margins than Europe? I see little prospect that a country that spends six or seven points of GDP more than the OECD average (and which sadly looks likely to continue for a long time) won't continue to be Big Pharma's cash cow.
It doesn't. It's too broad a claim to say the US gets "new drugs a year earlier than Europe." It depends on the drugs. And on the European country in question.
Wrong, it's an accurate claim.
http://www.nature.com/nrd/journal/v6/n4/full/nrd2293.html
"On average, the FDA approval came 1 year ahead of clearance by the European Medicines Agency (EMEA)."
Are you seriously contending that the US market won't continue to offer higher margins than Europe?
/facepalm. You were just complaining a minute ago that U.S. care was more expensive and suggesting the government should do something about it.
Beyond getting them sooner is the problem of how many drugs will not be profitable enough to pursue at all once the last big free market is eliminated. Right now the Euro market is only profitable on a post-R&D marginal basis.
Jasper, americans live on a diet in which the main ingredient is corn syrup.
you don't think that might just be a bit more important to health outcomes than doctor and hospital visit frequency?
we must have fantastic healthcare already because americans are severely nutrient-deprived and yet live about the same amount of years as canadians and western europeans.
changing to a system with even more rationing when the nutrient deficiency problems aren't being fixed will just result in more people dying. america is kind of a test case of how far you can go just ramping up technology to paper over poor nutrition's effects on health and fitness and longevity.
not sure why you want americans to actually die from the horrid diet they currently exist on and thrive on thanks to the current version of the american healthcare behemoth.
Actually, if you look at a map of U.S. life expectancy it appears Southern cooking may be responsible. I'm guessing the saturated fats do it. Maybe they smoke more too, I don't know.
Another problem is that for whatever reason, African-Americans skew the statistics, possibly due to a combination of diet and Vitamin D deficiency.
States like Minnesota and North Dakota would do as well as the longest-lived countries in the world.
you don't think that might just be a bit more important to health outcomes than doctor and hospital visit frequency?
I have no doubt lifestyle factors help drive poor health outcomes in the US. I also have no doubt -- because it's public information -- that we spend wildly more than other rich countries on healthcare. So the question is, what are we getting for our money? Because it sure as hell ain't an equalization of outcomes. And regardless, eating healthier or exercising more doesn't obviate the need for good health insurance. Fit people still get cancer. Or get exposed to viruses. Or get in car accidents.
that we spend wildly more than other rich countries on healthcare.
We spend more on most things, because we're wealthier thanks to our freer markets.
We probably spend more on health care in particular because we are more religious. Most other countries don't have our obsessive reverence for human life.
So the question is, what are we getting for our money?
Better healthcare, of course.
@ TallDave
Saturated fat is healthy for you. southern cooking does feature overcooking of food and a surfeit of sugar/corn syrup, which would result in...nutrient deficiencies, even if the food is reasonably sourced (not likely for most americans).
@Jasper
There is some absolutely interesting premliminary evidence that proper diet means low/no risk of cancers (cancer is in some ways merely a response to nutrient deficiency and in other ways more a sign of aging caused by time or diet or genes), even if you smoke. and getting into a car accident is easily dealt with by (drumroll) catastrophic insurance!
infection and disease resistance is also quite high given quality diet. and even if not, that can be solved with a quick cheap visit to urgent care clinics, if only more would be built. much cheaper to build those than hand out health insurance subsidies.
but then it would also be cheaper to end corn subsidies and watch the diabetes and alzheimer's epidemics mysteriously vanish.
Shrug. Appeals to authority don't prove anything.
Please. The fact that your source is not authoritative proves everything. How about it, TallDave? Show us some folks from Hokpkins, or HSPH who agree with your crackpot views on amenable mortality and the US healthcare "system."
No, they aren't. They make no sense considering we have far superior care in actual measured outcomes. When comparing a specific to a general, the specific is always more trustworthy.
Huh? The United States does not "have far superior care in actual measured outcomes." It does a bang up job in some areas (cancer, say) and not so good in others (prenatal care). Moreover, one suspects such statistics fail to account for or at least grossly undercount those who don't receive care, and so for whom there is no "outcome" from treatment, but rather death from lack of treatment.
The number of people who can't afford treatment is far smaller.
Smaller, yes. Far smaller, no. And this is before we consider the very serious problem of underinsurance -- an issue that, while not receiving much attention, is at the heart of the current reform bills.
Please. The fact that your source is not authoritative proves everything.M
In other words, you can't argue on the facts. You lose.
Show us some folks from Hokpkins, or HSPH who agree with your crackpot views on amenable mortality and the US healthcare "system
This is deeply stupid. The fact the U.S. has the best cancer survival rates, does twice as many transplants, has twice as many MRIs is not "crackpot." There is no reason to think we are better in major outcomes and worse overall.
and not so good in others (prenatal care).
We do far better in prenatal care, too. Again, you don't seem to understand the problems in comparing U.S. perinatal statistics with countries that let preemies under a certain weight die and don't record them as births.
Smaller, yes. Far smaller, no
Yes, far smaller. How often do hospitals refuse to treat now and bill later? How many people who can't afford insurance aren't eligible for Medicaid?
underinsurance -- an issue that, while not receiving much attention, is at the heart of the current reform bills
Yes, they will eventually make everyone underinsured.
Also, your appeal to authority is espedcially lame considering I do not actually dispute their findings, just your interpretation... and the WHO itself says the study is bunk.
We spend more on most things, because we're wealthier thanks to our freer markets.
We're wealthier in no small part due to our freer markets -- on this we agree. But it obviously doesn't follow that we spend, or we should be spending "more on most things" because of our greater wealth, TallDave. In fact plenty of things are cheaper in absolute terms in the US than in some of our less wealthy trading partners. And in any event generally when we do spend more on something we want to get higher quality or more quantity. In the US, we largely don't when it comes to healthcare, at least compared to the higher performing (and all much cheaper) healthcare systems of the rich world.
We probably spend more on health care in particular because we are more religious. Most other countries don't have our obsessive reverence for human life.
Is that some kind of joke? The country that wages aggressive wars of choice and engages in capital punishment and lets its own citizens go untreated for major illnesses is your idea of "obsessive reverence for human life?" Um, okay then (Though I do agree that we're turning things around since Obama took the oath).
Better healthcare, of course.
No. We're getting little or no healthcare for a significant portion of the population, and overall outcomes that are weak by rich world standards.
But it obviously doesn't follow that we spend, or we should be spending "more on most things" because of our greater wealth, TallDave.
It obviously does. I don't think you understand what "wealthier" means in the this context. It means we are able to get more of things and better quality.
In fact plenty of things are cheaper in absolute terms in the US than in some of our less wealthy trading partners.
Thus we can buy more of them. That's covered in the PPP per capita GDP measure.
And in any event generally when we do spend more on something we want to get higher quality or more quantity
Which we do. Again, PPP.
The country that wages aggressive wars of choice and engages in capital punishment and lets its own citizens go untreated for major illnesses is your idea of "obsessive reverence for human life?"
Are you going to suggest Germany or Japan have better records in this regard? Italy? That's, what, something around half the rest of the OECD by population?
But let me stipulate innocent life. Babies born under a certain weight are left to die in other countries, and when people get too old they may go untreated to save money. I've linked documented cases of this happening. Here we take better care of people, unless they've committed horrible crimes in which case they may be executed.
We're getting little or no healthcare for a significant portion of the population
Utter bullhooey.
and overall outcomes that are weak by rich world standards.
No, we have the best outcomes unless you measure things having nothing to do with healthcare.
There is some absolutely interesting premliminary evidence that proper diet means low/no risk of cancers...
Great. Cites please. And which is it, low or no? And what about other environmental factors? Does eschewing HFCS protect one from growing up next to a pesticide plant?
...and getting into a car accident is easily dealt with by (drumroll) catastrophic insurance!
Both cancer and car accidents could be "dealt with" if one has a good, solid catastrophic insurance plan. Who's arguing otherwise?
infection and disease resistance is also quite high given quality diet. and even if not, that can be solved with a quick cheap visit to urgent care clinics, if only more would be built. much cheaper to build those than hand out health insurance subsidies. but then it would also be cheaper to end corn subsidies and watch the diabetes and alzheimer's epidemics mysteriously vanish.
So you claim. But I notice you provide no evidence. (Not that I like farm subsidies, mind you; I'll happily support you in calling for their termination. I just don't see how you think that's going to obviate the need for good health insurance).
@Jasper:
first let's see the evidence that any comparisons between the US and Switzerland/Germany/France/Canada/insert desired country have vitamin d, vitamin k2, omega-3 and b12 deficiencies in the US (particularly the black/hispanic) population corrected for in life expectancy data.
i can't remember if i posted links here in which studies link vitamin d and omega-3 deficiencies explicitly to low birth weight, premature birth, and infant death. i definitely have linked to studies regarding nutrient deficiency and diabetes and alzheimer's. there are also studies showing strong links to consumption of processed carbs and hydrogenated vegetable oils and obesity. thus, 'accounting' for obesity while ignoring foods consumed by a given population will not actually be a proper correction statistically or scientifically.
cleaning up the food supply by removing the artificial cheapness of corn and soy (soy formula is also implicated in health damage to infants and toddlers) would in fact dramatically improve people's health.
i mean, the going claim is that the freaking *hospitals and doctors* in a given country are that country's sole means to live longer. there is not a solid connection, just a correlation, and a weak one at that. macau has a remarkable life expectancy without the sorts of changes being suggested for the US health care system. the united states does about as well on life expectancy as denmark or ireland, despite having a very different healthcare system to either nation.
the numbers other countries have for female expectancy (which as i've noted is specially affected in america by nutrient deficiencies) boost their overall expectancy, not so much 'everyone goes to the doctor four tuesdays a year'.
the male numbers are all much closer together, giving some credence to talldave's 'shooting/stabbing' theory of difference regarding the US as compared to western europe and canada.
you are what you eat, and americans eat corn, soy, sugar and wheat, in roughly that order. erase the subsidies for these things so that healthier foods are competitively priced, and our numbers would look like other countries who don't subsist on those foods primarily.
what there is no data on is 'going to the doctor extra makes you live 77 years instead of 75'. that correlation simply has not been proven in any country. diet and lifestyle are always more correlative and causative. they are also the part of healthcare that are relatively cheap to offer incentives to change in.
There is a saying in quality control "That which is not monitored is not controlled". I can't see how any bill, with any objective, can produce desired outcomes if it has not been read by the very people who write it, much less the ones that have to decide to implement it into law
Wrong, it's an accurate claim.
