by Ugh
Since the ACA has come up in so many threads lately I thought I'd ask what a functioning, "conservative" market in health care in the United States looks like? It's not clear to me from comments what such a thing would be or how it would operate.
Do we all have insurance? Do we treat it like any other market and do fee for service/good? What role (if any) does the government have to play? Is the current system just fine?
I'm genuinely interested. Thanks!
Update: Other questions: What is wrong with the current U.S. health care system, if anything? How do we move from the current system to whatever is the preferred conservative alternative?
“I’d ask what a functioning, “conservative” market in health care in the United States looks like?”
Picture chickens and/or other poultry (obviously suburbanites living under codes strictly limiting the raising of barn animals would be at a disadvantage in this scheme) being exchanged by would-be patients for medical services and procedures.
Hers’s some help with the picturing:
http://www.photographyblogger.net/19-great-pictures-of-chickens/
Further picture medical practitioners saving up whatever number of chickens would be required to purchase MRI machines and such.
Imagine ambulance crews inquiring whether the elderly woman bleeding to death while balancing the chicken on her head would like to trade her chicken for a ride to the emergency room and her responding: “No, I need the eggs.”
i’ll guess:
Dr. graduates Dr. school, leases a space in a strip mall, hires a cute receptionist, starts taking patients.
Dr charges what the market will bear.
Dr will perform whatever procedures people can afford to pay: maybe takes credit for trusted patients. otherwise, Dr is a death panel of one.
and through the magic of non-regulation Dr can’t be sued for more than some fraction of Dr’s annual income if, by negligence or malpractice, a patient dies.
Here’s Ryan’s Patient’s Choice Act, from 2009.
Don’t know if this is still the state of the art for conservative thinking or not.
An analysis of Ryan’s plan.
It’s not fundamentally different from ACA. I don’t see anything about a federal exchange – there are exchanges, but they’re at the state level, so it has that nice federalism aroma – and instead of an individual mandate, you get auto-enrolled in a state exchange.
Some other stuff is different.
But it’s not fundamentally different from the ACA.
So, I guess I’m confused about what the fuss is all about.
or maybe this is one of those things where it’s something proposed by a conservative but it’s not really conservative.
I’m at a loss.
Sorry for the serial posts.
Douthat’s recent column is getting a lot of play on this issue.
I’ve read recently that veterinary care is the closest thing to the right-wing ideal for health care. Transactions are between the buyer and the provider directly and only, and there’s plenty of competition. Buyers are the sole decider when multiple treatments are offered, and make their own judgment of cost vs. benefit. Insurance policies are rare.
Of course, many patients simply die due to lack of treatment or are even euthanized. It’s a separate debate as to whether, for conservatives, that would be a feature or a bug.
Elective medical care, like lasik eye surgery and cosmetic surgery, have seen a steady decrease in prices and improvements in service.
The conservative plan would work like this: after going into a diabetic swoon at the President’s speech, you’d be sent to Dr. Kristol Dr. Barnes, Dr Podhoretz, and they’d diagnose that you were faking your illness and refer you Nurse Death Panel for some rehabilitative ridicule:
http://www.usgovernmentportal.com/karmel-allison-obamas-staged-fainting-g769272578?language=en
The conservative health care market would be completely deregulated. Insurers could charge whatever they want, and turn away anybody they want. Any disagreements about whether they should have paid for something would be settled in court, with multiple high-powered attorneys on the insurer’s side and probably quite a bit less firepower on the other. Insurers would also never use their monopoly/monopsony position to extract rent from either subscribers or providers.
Anybody who was denied insurance and couldn’t pay for care out of pocket would go to a charitable hospital. Those would be well financed from private donations and would provide excellent care. They would never place religiously based limitations on who they accept or what care they provide, so they’d still be tax exempt (and donors would get an exemption too).
It’s all a complete fiction, of course, but that’s what the hypothetical conservative plan would look like. I can describe what a unicorn looks like too, even though they don’t exist either.
Elective medical care, like lasik eye surgery and cosmetic surgery, have seen a steady decrease in prices and improvements in service.
One reason they are elective is that you won’t die if you don’t get them.
That, among several other reasons, makes them a more suitable commodity for market price setting than, frex, a cardio stent, or surgery radio or chemo for cancer.
I know elective means you don’t die without it, but something like lasek can make the difference between functional, able to hold a job, and not. Before I had lesek I had no effective vision in one eye. That screwed up my depth perception to the point that I could not drive safely. I could not judge distance!