The cite you provide does not back up your claim. It's an article about Europen price controls.
/facepalm. You were just complaining a minute ago that U.S. care was more expensive and suggesting the government should do something about it.
Agreed. And you apparently think the high cost of US healthcare is a good thing?
Beyond getting them sooner is the problem of how many drugs will not be profitable enough to pursue at all once the last big free market is eliminated.
Such a problem does not exist. In the first place the US market isn't "free" by any reasonable standard, but a higly regulated, hybrid system where the public sector accounts for a large share of total spending. It will continue to remain so, and we can therefore confidently predict the US will continue to remain a highly profitable market for the pharmaceutical industry.
The cite you provide does not back up your claim. It's an article about Europen price controls.
For God's sake, the claim is a direct quote from the article.
Agreed. And you apparently think the high cost of US healthcare is a good thing?
Of course it is! We spend more, we get better healthcare. Why would we want inferior European levels of healthcare?
Such a problem does not exist
Yes, it does. It's simple math. If you cannot recoup R&D, you don't pursue the research.
In the first place the US market isn't "free" by any reasonable standard, but a higly regulated, hybrid system where the public sector accounts for a large share of total spending.
Of course. I did not say the U.S. was a completely free market. But it does have the last big free market.
It will continue to remain so
The public option is going to negotiate gov't rates. The bigger it gets, the smaller the free market gets. Eventually progressives want us on single-payer, eliminating the free market entirely.
For God's sake, the claim is a direct quote from the article.
TallDave: My original point @ 5pm clearly acknowledged that on average the US may get new drugs more quickly (I simply objected to your initial lack of precision by failing to qualify it this way). I went on to question the relevance of the article you cited in disputing your claim that ObamaCare will stifle innovation. My point is, you apparently think an article in Nature about drug price controls is germane to our discussion. But it is not germane, because ObamaCare introduces no such price controls, and therefore (to repeat again) it is unlikely the US will anytime soon relinquish its role as chief cash cow for Big Pharma.
We spend more, we get better healthcare. Why would we want inferior European levels of healthcare?
We don't spend more. We spend vastly more, and we leave many millions of Americans uncovered. And "we" as a people don't "get better healthcare." Some of us do indeed have access to excellent care, although even for such groups (the affluent, the elderly) results are mixed, as studies have been done that suggest that, even when controlling for such factors as income or obesity, America's system yields poorer overall results. But in any event higher performing European systems (ie France, Holland, Germany, Switzerland) outperform the American model on outcomes and save money.
I did not say the U.S. was a completely free market. But it does have the last big free market.
Lots of other countries maintain significant private sector involvement in the provision of healthcare, but there's no such thing as a rich world "free market" in healthcare, just differing levels of government control. America is at about 45%. ObamaCare will boost us to about 50%. Scare tactics to the contrary, we're not talking about a government takeover.
The public option is going to negotiate gov't rates.
We don't even know there's going to be a public option. I'm rather skeptical, personally, although we shall see.
The bigger it gets, the smaller the free market gets.
Well, if the "free market" in health insurance managed to cover everybody, we wouldn't be having this discussion.
Eventually progressives want us on single-payer, eliminating the free market entirely.
False. Canada has a single-payer system, yet nearly all Canadian doctors are privately employed. And most hospitals and clinics and labs are privately owned -- a good number of them on a for profit basis. The point is, even a "classic" single payer model like Canada's doesn't eliminate "the free market entirely" with respect to healthcare. So it's vanishingly unlikely to occur in the US, where people will almost certainly continue to be able to spend their money on private health insurance if they so choose, for the foreseeable future (Heck, even in Britain -- which operates a healthcare model that could legitimately be described as "socialist" -- people are free to opt out and purchase private health insurance).
My original point @ 5pm clearly acknowledged that on average the US may get new drugs more quickly (I simply objected to your initial lack of precision by failing to qualify it this way
Meaningless distinction. We get new drugs sooner. This is a superior outcome of our system.
But it is not germane, because ObamaCare introduces no such price controls,
Again, the public option will have Medicare-like price controls.
And "we" as a people don't "get better healthcare."
Yes we do.
as studies have been done that suggest that, even when controlling for such factors as income or obesity, America's system yields poorer overall results.
Uh huh. And yet everyone agrees we have the best cancer survival rates. How can that be? Cancer is expensive, and our uncovered people who supposedly get no care for it should be dying at higher rates. The answer is that people who need medical care generally get it, and our care is better.
But in any event higher performing European systems (ie France, Holland, Germany, Switzerland) outperform the American model on outcomes
No they don't. They are markedly inferior.
Lots of other countries maintain significant private sector involvement in the provision of healthcare, but there's no such thing as a rich world "free market" in healthcare, just differing levels of government control.
We are about the only country in which a large percentage pay free market drug prices, which was the point in discussion.
We don't even know there's going to be a public option
We can only discuss the plan we have.
Well, if the "free market" in health insurance managed to cover everybody
It covers enough. Medicaid can get the rest.
False. Canada has a single-payer system, yet nearly all Canadian doctors are privately employed.
The free market in drugs.
In other words, you can't argue on the facts. You lose.
In other words, your crackpot denialist blogger quote can't disprove the facts as presented in a peer-reviewed study by legitimate researchers. I win.
The fact the U.S. has the best cancer survival rates, does twice as many transplants, has twice as many MRIs is not "crackpot." There is no reason to think we are better in major outcomes and worse overall.
Lots of claims. Not many cites. Little coherence (What exactly is "twice as many transplants" supposed to mean? -- nobody disputes the fact that America lavishes its healthcare sector with vast sums of money, and this naturally means we do lots of certain procedures compared to other rich countries. Is that supposed to be a strength?). And in any event, there is plenty of reason to think we are "worse overall" (life expectancy, infant mortality, amenable mortality, cost, lack of universality, etc.). I think reasonable people can disagree about specifics, but just claiming there's "no reason" to conclude the US system delivers inferior overall outcomes is loopy. Even a lot of Republicans would admit to that.
We do far better in prenatal care, too.
Huh? You're venturing into absurdity here, TallDave. I'm not sure what your reference to the infant mortality statistics debate has to do with prenatal care. But if you've got the time to come up with cites, I'll be happy to take a look. Everything I've ever read on the subject pretty much screams prenatal care happens to be one of the things the US system does worst, hence my use of it as an example.
Yes, far smaller. How often do hospitals refuse to treat now and bill later?
For emergency stabilizations, probably not many. For non-emergency care, it's a pretty large number, I reckon, given the non-trivial number of Americans dying each year because they're uninsured.
How many people who can't afford insurance aren't eligible for Medicaid?
Ballpark estimate, maybe 3/4ths of them? I doubt when ObamaCare passes more than a third of the decrease in the proportion of the uninsured will flow from people being prompted by fines to sign up for Medicaid. Obviously that could change depending on the provisions of the final legislation with respect to Medicaid eligibility.
Yes, they will eventually make everyone underinsured.
Not very likely. Insurance companies will be forced to do more, not less, under ObamaCare. Indeed, Democrats have savvily been careful to make sure a number of such provisions take effect in 2010, in the runnup to the midterms.
In other words, your crackpot denialist blogger quote can't disprove the facts as presented in a peer-reviewed study by legitimate researchers. I win.
No, you just prove you don't understand logic or the study or the data and can only make blind appeals to authority having little relevance to the argument. You lose in a blowout.
For non-emergency care, it's a pretty large number, I reckon,
You reckon. Uh huh.
Ballpark estimate, maybe 3/4ths of them?
Wrong. It's one-quarter according to the U.S. Census data.
Not very likely. Insurance companies will be forced to do more, not less, under ObamaCare.
They will be forced out of businesss eventually down this road. Then we'll all get substandard gov't care.
Wrong. It's one-quarter according to the U.S. Census data.
Actually, my mistake, it's closer to 1/5th. There are 50 million people on Medicaid and 12 million who are not eligible and making less than $75K.
Everything I've ever read on the subject pretty much screams prenatal care happens to be one of the things the US system does worst, hence my use of it as an example.
Those tend to be based on flawed IM/perinatal comparisons.
Huh? You're venturing into absurdity here, TallDave. I'm not sure what your reference to the infant mortality statistics debate has to do with prenatal care
You really don't see the connection between prenatal care and perinatal mortality? And you think I'm being absurd?
Sheesh. If you're not even going to try to be halfway intelligent...
And in any event, there is plenty of reason to think we are "worse overall" (life expectancy, infant mortality, amenable mortality, cost, lack of universality, etc.).
Except none of those things measure heath care outcomes, so claiming they measure health care quality is either deceptive or ignorant.
People aren't being fooled by this stuff anymore. The poll numbers are dropping like a rock as more people figure out the difference between propaganda and reality.
Except none of those things measure heath care outcomes...
Every single one of them does at least in part. Life expectancy obviously isn't determined solely by health care quality. I'm not claiming otherwise. But it plays a role. Same with infant mortality. Amenable mortality obviously by definition is a measure of health care quality. Lack of universality is self-evident.
The poll numbers are dropping like a rock as more people figure out the difference between propaganda and reality.
A bill will reach Obama's desk by before the State of the Union, and poll numbers will jump.
Every single one of them does at least in part.
And the differences being measured are tiny, and the confounding effects are large.
This is fairly obvious when you look at individual states (many relatively poor) that do just as well as any country despite not having socialized health care.
A bill will reach Obama's desk by before the State of the Union, and poll numbers will jump.
Off a ledge, I expect.
We get new drugs sooner. This is a superior outcome of our system.
No argument here. Happily this won't change under ObamaCare.
Again, the public option will have Medicare-like price controls.
Medicare doesn't impose price controls on drugs, hence the hefty price tag on Medicare part D.
Uh huh. And yet everyone agrees we have the best cancer survival rates. How can that be? Cancer is expensive, and our uncovered people who supposedly get no care for it should be dying at higher rates
It's mostly because cancer disproportionately affects the elderly, who in turn are disproportionately likely to have health insurance, because of the existence of a government program called Medicare.
No they don't. They are markedly inferior.
On the contrary. The Swiss, Germans, French and Dutch all live longer than Americans, all suffer from fewer preventable deaths than Americans, and all on average pay less for their healthcare. And none of these European nations are affected by job lock. And in none of these countries do medical bills bankrupt people. In fact these other models are markedly superior to America's.
We are about the only country in which a large percentage pay free market drug prices, which was the point in discussion.
Nobody is proposing price controls on drugs.