This comment may seem a bit more combative than I intend it to be, so take it with the requisite amount of salt, but after the discussion about how the Heritage plan does not represent conservative values, I’m hesitant to look at any actual plan as a representative of conservative values. Conservatives complain that a system like that moves us to where the government tells people what to eat, but there are just too many ways a private company can find to cut corners. In that sense, the conservative ideal is whatever screws up the liberal plan. I mean, after reading the background, the Heritage plan was simply a proposal to try and and undercut the Clinton proposal, so it seems like a conservative proposal on health is simply one designed to undermine a liberal proposal, which is that anything that gets closer to a single-payer system.
Russell, your link to Ryan’s perfectly reasonable healthcare policy proposals from 2009 is enlightening.
Considering what has transpired since, I can only conclude that Ryan has supported the marauding, nihilistic vandals of the Tea Party to make his “absurd” (good term, I forget who suggested it here recently, but if folks like it better than “vermin-like”, I’m happy to go with the flow) dalliance with Ayn Rand appear like various deep worldly philosophers dropping their pants in Times Square and calling it a worldview, in other words a youthful mistake carried into adulthood, and maybe his staff should listen to “Sgt Pepper” instead of reading “Atlas Shrugged”.
But it also reveals that discussions about “what is conservative and what is not” are pointless in this confederate pre-1963 Dallas period of time and what really matters is the extent to which Ryan and the Republican Party hate one man and will go to any lengths to destroy his works even if it means burning down their own houses.
I say this with due respect to legitimate conservatives, disagree with them as I do.
I’d begin with “free” immunizations as an initial effort to have government-supported healthcare services that could save money.
Well, I’ve proposed that the current tax status of employer provided health insurance be extended to health insurance purchased through anybody: Personally, through a credit union or bank, the NRA or ACLU, Kroger’s, special organizations formed for the purpose.
Ideally employers would pay you in money, and not have to shop for health insurance or other benefits just to help with your taxes. And you would get your health insurance through some organization of your own choice, large enough to have negotiating power, and of the sort you didn’t have to quit if you changed jobs.
Most distortions of the health insurance market are due to this business of buying your health insurance through your employer, which is driven by tax laws. It can be fixed by tax laws, too.
Give insurers large, stable groups to insure, and they have much more motive to support preventive care, (Because they’re likely to still be insuring the person getting it when the benefits arrive.) and much less motive to cause trouble over “pre-existing conditions”, because mostly there wouldn’t be such a thing.
Expand HSAs, and don’t mandate that health insurance include things that aren’t actually insurance, and you’d solve most of the problems.
Mind, you could achieve many of these benefits by simply ending the favorable tax status for benefits. My objection to this is that it would be a massive tax increase for most people. But perhaps a one time adjustment could be arranged, to get the government entirely out of caring about what you’re spending your money on.
Brett – one question: in your scheme, how do people who cannot afford health insurance get health care?
How do people who can’t afford food get food? I notice it’s not by forcing grocery stores to give food away, and forcing people who aren’t poor to buy food at inflated prices.
Have you considered “health insurance stamps”?
Give insurers large, stable groups to insure
they already have that.
Actually the ACA exchanges could be conceived of a health insurance stamps since they provide all or part pay for insurance.
No doubt another aspect of the conservative paradise would be the middle class paying substantial subsidies through their taxes to the wealthy for various large businesses while the wealthy bitched and moaned about confiscation and tried to cut the insurance stamp funding and reduce their employees’ pay.
And you would get your health insurance through some organization of your own choice, large enough to have negotiating power, and of the sort you didn’t have to quit if you changed jobs.
I pick ‘the federal government’. ‘Citizen’ is a very large group, and would have massive bargaining power with providers. Why, we could even bypass insurance companies altogether and deal direct. This is known in some circles as “cutting out the middle man” or “buying wholesale”….sorta’ like Costco.
There are two things I agree with Brett about, and one of them is that health insurance ought not be coupled to employment. As those of us who are not tenured professors know, jobs are not permanent.
On the other hand, NOTHING is permanent, not even NRA membership necessarily. Would I want to feel captive to my membership in the ACLU “for the health insurance”?
If I decide to drop my affiliation with the club, church, or supermarket I’m buying insurance from, would the NRA or the ACLU be required to accept me as a member? Or would they be free to turn me away because of pre-existing conditions?
Note that I’m not even talking about “the poor” yet. Note also that I’m talking about the financial service called “insurance”, not the medical service called “health care”.
If health care were less expensive, the arguments over health insurance would be less bitter. The charming notion (held by Libs and Cons both) that proper jiggering of the insurance system would reduce the costs of medicine seems doubtful to me.
Whatever insurance system you adopt, the following has to be true because it is a mathematical definition: the average person, over a lifetime, must pay the average person’s lifetime medical costs. If we take it for granted that nobody is exactly “average”, then somebody must be paid to handle the money — to “redistribute” it, if you prefer.
For my part, I’d prefer the “somebody” to be Uncle Sam, rather than John Hancock or even Wayne LaPierre. My affiliation with Uncle Sam is the one affiliation I consider permanent enough to rely on. Secessionists may feel differently.