It covers enough. Medicaid can get the rest.
Not under current rules it can't. I wouldn't imagine you of all people would favor an expansion of Medicaid over simply allowing private health insurance companies to compete for business, as ObamaCare does.
you can't keep arguing that life expectancy is not primarily or solely determined by doctor/hospital access, and then claim doctor/hospital access is a primary factor in the better life expectancies of countries frequently compared to the united states.
the simple fact is that lifestyle factors (i.e., diet and such) are the most important, and if you minus that out, the united states whips ass in healthcare provision and outcomes.
It means we are able to get more of things and better quality.
Sure. And the lack of this effect with respect to healthcare suggests the US system isn't optimal, and needs to be improved. We pay vastly more for the same procedures in the US than is the case in other rich countries. An American MRI isn't any better than a German MRI.
Thus we can buy more of them. That's covered in the PPP per capita GDP measure.
Right. But again, the problem is we don't see this effect when it comes to healthcare.
Which we do. Again, PPP.
No, we don't, not when it comes to healthcare. Even your buddies in the GOP caucus admit this much.
Are you going to suggest Germany or Japan have better records in this regard? Italy? That's, what, something around half the rest of the OECD by population?
Sadly, since World War II, they do have better records. Two of those three countries have outlawed capital punishment. All of them guarantee healthcare coverage to all their citizens. All of them are far less murderous nations. None of them have invaded other states. Bush the Elder hinted at America's lack of reverence for human life in his "kinder, gentler" speech. Finally the country may be in a position to effectuate his vision.
Babies born under a certain weight are left to die in other countries, and when people get too old they may go untreated to save money.
And in America uninsured children die from tooth decay. You're the one making the claim about the greater reverence for human life in the US than in other rich countries. I don't see any evidence for this.
No, we have the best outcomes unless you measure things having nothing to do with healthcare.
No, we for the most part do get excellent outcomes for those with access to the lavish resources we put into healthcare, but that obviously leaves millions of people -- those who lack health insurance or who are underinsured -- behind. Of course there's also plenty of evidence that even for those with access to robust healthcare delivery, America gets some major items badly wrong -- I'm thinking primarily of over-utilization. And over-utilization itself is a deadly problem. America also suffers from depressingly high rates of medical error. And of course all this comes at the highest prices on the planet.
Right. But again, the problem is we don't see this effect when it comes to healthcare
Yes we do! We have twice as many MRIs, do twice as many transplants, best cancer survival rates, etc. Why do you think they aren't doing as much in other countries? It isn't because of greedy doctors, it's because they have to do more rationing.
And in America uninsured children die from tooth decay.
Heh. You clearly aren't familiar with British dental care.
Sadly, since World War II, they do have better records.
No, they don't. We liberated 25 million Iraqis from a brutal police state and removed a heinous regime in Afghanistan, defended Kuwait, defended S Korea, defended the Kosovars from genocide, defended Western Europe... they sat on their asses.
but that obviously leaves millions of people -- those who lack health insurance or who are underinsured -- behind
There's little evidence that actually happens on any significant scale.
America also suffers from depressingly high rates of medical error.
No, we're just more likely to complain about it, because of our tort system.
Jasper,
You're grasping at straws with the Bush the Elder quote. That was a dig at President Reagan during the 1988 election, and a signal that he would not be taking the same hardline attitude toward the Soviets that Reagan took. Of course, not long after, the Berlin Wall came crumbling down, the Soviet Union dissolved, and the people of Eastern Europe were liberated from their Communist oppressors, all of which vindicated Reagan's approach and confounded his liberal critics. Bush's quote comes across as foolish now, and it cuts against the point you're trying to make.
Well, there are two issues here. One is whether or not the HCR bill bends the cost curve of healthcare spending as a whole (and especially, with respect to government finances and the deficit, Medicare and Medicaid).
And then there's also the issue of this particular new (subsidies/public option) entitlement's effect on the deficit.
I think in this case we're likely to get something that unfortunately doesn't guarantee any long term improvement with respect to the first issue, but nonetheless over the long-term doesn't force the government to borrow more money than it would otherwise have to borrow. So, no, I don't think it's true to claim we're "planning to increase the budget deficit" over the status quo's path. What we are planning to do is increase spending to deal with a critical gap in the safety net, and pay for it in real time with taxes and spending cuts. And then not really do much either way with respect to slowing the growth in overall medical spending, or spending on Medicare and Medicaid.
So yes, the Senate bill in its current doesn't provide specifics on how it plans to decrease deficit spending in its second decade (which, if I'm given to understand correctly, depends on decreasing the growth in Medicare spending from 8 to 6%). I just don't see how it makes the deficit situation worse, hence my problem with Megan's claim about an increase in the budget deficit.
I just don't see how it makes the deficit situation worse.
I thought Megan's explanation was fairly obvious: the claimed spending cuts will never happen due to political pressure, and the claimed efficiencies probably won't materialize.
In other words, magical gov't healthcare ponies are no more real than Santa Claus or the Tooth Fairy.
And even beyond that, "revenue-neutral" still means "massive tax hike." Someone promised us people making under $250K wouldn't see any new taxes.
Just an observation: sometimes you really come across as a jerk with your consistent belittling of those who disagree with you.
Odd to belittle someone for belittling. Especially odd because TallDave didn't belittle anyone. He simply disagreed with (belittled) their points. That's okay; we're having a discussion. What you wrote isn't.
Fair enough. I apologize to Santa Clause and the Tooth Fairy, and will try to be more respectful of them in the future.
This:
"magical gov't healthcare ponies are no more real than Santa Claus or the Tooth Fairy"
is not discussion. It is caricature. It is not disagreement. It is mocking. I find it obnoxious.
Obama won't raise taxes on the middle class - just on their soda, beer, stents, drugs, pacemakers, blood sugar testing devices and other frivolous luxuries.
In other words, magical gov't healthcare ponies are no more real than Santa Claus or the Tooth Fairy.
Taxing the wealthy and the value of health insurance premiums paid by employers isn't magical. Nor is the increasing payroll tax revenue generated when employers rationally respond to the the weakened (tax code-induced) market incentives by shifting compensation budgets away from insurance. Again, I make no claims the reduction in Medicare spending growth in the second decade is going to "magically" materialize, hence my skepticism HCR will decrease deficit spending. I just don't see how it makes it worse. Nor, apparently, do you.
Medicare cuts are magical.
Promises you can keep your doctor when you can be dumped onto a public plan your doctor may not accept are magical.
Expectations that providers will find ways to efficiently provide care at the new, lower rates, rather than just stop serving Medicare patients are magical.
Hundreds of billion in savings from "waste, fraud, and abuse" are magical.
I could go on...
Doug Elmendorf and the head of CMS have been saying, as clearly as they are allowed to, "These cuts you are using to 'pay for' the new bill will never actually be made, because they are too painful". It's pretty clear that the actual effect of this bill will be a substantial increase in the deficit. But CBO doesn't score what Congress is likely to do in the future; it scores what congress says it wants to do today. So, for example, literally no one on the planet believes that the sustainable growth rate cuts to doctor payment rates will actually be made. But the CBO scores them as actually happening, because that is current law--even though everyone knows that congress will keep overturning that law. Ditto the annual AMT "fix".
Medicare cuts are magical.
I doubt they're magical. But long term, they're coming, because the country can't afford to increase Medicare spending at the rate it's been doing.
Promises you can keep your doctor when you can be dumped onto a public plan your doctor may not accept are magical.
That's not magical. That's the status quo. You can lose your job under the status quo, and therefore your insurance, and therefore your doctor. Or your employer can switch plans to an insurer not accepted by your current doctor. It seems to me changing the status quo toward fewer gaps in coverage makes it more, not less, likely you'll be able to keep your doctor. Plus, it's hardly likely heroic libertarians like you are apt to let mean socialists like me make it illegal to pay out of pocket for whatever services or procedures or providers you want.
Expectations that providers will find ways to efficiently provide care at the new, lower rates, rather than just stop serving Medicare patients are magical.
I don't have such expectations. I expect healthcare spending to increase as a percentage of GDP for a very long time. I just don't want it to increase as rapidly, and I want better value and greater universality of coverage for the increases we do have to shoulder. I also think that, given the elderly's increasing share of the population, predictions that the nation's doctors will be able to abandon old people as a critical customer base are wildly overblown.
Hundreds of billion in savings from "waste, fraud, and abuse" are magical.
Gotta cite anybody's actually making such a claim?
But long term, they're coming, because the country can't afford to increase Medicare spending at the rate it's been doing.
They're not coming anytime soon, and if we can't afford Medicare we DEFINTELY can't afford Obamacare.
You can lose your job under the status quo, and therefore your insurance, and therefore your doctor.
Besides the fact Obama made the promise, that's obviously not the same thing as being dumped onto a government plan and losing your doctor because of this bill.
I don't have such expectations.
Regardless, it's in the bill.
I also think that, given the elderly's increasing share of the population, predictions that the nation's doctors will be able to abandon old people as a critical customer base are wildly overblown.
They already are. The customer-seller relationship is pretty basic.
Gotta cite anybody's actually making such a claim?
For God's sake, we had a whole discussion about it here. Do you guys not listen to our own President?
If your premise that this will not raise the budget deficit is based on real-time spending cuts and taxes, then I think maybe you are missing the point. There will be nothing real-time about any of the cuts, since history and the present dictate otherwise. Not only can you not count on Congress (which is waiting for this bill to permanently repeal a previous Congress' attempt at cuts) to make the cuts, but the POTUS has promised providers exemption from the commission's recommendations. The commission is mostly for show, since giving it teeth would break the promise, and unleash the attack ads it holds at bay.
Once more of the public actually understands what constitutes "Cadillac" coverage in this bill, the tax portion is questionable too. Many people have them based on geography, not just union or wealth status, and most are not extravagant plan choices. Simply taxing based on the cost is amazingly short-sighted, and will affect enough people to not last long.
I continue to be puzzled by these posts that seem to cast the President's assurances on health care reform into doubt.
Has he not made it perfectly clear that these plans will expand access, cut costs and begin the necessary process of completely revamping our health care delivery systems all while preserving untouched the experiences of the majority of those with health insurance who are happy with their existing setup?
As the President says, anyone who tells you that these bills do not accomplish all of these things and more is lying.
As a long-time reader of Megan's blog, I must wonder why she keeps trying to peddle these obvious lies to us? Does she think we haven't heard the President say these are lies? Does she think we don't trust him implicitly when he tells us these bills can be all things to all people, forever?
You are being intentionally disingenuous.
Obama has said nothing of the sort. There have been demonstrable lies about the bill. Obama has not said that all criticism amounts to lies. He has done what he can to shape the bill to the policy goals he has set forth, but we have a legislative branch in this country. Obama can shape the debate, but he can't hold a gun to Congress' head.
It is fair to argue that Obama's leadership has been less than stellar, and maybe he is less effective in dealing with Congress than he should be. I'm not sure I agree with that, but it's a fair point.
Saying that Obama or liberals equate all criticism of the bill with lies is patently dishonest.
Well, let's just take a quick look at the President's address to a joint session of Congress on health care reform, shall we?
"The plan I'm announcing tonight would meet three basic goals. It will provide more security and stability to those who have health insurance. It will provide insurance for those who don't. And it will slow the growth of health care costs for our families, our businesses, and our government."
"Here are the details that every American needs to know about this plan. First, if you are among the hundreds of millions of Americans who already have health insurance through your job, or Medicare, or Medicaid, or the VA, nothing in this plan will require you or your employer to change the coverage or the doctor you have. (Applause.) Let me repeat this: Nothing in our plan requires you to change what you have.
"What this plan will do is make the insurance you have work better for you. "
So his description of "the plan" describes it exactly as I said he did.
To your point about Congress having a say and Obama doing what he can to "shape the debate", I would call attention to this phrase later in the speech: "As soon as I sign this bill..." It sounds almost like he's talking about a specific bill there, doesn't it? Was he not?
In that particular speech he singled out three lies:
1) that there would be bureaucrats deciding who would live & die: the so called "death panels"
If you'll read the above comments, you'll note that everybody knows there will be rationing, that even a stanch defender of reform like Jasper admits it but feels that it will be better than the rationing that exists now. This, of course, completely misunderstands 'rationing' and why it has the pernicious effects it does, but that's neither here nor there, the "lie" has been accepted as true even by defenders of reform.
2) that illegal aliens would be insured under "the plan"
Hard to say whether this is or is not the case but given that they are a significant portion of the "uninsured" that are the whole reason d'etre for this reform movement and given that any requirements for screening for citizenship to benefit from this plan have been steadfastly opposed, it seems odd to say this isn't so. We'll call it a wash.
3) that federal dollars would go for abortions.
Well, to get the House version over the goal-line an amendment explicitly codifying that this wouldn't happen was passed. But why was that necessary if no dollars would have gone anyway? If saying that they would was a "lie"? And, more importantly, why did the President express his desire to have that amendment removed if all it did was restate what was already his understanding of the plan?
Perhaps the President was having a bit of fun with the truth in calling that a lie.
And this, I should stress, is just a quick breeze-through of the most high-profile speech on health-care by the most high-profile supporter. If I were to take some serious time and start going through where the President has called folk liars in his smaller, more off-the-cuff remarks and what lesser supporters of the bill like Speaker Pelosi or Majority Leader Reid have labeled opponnents of thier measures, you can bet I'd find much worse.
I'm sorry that you're disappointed in your side's handling of the issue and pejorative labeling of their opposition but it's not my fault, please don't take it out on me when I purport to take them at their word.
Rationing is not the same thing as death panels. It is not the same thing as bureaucrats deciding who will live and die. To suggest that it is, well that's a lie.
And anyway, there is very little rationing in the bill. That's the whole point of Megan's post. Rationing is a way of bending the cost curve. That's not happening here.
Illegal immigrants are not covered, never were, and suggesting that they were is a lie. As is your claim that providing insurance to them is the whole raison d'etre of the plan.
As for federally funded abortions, that was the case in the original bill. The House amendment goes much further than that.
He was also commenting on a very different version of "the bill." One problem is that, despite the best efforts of folks like Harry Reid (the value of those best efforts being somewhat questionable), the bill keeps evolving. There hasn't been a single, stable bill for more than a week, it seems.
Edit above comments to read that there were no federal dollars for abortions in the original bill.
It is not the same thing as bureaucrats deciding who will live and die. To suggest that it is, well that's a lie.
Merely labelling things that are already happening in such systems "lies" doesn't actually make them so.
I think Megan is largely right in this analysis. Her position is a bit too strong (infinitessimal is not the right word, and is definitely not equal to zero), but qualitatively correct.
But there are a few points to be made:
1. Expanding health care coverage is still worth doing even if it costs money in the short term. There are children dying in hospitals because they don't have access to good health care.
2. What is difficult to measure is the long-term beneficial economic effects of better and more available care. I used to have bare bones insurance because that was what my employer offered and as a young entrant into the workforce, I couldn't afford (or didn't think I could afford) proper mental health care. I lost years of productivity, which was not only a personal cost but an economic cost to society. My contribution to our national human capital was diminished. Now that I am much better, and again successful, I can see how tragic were my struggles as a young man.
That said, I have nothing but my own experience, and those of several friends, to base this on. And what's more, I have no control group. Would I have received better care if I had better insurance? I think so, but I do not know so.
So on this point, my belief is probably close to "wishful thinking." That doesn't mean it's wrong, only that I can't prove it is right.
Megan,
#1 You really are shameless in application of your double standard. This is practically back to back with your "Megan hearts CMS" post. You're skeptical of all CBS's assumptions and completely credulous of the CMS.
#2 To me, $650 Billion seems quite distinguishable from $0. Are you sure you're wearing your glasses?
#3 Your "Congress may reverse these cuts" is irrelevant. This is not a reason to oppose this cost saving legislation, it is a reason to oppose the future savings-reversal legislation.
#4 Your boilerplate "Congress may reverse these cuts" point is also at odds with the historical record. Congress has been able to get the country out of debt a number of times. As you know, we had a surplus about 10 years ago.
#5 excise tax...lol..."Ends up being a tax...", Conservatives are the group that originated the push to eliminate the health care tax preference. I guess your estimation of the quality of an idea mainly depends on whether the idea is being passed in Republican or Democratic legislation.
Overall: You are complaining that cutting spending reduces benefits. Duh! Please contribute a non-trivial observation to the discussion.
1) No, I'm not being inconsistent. The CMS report says exactly the same thing that I'm saying. It also says virtually exactly the same thing Doug Elmendorf, the head of the CBO is saying: these cuts will be very painful, and in the past, congress has enacted and then reversed these sorts of painful cuts. You're the one applying a double standard.
2) The Subtitle A section savings are under 3 billion
3) If I think that the cost cuts won't work, and are being used to pass legislation that massively expands government spending, then it is indeed reason to oppose it. If you're in a hole, the first thing to do is stop digging, not promise that you'll fill up the hole at some later date.
4) We had a surplus for three basic reasons: Republicans gained control of Congress adn wouldn't let Clinton spend money, while he wouldn't let them cut taxes; we had a HUGE peace dividend from the end of the Cold War; and the capital gains revenue from the stock market bubble boosted top incomes by an amount that took everyone by surprise, so they couldn't plan to spend the money. Oh, and Social Security and Medicare were in surplus; if you take away those revenues, we never had a surplus. Your argument is "Congress can magically fix this later so hey, let's make their job harder!" Since 1960, we have run surpluses for three or four years out of fifty.
5) No, conservatives are in favor of ending the tax deduction that ties health insurance to employment and insulates consumers from costs. This doesn't do anything like that; it just randomly punishes a subset of people who have, for one reason or another, more expensive insurance than average. It's got nothing to do with partisan considerations.
Anyway, mote, beam, etc.
#5 is wrong. Of course the current bill helps expose consumers to costs. Not all consumers to all costs. But a half-measure is still a half, it's not zero and it's not random.
#4 is wrong. Republicans gaining control of Congress had little to do with it; the major deficit control package was passed in 1993. Your argument that there would have been more spending but for Republicans is speculative, and hard to swallow given Republicans' spending habits in the 200s.
The peace dividend was not a big factor. Look at the defense budget in 1999 and compare to 1991. It shrank as a percentage of GDP, but mostly because GDP rose so much. And you make this seem as if it was something other than a conscious choice.
Capital gains taxes were a factor in taking us from a small deficit to a small surplus. By far the most important factor was the extremely high employment levels and the wage growth of the 1990s.
#3 is a valid point, if your primary criterion is cost-cutting.
Actually, the major deficit control bill was passed in 1990, and cost George W. Bush the election.
#4 has EVERYTHING to do with it. The Clinton projections were not to close the deficit; they were to shrink it. Then when revenues started rising much more than expected in 1995, Bob Rubin started telling everyone they didn't have to actually close it--they could spend the money. The Republicans said no.
#5--would you care to elaborate? There is no measure I am aware of that exposes consumers to more costs than they currently bear; rather the reverse. Abortion might be the major exception, but many of those are already purchased off-insurance.
#1 A. The fact that someone agrees with you is not a good reason to be uncritical of their methodology. When your opinions could be charitably characterized as an educated guess, they add nothing to the understanding of fact. I would argue that we should be critical of both methodologies, as they both have weaknesses.
B. The CBO provides much more detail about how they make their decisions, the models used, as well as providing historical analyses of their past track record. The CMS report is more of a statement of results. With essentially no discussion of method.
C. Yes, I'm partial to the CBO report, because they provide enough information to evaluate their conclusions. If I am to believe the CMS, I just have to trust them.
#2 A. The excise tax and the productivity benchmarking appear to provide large savings, and incentivize reforms, why limit your scope to a particular clause?
B. Have you looked at the uncertainty involved? CBO actually provides reports that analyze this in detail. From what I've looked at, the uncertainty on the $3B number is going to be something like +-10%, not +-100%. So yes it might be only $2.7 B, I guess that falls below your arbitrary threshold for caring?
#3 A. Your analogy makes sense, but doesn't apply. This bill stops digging, and fills the hole a little bit. You're saying we should fill the hole a little bit because we might decide to start digging in the future....
B. You would have a point if we could do a cuts-only bill, but that has even larger political barriers than preventing future cut-revisions. Basically world B is better than world A, but because impossible world C is better than world A and B, we shouldn't do world B, and keep hoping for the impossible.
#4 A. I disagree, but clearly our politics differ, so I don't see any benefit to debating who is responsible for the surplus. The point is that it can and does happen regardless of the actor, which disproves your spending is inevitable argument. (Not just in the 1990s, but numerous other times throughout our history, 1990,1950,1920,1890,1880)
B. That said, you mischaracterize my argument. I'm saying that we should make our job a little easier today, and keeping working to make it a little easier tomorrow. If someone tries to make it harder tomorrow, we can worry about it then, but that has no bearing on today.
C. Massachusetts reforms indicate that expanding coverage actually helps build political will to cut costs, because keeping the benefits requires keeping cost under control. It 30 Million more people incentives to want cost control.
#5 A. Lol, You are using the same argument that liberals used against Reagan's trickle down economics: "We shouldn't do something that ultimately helps everyone because it helps some people more than others". Personally I value utility over fairness.
B. It partially removes the exclusion, by removing the exclusion above a certain threshold. If we could remove it all, I'd be even happier, but in lieu of that, I'll take what I can get.
I must admit I'm impressed, I'd never imagined a hard-nosed conservative could be so adept at adapting the arguments of an uncompromising liberal idealist.
Zosima, are you under the impression that people over the age of 15 wither under the steely gaze of LOL?
#1A: I have one critique of the CBO report. The CMS report backs up my critique, based on the historical legislative experience. Critically, the head of the CBO also seems to agree with me, and has basically said so in both the caveats, and his testimony to Congress. I'm not cherry picking the reports.
#1B: I'm sorry, but it sounds like you're stretching for some pretense for preferring the report that agrees with you. This one is pretty thin. The CBO is explicitly forbidden from considering future legislative behavior, which is the topic at hand. It is not forbidden from doing so because this will not impact what we end up spending. It is forbidden from doing so because the CBO needs to be apolitical; it is well known, and admitted by CBO directors, that the CBO method prizes consistency over accuracy.In fact, the CBO tells you in their report that we should consider this problem, even though *they* can't, and they basically agree with me and the CMS: Congress has a well established history of overturning cost cutting measures. Most of the savings passed in the BBA have basically been gutted one way or another
#1C: Can you cite your basis? The CMS report is lengthy, and in my reading contains just as many explanations of their assumptions as the CBO report does. Their explanation of the problem with the provider payments, in particular, is very well elaborated and extensively footnoted.
#2 Because as I said, that is not delivery system reform. It's payment cuts. Delivery system reform is things like changing the way you reimburse treatments to alter provider incentives, not just cutting their pay. If your boss gives everyone a 10% pay cut, did he "reform" your department? As for caring--first of all, in the scope of the budget, $3 billion over 10 years is below my threshhold for caring. It's what we could save by getting a slightly better deal on pencils for federal workers. Second of all, their stated uncertainties do not cover the actual uncertainty in the estimate; it just states the uncertainty of the parameters they chose.
#3 A No, it doesn't. That is the point. If I am right, this bill will put in place a program that is very hard to repeal, while establishing a payment mechanism that is virtually certain to be repealed. You can keep saying that that doesn't have anything to do with the deficit, but there's a very long history of US government behavior, and a very large body of public choice literature, that disagrees with you. Your statement that world B is better than world A depends on the assumption that in world B it is easier, or at least as easy, to do budget cuts as in World A. But in fact, it's going to be harder. In World B, we're in the same position we are now: there's a substantial endowment effect. Only in World B, more people have the endowment. Every piece of poli sci literature tells you that the more voters have an endowment, the harder it is to cut. So World B is only better if you basically don't care about the deficit/tax finance problem it hands us.
#4 As I noted, in the past fifty years, we have run 3 on-budget budget surpluses. Moreover, we ran all three when Social Security and Medicare were in Surplus. By the end of this decade, both will be in deficit, and heading deeper. I don't see why you think a massive new entitlement that, AT THE VERY BEST, sucks up a lot of the tax dollars and spending cuts that would otherwise be used to close the deficit we actually have, makes the problem better. As for your assertion about Massachussetts, you don't actually have any evidence for this. What you have evidence for is that fourteen people who are not themselves facing re-election can recommend payment reform. I'd like to see some evidence that there is any actual political coalition for making it.
#5 It doesn't remove the exclusion at all; all it does is encourage employers to keep the price of their policies down. It does nothing--zero, nada, zip--to reduce or eliminate the third-party purchaser problem, nor the tying of insurance to employment. You seem to grossly misapprehend the reason that conservatives, at least, wish to remove the tax exclusion. That you would confuse this for having basically any of the same characteristics of removing the tax exclusion is kind of weird. Nor is the problem with the tax that it hits some people and not others, which is trivially true of any tax. The problem is that I don't think it's well designed to accomplish any public policy purpose. On what grounds do you declare it utility enhancing? Whose utility? Please show your work, comparing it to other possible methods of tax finance.
Overall, you aren't really responding to what I'm saying. You're just repeating how awesome everything would be if it worked, and calling me names in an ostensibly indirect college-frosh style that didn't even work on me when I was a college freshman. I think I have a vastly better methodological claim to consistency than your bizarre assertion that the CMS doesn't show its work, and the CBO does.
I use "LOL" to indicate that I'm laughing at the silly things you say, as the emotion doesn't show up in the body of the text. I could use emotes if you prefer, but I'm just adopting my language to limitations of the medium.
#1 A I get it, you believe the CMS regardless of whether they have published methods because they generated a conclusion that fits your preconceptions; which ironically is a bad methodology.
#1 B I don't doubt that CBO has methodological limitations, but at least we can state those precisely. You seem to assume that since the CMS provides none, that there are none. (Trust me, there are)
#1 C As for examples of basis, yes. The CMS report says "We estimate", "Our model shows" probably twice a page. But what model? They never describe a model. They don't show the calculations they use. The CMS report was 31 pages, the CBO report I was 236, with tons of additional supplemental documents(like the historical accuracy measurements I noted, another 50 or so pages of probabilistic analysis.)
#2 Excise taxes and productivity targets create incentives to reform without micromanaging the details, much like the testing approach conservatives take with education reform.
They also look at what their track record is after historical data is available. So they prospective uncertainty estimates, and retrospective accuracy estimates(to be specific RMS error for actual, corporate, and administrative)
#3 A. You make a mistake when you lump world B at t_0 and world B at t+1 into the same world(t+1 being the time you expect repeal of reforms). We can worry about the future when it comes.
B. The Massachusetts results would seem to conflict with your expectation.
#4 I think I addressed this in a separate post.
#5 A. Back to the same point, not doing enough is not a reason not to do a little. It is generally agreed that the excise tax would decrease the cost of healthcare. Employers making decisions to purchase cheaper plans decreases costs.
B. If there is some secret alternative reason why conservatives want to remove the tax exclusion, please enlighten me.
C. As to third party purchasing. The excise tax doesn't help, but the exchange allows people to move into plans where they pay directly. I would be very happy with Wyden/Bennett if the exchange were made even more accessible.
Complaining about ad hominems only works when you don't use them yourself, otherwise you end up looking like a hypocrite. If it makes you feel any better, I feel like you are being as unresponsive to my points as you feel I'm being to yours.
I had one more thought. I'm going to birds-eye this argument for a second to try to get at the fundamental point of disagreement. Incidentally, this is exactly the same argument that Holbo made against you several months ago, and it is really the hallmark of your argumentative style.
A claim that something might go wrong is not a sufficient reason for anyone to change their behavior.
I see this in the work I do all the time. We see a problem, we have a bunch of meetings about it, then someone actually does a basic calculation, I mean with huge margins of errors and approximations: worst case. We look at the numbers,and it turns out that the problem that appeared important qualitatively is such a small contribution quantitatively that it couldn't possibly matter.
What I learned is that my preconceptions give me very little accurate information about fact.
If you want to make a persuasive case for any claims you make, you need something like a probability weighted cost. You can even include a margin to represent our tendency to risk aversion, which would bias towards the status quo.
Claims that you are right because someone else said something that meets your preconceptions is just not persuasive. We don't know whether the problem will happen 1 in 10 times, 1 in 1000 times, 1 in 100,000, 1 in a trillion times. Without some back of the envelop calculations, it is very easy to disregard what you say.
That LOL comment just soared right over your head, didn't it? "I'm laughing at you" stopped being a killer argument in eighth grade; deploying it in a conversation with adults just makes you look as if . . . well, you can finish that sentence.
Seriously, condescension is not an argument. You are arguing about a junior high level here. When I give you my reasoning behind believing the CMS estimates, your stunning rejoinder is, "Okay, I see, you're totally biased, unlike me, who came up with this incredibly compelling pretext for denying that CMS could be right!" On the specific point that I'm discussing, you can't say you believe the CBO's methodology and not the CMS methodology, because the CBO doesn't address the question, except to say, "This is a huge and important problem". The CMS, which administers the stuff, says, "this is a huge and important problem". You're stating that you "believe" the CBO's methodology, but that is nonsensical in this context. If you do not think that this is a substantial risk, you are not agreeing with CBO and disagreeing with CMS; you're disagreeing with them both. And pretty much everyone, including the liberal health care analysts, who all understand that this is a giant potential problem.
#2: Maybe they create incentives to do delivery system reform, maybe they don't--but they are not delivery system reform. The incentives are incredibly blunt, and there are multiple behaviors they could incent, some of which are very bad. That's the core point, and you can dance around it all you want, but you aren't addressing it; you're just asserting what was to be proven, while I'm giving reasons to believe this is really risky.
#3: No, they don't--again, you're assuming what was to be proven. None of the politicians in Massachussetts have implemented any such changes. They threw immigrants out of the system, which is exactly what MY model would predict they'd do. Meanwhile, "we can worry about the future when it comes" is indeed what you want to do, but I'd rather worry about it now, thanks, before we make things worse.
#5: Non responsive. The excise tax does not lower health care costs; it possibly causes some employers to purchase less health care for their employees. And then again, possibly not.
Now, to "birds eye" this for a bit, if it is very probable that something will go wrong, this is, in fact, a very good reason not to do it. Let's apply your logic to the Iraq War, for example: were the concerns about how the whole thing might play out a good reason not to do it?
If you want a probability weighted cost, based on the history of Congress: P(excise tax repealed)=.5
P(provider payment cuts repealed)=.9
P(medpac recommendations ignored)=.99
P(Medicare Advantage equalization repealed)=.3
P(excise tax raises less money than expected because of sticky labor markets and shifts to other tax-advantaged benefits)=.75
P(the new rube goldberg device we are building does not bend the curve and increases the deficit)= .99999
I could multiply this by the projected cost savings and give you an estimate. Did sticking arbitrary numbers on it make the discussion more enlightening? Or was this a fine bit of PM silliness?
Ultimately, your arguments boil down to the fact that you do not consider a runaway cost problem to be a good reason not to do national health care. It's absolutely true: you don't. Dressing it up with quasi-technical quibbling does not improve the quality of the debate. And the fact remains that while you don't really care about the cost side, many of us do, and this caliber of argument is not going to deter us from discussing those problems early and often.
@Megan
Just wanted to drop a kudos to you on your reponses in this thread. You've been absolutely on fire with these fantastic comments!
I hope this means your feeling back to 100% but regardless, way to go!
Megan & Ken Magalnik, on the 1990s debt:
You are just wrong. We showed an overall surplus, debt went down, and if you take away Medicare and Social Security. We still showed a surplus.
I'm not sure where you are getting your information, but they are wrong too.
http://www.whitehouse.gov/omb/budget/fy2009/pdf/hist.pdf
The data is in the document above.
Well, the pdf you posted takes a year to load up, so I found this:
http://www.treasurydirect.gov/govt/reports/pd/histdebt/histdebt_histo4.htm
As you can see, in monetary terms, the debt had not gone down in the 90's, not even by a single dollar. True, our debt went down as a percent of GDP, which of course is great, but that means that our economy grew faster than our debt, not that there was a surplus. A surplus would mean that the gov't took in more money in revenue than it spent, and the rest went to reduce the federal debt. That has not happened. Instead, our economy grew at a faster rate than gov't spending was growing, but our gov't was still running a deficit, just that the deficit grew slower than our economy did, but it still grew.
And I'm all in support of a world in which economies grow faster than gov't spendings. However, it seems that our gov't quickly adjusted to its increased ability to borrow (And certainly Bush deserves a good share of the blame), and now our gov't seems to be having a hard time adjusting to a slower growing economy.
No, you are right--we ran a tiny on-budget surplus one year. Three years in the fifty since 1960. Now, based on the historical evidence, whose belief about Congress's future behavior is more reasonable: yours or mine?
Megan,
Well, I'm to delve into a little bit of basic macro here, but since inflation is generally a small positive number, and GDP generally grows(faster than inflation), I don't think the absolute value of the debt is really a very good metric of the cost of the debt(in the sense of lost growth or risk of default).
I was mainly quibbling because I like to be right. But positive debt ultimately gets smaller in terms of our capacity to service it because it gradually inflates away and we produce more per capita to pay the interest.
The fact that we can surplus in absolute terms means we're overshooting the goal we need to meet from an economic perspective. Many economists would agree it is a good thing to run a modest amount of debt, and some economists that I agree with, would say it is good to run a lot of debt during economic crisis.
Concluding, I would say that the historical record indicates it is reasonable to believe that congress will meet the debt targets needed to maintain growth and stability. The best thing we can do today, is take a step in the right direction and worry about tomorrow,well, tomorrow.
You just massively moved the goalposts. If you like to be right, you have to pick an argument and be, well, right about it.
To get all macroeconomic and stuff, how well does your model work if we have a prolonged period of deflation?
For the case of this argument, I scored a goal with the original goal posts. Debt declined in absolute terms. You never asked what level of debt I considered appropriate, but if you would have asked, I would have given you the same answer I just gave you. It is pretty standard: percentage of GDP.
Ahem, that was not a surplus we had 10 years ago. If we had a surplus, national debt would have gone down. But it didn't, it still went up. In other words, our gov't borrowed more money than it managed to spend. That is hardly a surplus
Should not this analysis also note that a large portion of the Reid Bill's "expanded coverage" is by simply expanding Medicaid to cover more people, which will have a huge impact on state budgets? Now, I realize that New York, California, Florida, New Jersey, Michigan, Nevada and others are all running healthy surpluses, so they should have no problem absorbing billions in additional Medicare costs, but isn't it even worth a small mention?
One more point, alluded to by an earlier poster: We need to pass some health care reform in order to cut through all the fear-mongering and BS.
It's painfully obvious now that we simply cannot get a good health care bill passed as long as a sizeable proportion of people are afraid of death panels and so-called "socialism." Once we get a bill passed, and people see that on the whole, it has made their lives better, it will be much easier to follow this with a bill that does much more meaningfully address costs.
Nick Kristof wrote a good column where he revisited some of the rhetoric surrounding the introduction of Medicare. The same groups yelling socialism now were yelling socialism then. But Medicare passed, and it is now wildly popular. So popular that conservatives are actually claiming to be trying to save it from Obama's new socialist plan. There are still a few outliers who complain, but in general, Medicare has proved itself. Nobody believes that it is socialism.
I'm also reminded of the Clinton tax hikes in 1993. Conservatives back then were screaming bloody murder about how this was going to destroy our economy, lead to a new recession, etc. Of course, what actually happened was the largest economic expansion in the country's history.
Of course, it is important to follow this health care bill with a cost-cutting one sooner rather than later. Forty years after Medicare has proved too late; people have forgotten the bogus cries of socialism then and are willing to buy into them now.
But if we pass this bill now, and then address the cost issue specifically (hopefully with bipartisan support) in a few years, more progress can be made. What is perfectly clear is that the status quo is unsustainable. And until conservatives put forward a serious counter-proposal, this is the blueprint we have.
P.S. We've had the discussion before about the merits of conservative counter-proposals. Conservatives have some good suggestions on individual measures, but they fall far short of a coherent, successful policy. You can see this most clearly in the constant references to tort reform as some sort of panacea.
One more point, alluded to by an earlier poster: We need to pass some health care reform in order to cut through all the fear-mongering and BS.
...
What is perfectly clear is that the status quo is unsustainable...[Conservatives] fall far short of a coherent, successful policy.
Ah, the self-refuting comment.
But Medicare passed, and it is now wildly popular.
Medicare was always popular and had wide bipartisan support.
Obamacare probably doesn't even have enough Democrats to pass, and people appear to hate it.
Conservatives have some good suggestions on individual measures, but they fall far short of a coherent, successful policy.
And progressives have a magical government healthcare pony that will be all things to all people.
Just for giggles, consider the possibility that this actually makes more people worse off than better off. What happens to the prospects for reform then?
Well, then, hopefully we will either 1) know how to fix it through incremental change or 2) start over. I doubt that will be the case, but it is not impossible.
Uncertainty is not a good reason to accept the status quo if the status quo can't be sustained. Every year we are digging ourselves a deeper hole.
Our legislative system has so much inertia in it. Yes, that was partly by design (though the Framers would be appalled at the 60 vote rule), and sometimes it is a good thing. But sometimes it prevents any sort of progress at all. Smashing the inertia is a necessary step to reform of any variety. If the inertia wins again, then there is no reason to think it will ever lose.
We know what the challenges in health care policy are, and they aren't going to change. So let's get started.
I agree - full steam ahead with a bad policy! Once we pay 3 years of taxes, suffer reduced growth and are still mired in a recession, we can start experiencing Obamacare's negative effects on our healthcare. Then we can 'start over' like nothing happened.
Great F'ing plan
It's not a bad policy. YOU think it is a bad policy. I think it is a good policy. If it turns out to be a bad policy, then I will be the first one out trying to fix it.
Funny thing about conservatives. They are so often wrong when they sound the alarm of economic ruin, but they still sound it every chance they get. We need look no further than the stimulus bill. Conservatives screamed that it would ruin the economy. Guess what? It's working as intended.
Another funny thing about conservatives. They are willing to take extraordinary risks when championing their policies, but demand utter certainty from liberals.
Let me ask you a question: is the success of health care reform more or less probable than Star Wars or missile defense? More or less probable that Saddam had WMDs, would give them to terrorists, and that we could waltz into Baghdad and be greeted as liberators? More or less probable than investing Social Security assets in the stock market?
I am being frank here. If a single payer option is taken off the table, the challenges of health care reform are formidable. We might not get it just right the first time. The reward is worth the risk.
Technically, the CMS and the Dean of the Harvard Medical School think its a bad policy too - and I prefer them over an idealogue like yourself.
51% of Americans think it's a bad policy.
36% think it's a good policy.
"Once we get a bill passed, and people see that on the whole, it has made their lives better,"
And, of course, if by some weird twist of fate it actually makes things worse, that will not be in any way a suggestion that it should be repealed.
Because when the free market fails for any length of time, that is proof positive that we need a strong government program to intervene and correct the problem.
But when a government program fails, that too is proof positive that we need a stronger government program to intervene and correct the problem.
And all of this, of course, is to completely ignore unseen opportunity costs. What will we be forgoing by adopting this health care system and then forever tinkering with it in search of perfection?
If the government had been in charge of television, we'd still be watching black and white sets w/o remote controls. When the first remote control was invented, there were execs who didn't see the point. After all, they reasoned, no one was complaining about having to get up to adjust thier tv, so clearly the current system was working just fine. People were happy.
If we had gotten universal government health coverage back in, say, the mid 1970's, what innovations would be missing today? MRI's? Many types of organ transplant? A whole slew of various drugs? Ah, but it wouldn't matter one jot, because people would be quite happy with the care they were getting. And, more importantly, no one would be dying becuase of lack of health insurance. Dying because of lack of technology, yes, but there's no way to actually see that, is there?
Ignorance truly is, as they say, bliss.
Well, let's see. The government has been in charge of the armed forces since the beginning of the Republicans. Since the 1970s, I would wager that no sector of the economy has contributed more to innovation than the military. THEY invented the internet, you know. In any event, the technology advances in the military show how silly it is to claim that the government can't promote innovation.
Are you aware that the primary source of innovation in health care is the basic research funded by . . . the government? The NIH would have existed no matter what type of coverage system we have, and it would have continued to develop medical technologies.
Are you aware the Medicare has often been on the leading edge of paying for/adopting new treatments? It is usually the private insurers who resist new types of procedures.
The idea that government involvement in the economy stifles innovation is pure nonsense. If the government wants to foster technology it can. Just look at Japan. They became the most technologically advanced society in the world because of active government support.
P.S. This is not suggesting that all government policies are wise, or that we would be better off having government run everything. I am quite happy with market systems where they work well. I am responding to the idea that government necessarily stifles innovation.
Here's what I always wonder about folk like you & Nimed below's arguments & belief systems.
You seem to honestly believe that a government run system will be better in every way, including fairness, including innovation, including efficiency, just plain better across the board.
I get that. You also seem to believe, based on your responses to innvoation arguments, that this is not just true of government in the weird-and-wild-world-of-health-care with its odd properties that make it uniquely suited to benefit from government involvement, but is just a general truism about government involvement: it makes things better by just about any measure. (And, in fact, you all are often at pains to point out that 'free market innovation' is actually just piggy-backing off the noble & necessary work done by government, without which nothing good would ever happen.)
Okay, I can understand all that. I disagree, but at least it makes logical sense given your apparent starting beliefs and the evidence you are willing to acknowledge.
But then you often go and tack on a pro-forma "but I'm not oppossed to the free market for what it does well" codicil. My question is why? If you genuinely believe that the government produces a better result in just about every area of human endeavor, why would you not want to have that better result applied in every aspect of life? Why would you be happy to let the market handle food or cell phones or clothing or whatever when the government would, by your understanding, do a better job in just about every way?
Is it because those areas are less important so you're willing to tolerate inefficiency for some other good? But if so, what is that other good? In other words, if there's really almost nothing that the free market brings to the table that the government can't match & exceed, why would you want any area of life to not get the benefit of intense government involvement & control? Why wouldn't that result in a better world overall?
I love the vague expression "in charge". The correct analogy to our health care system would be: if the government would artificially increase demand by subsidizing televisions for low-income and over 65 watchers, televisions would probably be much more advanced by now.
And the development of the MRI is truly an unfortunate example. Not only was the project subsidized by a government grant, it was actually created at the State University of New York.
And what organ transplants exactly do you have in mind? The first successful heart transplant, for instance, was performed at Stanford University - funding provided by an NIH grant.
No, there isn't. Wich, of course, makes this particular argument useful to justify all sorts of stuff. For instance, since most groundbreaking research comes from government-funded science through the grant system, who knows what kind of world would we be living in right now had we spent twice the money in science in the last 30 years. We've already lost an incalculable number of lives. All because we didn't raise taxes a little, or diverted funds to several war efforts.
Therefore, we should multiply by 10 our science budget right now. Future lives demand it!
Hurray! Quinnipiac has Obamacare at -16.
51-36 against. This thing may still die before it can kill any Americans.
I think it unwise that liberals continue to think that opposition is based solely on irrational fears, simply because the most extreme elements are the ones showing up in their reading. This effort has not been just losing the support of the whack jobs who would never support anything.
You should consider the implications and arrogance inherent in the argument that if you just force it on the "stupid" and "paranoid" people, then they will see how good it is for them. There are some religious conservatives who would say that, if they could just force you to pray, go to church, read your Bible, and stop having sex and abortions, then you would see how good it is for you.
P.S. You concede that this bill only addresses coverage and punts on controlling unsustainable costs, but you complain that conservatives fall short of a coherent, successful policy...
It doesn't punt on controlling unsustainable costs. It takes steps to address those costs that aren't immediately realized, and may not be realized. It is a start.
Conservatives fall short of a coherent successful policy because they offer no realistic alternative to what they ultimately complain about: so-called "rationing."
This is a big problem with the bill right now; conservatives and moderates are afraid of the bogeyman of "rationing" (as if we don't have that right now), so that's why we get less cost-control than we would if liberals could write the bill to their choosing.
The problem, of course, is that "rationing" is a purely rhetorical term, devoid of any real substance. Rationing implies shortages; but that won't happen. The problem is overutilization, which is cost-inefficient and also allocatively inefficient.
Conservative plans do not eschew rationing; they simply prefer market rationing. One problem is that markets don't work well in health care, for a number of basic reasons that are explained in Heath Care Econ 101. The other problem is that the market approaches tend to concentrate costs on the sick. They demonstrably fail to offer a cross-subsidy from healthy to sick, which is a moral requirement of any acceptable system of health care.
Rationing implies shortages; but that won't happen.
Yeah, increase patient load and decrease funding by $500 Billion - there's no way that results in shortages.
You want plans to attack rationing:
- federally mandate minimum plan requirements and scrap state mandates
- open insurance sales across state lines and minimize state interference in plans
- provide every citizen with catastrophic care coverage (transplants, major chemo, etc...) through government re-insurance
- allow non-employer risk pools (alumni groups, social groups, civic groups)
- tax health benefits as income, even for Unions
- allow posting of prices in medical establishments
- tax advantage HSA accounts, with matching funds for low income earners
Those are some points, I could probably go into more, and there's probably some help from reducing defensive medicine through tort reform.
Yawn. Been there, done that on the other thread.
None of those things attack rationing. Primarily, those ideas that simply shift the health care cost burden to the sick. A couple may be useful tools to tweak the system's overall efficiency, but tweaks are what they are.
I think it's funny that you call me an ideologue. As far as I can tell, I am one of the few people on this thread (the only one perhaps) who acknowledges that the "other side" has some good points. In fact, I do that on a lot of threads.
I haven't seen one single post from you where you deviate from a highly partisan, extremely ideological stance. In fact, I can't see that you even acknowledge that people can disagree with you without being morons.
I disagree Megan. I think it is pretty clear that any bill passed by this Congress will meaningfully bend the cost curve - it will bend it up. We start paying for this bill immediately while the benefits do not kick in until later. The slated cuts likely will not occur. Government programs (actually just about any project) typically end up costing much more than initial estimates. The bill's score is a result of temporal gimmicks, and moving costs off of the bill's balance sheet (such as to Medicaid as another commenter mentioned or to other/future bills). And we haven't even considered the rent-seeking that will occur.
I have no qualms with hyperbole when hyperbole is warranted. The idea that putting a huge government bureaucracy in charge of something will 1) improve the quality and 2) reduce the cost is pure lunacy. It goes in the same category as unicorns and fairy dust. I too feel that health care should accessible to all Americans. But the way to achieve this goal is not through the fairy dust of government mandates, regulations, and bureaucracy. It is through 1) the demonstrated mechanism of competition (interstate), 2) the elimination of minimum coverage law that force insurance companies to cover nonsense like acupuncture, 3) tort reform, and 4) granting individuals instead of companies the tax benefits for buying health care. Those who still need help should then get measurable subsidies or tax credits.
Congressional Dems are aware that most Americans know that bureaucracy and regulations will not improve quality and reduce cost. This is why they make every attempt to cloak their plans in the language of competition and competitiveness.
The current bills that give federal government a greater role will only increase rent-seeking. Government will decide the types of health care that can be rationed, and it will decide to whom such care will be rationed. The winners will those with the best lobbyists. Just like the banks seem to win when government bails out the financial industry, you can be sure that those with the best lobbyists will win (which means the companies with the most money) when it comes time to make tough health care choices.
Power should be decentralized. The current rent-seeking orgy should offend anyone who values their liberty.
We start paying for this bill immediately while the benefits do not kick in until later.
The Senate bill delays implementation of the reforms even further than the House bill - until 2014 - and still needs to crank up Medicare taxes, among others, in 2010 to pay for itself.
Just makes it easier for President Palin and a GOP congress to repeal the whole thing in 2012.
"I suppose the new Harvard study on ER mortality is also "godawful":"
The Harvard ER study is another example of how the advocates of Obamacare ignore inconvenient reality. For example, the study does not make any allowance for the fact that uninsured are much more likely to stab and shoot each other plus they are more likely to drive 100 miles per hour on the freeway. They call those confounding variables and, had they not been working hard to prove a point, they probably would have done adjusted for them.
Geriatrics is a heavily impacted field and there are no geriatric programs outside of academic institutions which subsidize them. For example,the only fellowship trained geriatrician in central Iowa was being harassed by Medicare and threatened with prosecution so she quit Medicare. She now practices for cash and is making a living. I met her at the Geriatric meeting last spring.
The only solution for healthcare reform is to adopt a variant of the French system and allow the Medicare patient to pay cash and be reimbursed at a lower rate. Right now, they are losing doctors so quickly that the program will collapse soon after the bill passes, whatever it is.
For example, the study does not make any allowance for the fact that uninsured are much more likely to stab and shoot each other plus they are more likely to drive 100 miles per hour on the freeway.
If only they had insurance, then we could prevent all those stabbing and shootings and accidents.
If only they had insurance, then we could prevent all those stabbing and shootings and accidents.
No. If only they had insurance, they would receive the same standard of care as insured patients (even when that insurance is Medicaid) admitted because of shootings or stabbings or accidents.
PPP poll has ObamaCare at 40-52.
For example, the study does not make any allowance for the fact that uninsured are much more likely to stab and shoot each other plus they are more likely to drive 100 miles per hour on the freeway.
Mike_K: It doesn't have to. It's comparing like to like (ER patients to ER patients), the only difference being the first group has health insurance and the second group is uninsured. The fact that, say, uninsured people are more likely to suffer gunshot wounds, while undoubtedly true, simply means uninsured people are more likely to end up at the ER because of this particular type of accident. It does not counter the conclusion the Harvard study would suggest that uninsured gunshot wound patients at emergency rooms receive inferior care compared to insured gunshot wound patients at emergency rooms.
For the life of me I have no idea what point you're trying to make with your mention of geriatrics and Medicare and French healthcare.
From the article:
But many hospitals don’t know who’s insured and who isn’t when a patient arrives at an emergency room after, say, a car crash.
Seriously, this is right up there with "greedy doctors stealing people's tonsils."
"Oh no, he's uninsured! Quick! Get him to the Inferior Care Unit!"
They might also have a lower rate of so-called health literacy, meaning that they may not explain their symptoms clearly to doctors, which can lead to inadequate care.
Again, correlation doesn't mean causation.
But many hospitals don’t know who’s insured and who isn’t when a patient arrives at an emergency room after, say, a car crash.
What's your point? The study is simply suggesting that not having health insurance is dangerous to one's health in America, even in the environment where the law supposedly means everybody is entitled to a reasonable and equitable degree of care. It's not claiming that medical professionals make a snap judgment as to what level of care to give the moment a person is admitted (although this could be a factor in some cases). Obviously this information could be revealed at a point after the patient arrives. The study points to a number of plausible reasons that likely explain the difference in outcomes, including quality of care, quality of provider, delays in transfers (or hurried transfers), etc.
Oh, and lest I forget, the study included Medicaid patients among the "insured" group, so it's hardly likely that the effects of poverty would account for much of the difference.
The study is simply suggesting that not having health insurance is dangerous to one's health in America,
This is like arguing learning Japanese will make you live longer and learning Swahili will make you die sooner, because there are clear correlations to those things.
Actually, the Medicaid population mostly excludes the young male group which is the risk group; poor women don't have mortality rates that look all that different from the rest of the population.
I mean, for the relevant age groups; poor women fare badly in older cohorts.
Wait a second, Tall Dave, have you finished eating Road to Serfdom?
http://andrewsullivan.theatlantic.com/the_daily_dish/2009/09/quote-for-the-day-1.html
Eff you, stonetools, everybody knows Hayek was a non-Randian. In other words a Commie.
Still lying about having read it?
OK, what was the theme of the book, and why is that quote deeply out of context?
Sheesh, quoting Trig-truthers at me now.
Eh eh. No, but he probably ordered "Hayek for Dummies" by now. Meanwhile, desperate bluffs will ensue. Should be fun.
This is like arguing learning Japanese will make you live longer and learning Swahili will make you die sooner, because there are clear correlations to those things.
No it's not like arguing that. There are no plausible causation mechanisms connecting the study of foreign languages and the life expectancy of the native speakers of those languages. There are rather obviously a number of plausible causation mechanisms connecting lack of health insurance to inferior ER health outcomes.
Jeez, TallDave, you're mailing it in tonight. You'd be better off simply saying something like "The free market rocks, even if clinging to it means more people have to suffer or die from untreated medical conditions" -- than trying to dispute every claim -- even the self-evident ones -- supporting the case for health care reform. Try a little intellectual honesty.
There are rather obviously a number of plausible causation mechanisms connecting lack of health insurance to inferior ER health outcomes.
I haven't heard any, except the "Inferior Care Unit" theory which is pretty laughable. I've heard lots more plausible reasons why the two might be correlated but have no causual relationship. You know, like learning Swahili and dying sooner...
Jeez, TallDave, you're mailing it in tonight
This from the guy who can't figure out the connection between prenatal care and perinatal outcomes.
Oh good, more substance from Nimed.
The legend grows...
but he probably ordered "Hayek for Dummies" by now.
There's probably a discount if you also order an abridged version of 1984.
LOL you guys can't even insult someone without revealing yourselves to be idiots.
The issue wasn't whether I had read it, it was my statement that I will eat my copy of ROS if stonetools had ever read it. (Given his obvious unfamiliarity with it, I'd say my copy is pretty safe, his claims to the contrary notwithstanding.)
Try to have some idea what's going on before jumping in, you'll find it less embarassing.
Oh noes, Megan doiesn't think nthe CBO scoring of health reform is right! Who would have predicted this? I'm shocked, shocked!
We should respond by noting, yet again, that :
1. The Republicans did nothing to control health costs when they were in charge.
2. Their latest "plan" have no cost control measures of any kind.
3.Megan has no cost control ideas of their own, and opposes any cost control measures that have been suggested.
4. Her commenters have no cost control ideas of their own. When pressed on the issue, they claim that cost containment measures are unnecessary and that the "free market" will somehow magically reduce costs.
Since I don't believe in the magical free market cost control pony, I've come to the conclusion that conservatives aren't serious about health care cost control- that it's just another tool in the giant flood of propaganda that they have released against reform. There's a way to quell the conservative cost control propaganda campaign-just ask them to come up with a cost control plan. And no, interstate competition isn't a cost control measure- any more than the creation of a national health insurance exchange is a cost control measure.
Until then, their criticism of the Democratic health reform efforts are completely hypocritical, in my view.If there are better ways to control costs while achieving universal coverage, then show your work and let's see it. Until then, shut up.
I guess it's easier to argue against a bunch of strawmen.
This from the guy who can't figure out the connection between prenatal care and perinatal outcomes.
Huh? What on earth are you talking about now? If you've got an argument about how the two relate that's relevant to the debate at hand, let's hear it.
I haven't heard any, except the "Inferior Care Unit" theory which is pretty laughable.
Which part is laughable? The part that says uninsured people are more likely to be taken to lower quality facilities? Or the part that says lower quality facilities are more likely to administer inferior care? I personally would like to see more evidence, and I'd be interested to read further findings about this subject, but I don't see how any reasonable person could dismiss such reasoning as "laughable." Or perhaps you think it's funny when Americans less fortunate than you receive inferior care? Is that what you're saying?
By this rationale the problem isn't the insurance, it's the facilities. This is exactly like claiming learning Japanese will make you live longer.
This is depressing. I like physics forums better. I don't have to constantly explain basic logic.
FWIW, here's a link to the many, many reasons U.S. healthcare is the best in the world.
http://shrinkwrapped.blogs.com/blog/2009/10/health-care-mantra.html
And when you're done with the "many reasons" provided by Dave's right-wing blog post, here's a link to a serious academic paper arriving (like most serious academic papers) at a different conclusion:
http://www.urban.org/uploadedpdf/411947_ushealthcare_quality.pdf
This just restates the same flawed general measures that don't measure healthcare outcomes.
My link has actual specific measures of healthcare outcomes.
Also, merely chanting "serious scademic paper" doesn't make the data any better, or change the fact its from a left-wing institution.
What's really amusing is when they look at specific diseases they generally agree U.S. healthcare outcomes are better. They have to reach back to the debunked "amenable" canard to ultimately conclude U.S. healthcare isn't better.
My beef with the current offerings, and particularly the Reid/Senate bill, with which I'm more familiar, is in keeping with my general gripe about the legislature as a whole. I can only conclude that many of these people are just not all that serious about substantive policy-making. I can find no other explanation for the foolhardy rubbish that they routinely champion (and that applies on both sides of the aisle, incidentally).
To cite but a few examples insofar as Reid's recent bill is concerned:
(1) The stated purpose of a mandate is, in a nutshell, to require that young/healty persons purchase insurance, to off-set the necessarily higher costs associated with elimination of pre-existing condition denials. Fair enough. Reasonable people could disagree about whether or not a mandate is a good thing, but I can at least comprehend the rationale. But then I look at the specifics of the Reid bill, and the individual mandate penalty is set at a whopping $750 PER YEAR. Is it not plain that this creates an economic incentive for young/healthy persons to forego insurance coverage, pay the very modest annual penalty, and only then purchase coverage if/when they get sick (at which point no insurer can refuse coverage under the new "no pre-existing condition refusal" paradigm)? And is it not equally obvious what this will do to insurance premiums overall? How could we possibly have debated this in earnest for nearly a year, only to have such an absurdly evident flaw on the table at this late date?
(2) What exactly is wrong with Ron Wyden's sensible position on consumer choice, i.e., if you don't like what your employer offers, you can take your employer contribution onto an open market, a la the existing federal exchange, and buy a policy that better suits your preferences and budget? I have posed this question to the few people I happen to know who work on the Hill, and the response is that it might make a ton of sense, but since labor unions and a few H.R. professional associations oppose it out of pure, unmitigated self-interest, it can't see the light of day in any spirited debate. When I protest and suggest that despite union/H.R.-rep political opposition, it would actually be really good and freeing for consumers, these same acquaintences generally agree, smile, apologize, and say that politics simply matters more than policy on this one.
(3) Tort Reform -- I do not think that this is a panacea as some on the right seem to believe. But here in Maryland and many other states, we already have very generous caps on non-economic damages in medical malpractice cases. And these generous caps do, by most accounts, make a slight but quantifiable difference in insurance costs. Even if we assume conservatively, as did Peter Orszag, that tort reform would lessen our overall healthcare expenditures by 1%-2%, would it not be worthwile to consider if we're serious about reducing costs? Plus, it would actually help Dems co-opt at least one major talking point from their Republican colleagues. But this subject, too, is apparently taboo.
And we could of course go on....I think for example that Megan's (and Elmendorf's) concern that the House/Senate will not actually impose the politically difficult Medicare cost reductions is extremely well-placed. I'd be willing to take the legislature at its word on the cost cuts in a general trust-thy-fellow-man sort of way, but then I recall the AMT fix, the Doc fix (which they have the audacity to take up concurrently within the broader healthcare debate), various off-balance sheet war expenditures, and seemingly a thousand other similar bits of budget shenanigans.
I'd like to think that we deserve better, but maybe it's just an inherent fact of life in our political system that we shall be represented perpetually by non-serious grandstanding blow-hards. So it goes. In any case, cheers for the stimulating comments, as always.
god, this thread is a mess. So much bickering that it's impossible to tell what's going on, other than a lot of people are absolutely certain that they are right and everyone else is wrong.
Here's my position in a nutshell:
1. The reform does at least one good thing, which is expand insurance. This is not only morally important, but it carries economic benefits as well.
2. The reform potentially does another good thing, by starting to cut costs a little bit and laying the foundation for future utilization reform, which may or may not happen. I am not as pessimistic as some because I have seen Congress make useful, cost-efficient reforms on smaller issues. Hopefully they can get their act together on the big ones.
3. There is a risk that the program will fall short of its coverage goals and exceed its cost estimates. What is certain is that the status quo is terrible and will lead to ruin. The reform might make things marginally worse.
4. The potential reward is worth that risk, which I think -- partly on faith -- is a low probability.
5. When a problem absolutely has to be solved, and vested special interests have beaten down various attempts to even address that problem over half a century, there is value in getting something passed. It breaks the inertia, and makes possible further reform or different reform if that turns out to be necessary.
I think Megan agrees with me on part of points 1, 2, 3. She is more concerned about the risk of failure than I am, and more pessimistic that the risk will materialize. She is less interested in the accomplishments of #1 and #2 than I am.
I have noticed that nobody has even attempted to refute point #5, about the value of breaking inertia. In part, that's because it's not really capable of refutation -- it's admittedly speculation on my part, and one answer to that is "well, I speculate differently." Neither one is falsifiable.
On the other hand, conservatives on this thread have talked a big game about the conservative "proposals" for better health care reform. I am skeptical of some points snd dismissive of others, but let's put that aside. Suppose that the conservative plan is wonderful. It is still completly politically unrealistic. Conservatives could get a majority in both chambers and the presidency, and run into exactly the same gridlock and inertia.
I contend that a conservative should want this health care bill to pass, because it opens the door to reform of all stripes. It provides an empirical test of liberal versus conservative strategies. If the liberal approach fails, then conservatives will likely be able to try our their proposals.
Let's be honest; if this health care reform doesn't work, the cost of that failure will be relatively small in the big scheme of things. Certainly a lot less than the cost of the bailout, and the Iraq/Afghan wars, and wasteful military spending. So if you're sure the bill won't work, why not let it become law and then you will have proof positive.
I think there are some big points of confusion out there.
1. The number of people who want but cannot afford insurance is small. According the Census, 80% of people who could not afford insurance have Medicaid already, and its a fair bet half of the other 20% are young people who don't especially want it anyway. This argues we can just expand Medicaid 10% and solve whole problem. Also, the number of people actually being refused treatment is eseentially nil.
2. Cost containment will be painful no matter how it's done. Lower costs will mean poorer care. There is no way around this.
3. U.S. health care, when measured for specific diseases, is the best in the world. Claims otherwise tend to be based on overly general measures that include confounding and non-comparable data. It's easy to see this is true because when you look at demographically comparable U.S. states they perform as well as any OECD country even in those measures.