–TP
Well, first you have to set up a medical FUTURES exchange.
You know “coronary bypass january futures are up $5 in morning trading”. Doctors would book appointments by selling on the futures market, and customers would have to buy a contract for delivery on a particular date.
I imagine that the 7-month maternity contracts will be especially popular.
The only problem is that brokers will charge extra if you buy heart-transplants in “odd lots” of less than 100, but hey, that’s just the invisible hand at work.
First, a conservative would try to meet the greatest needs first, which are the chronically ill. A conservative would probably look at analogous insuring programs at state levels such as assigned risk pools and state-created insurance associations. Premiums would be kept low by requiring–as assigned risk and state-created associations now do–admitted carriers to fund up to “X” amount of the cost of treatment. Any excess over X should, for administrative ease, also be born by the admitted carriers with an offsetting 100% tax credit, i.e. actually born by the feds, but it’s easier just to give a credit and not mess with the administrative hassle.
Conservatives would be honest,hopefully, and tell people that we are not doing “all in/everything covered”. Conservatives would continue to let the private sector fund most of the private insuring costs by lauding and not complaining that employees don’t pay tax on their insurance premiums (how liberals square this with wanting to pay for the whole damn thing has always mystified me).
Conservatives would treat adults like grown ups and let them live with the consequences of their own bad decisions, whether that is buying health insurance, riding motorcycles or unprotected sex–have at it, it’s your body.
And, for those whose employers don’t/won’t carry or who are self-employed, create quasi-private groups that purchase discounts in insurance through size. Either join or not, that’s up to the citizen, but have that out there as the option for those with limited bargaining power.
Finally, the issue of pre-existing condition/otherwise un-insurable person. First, the two are not the same. For example, if you are over 40, you most likely have a pre-existing degenerative spine, hips and knees. It’s the aging process. OTOH, you can be bedridden and unable to care for yourself. Somewhere between the two extremes you have the obvious gray area that will require some degree of judgment. On one side, the default is the assigned risk pool, on the other, the default is a max added premium of X percent.
This is just off the top of my head. I imagine someone could do better if they took a bit of time to think about it, and probably with less than 1500 pages of laws and ten times that in regs and a f’ed up website.
If I decide to drop my affiliation with the club, church, or supermarket I’m buying insurance from, would the NRA or the ACLU be required to accept me as a member?
Or if your insurance provider jacks up your rates or offers horrible service and you want to change providers. Or if they decide to terminate your policy. Or if the provider folds or gets out of the insurance business.
Decoupling insurance and employment does not eliminate the possibility of needing to change providers and being denied for pre-existing conditions.
McKinneyTexas — same question: how do the poor and the pre-existing cover the cost of their insurance? I don’t really understand what an “assigned risk pool” is but from my cursory reading it suggests that a pool of known high-risk claimants has to be insured, but to what degree and by who? Presumably the premiums in these assigned risk pool cases are exorbitant…?
a dynamic that appears quite often…
A conservative health care market would look much like the ACA except a (white, male) Republican would be president.
Conservatives would continue to let the private sector fund most of the private insuring costs by lauding and not complaining that employees don’t pay tax on their insurance premiums
This is kind of meta, but we’ve had several ‘what is a real conservative’ discussions lately here. And Im struck by how often the conservatives on the board draw lines around the word that I don’t see in the world. eg
Here is a conservative advocating getting rid of that tax break bc it is “distorting the natural market for healthcare”.
Not to blame McTex, I think the question suggested there was a single “preferred conservative alternative”. Of course, I still think of the Heritage-inspired ACA as something of a ‘conservative alternative’… 🙂
Now Im wondering why we don’t see this kind of line-drawing with liberals on the board- something to do with the preponderance of liberals in most of the discussions? Something to do with the two(?) philosophies involved, or the trajectories of the two groups at this point in time?
Or maybe we do and I don’t notice it.
Not really conservative, but I’ll chip in anyway.
I’d like to agree with the sentiment upthread that employer-based isn’t the way to go. I think it artificially restricts the free market. I, for example, have health insurance through my employer (which is good on paper) but I hate my HMO. Previously, I bought insurance from Kaiser, and liked it very much. It was super easy to, say, get my HepB titers checked and get a pertussis vaccine. My current HMO, it’s a nightmare of calls and appts to get anything done. Anecdotal, and likely not representative of the nation as a whole, but I’d rather have my employer pay me more instead of taking a huge chunk of my costs (about 30% of my compensation is health insurance), be taxed at some rate, and find my own insurance.
I think exchanges are a great way to do this. I think exchanges, done well, are a good example of the government facilitating a free market. I think there can be some reasonable limits on participating in the insurance. A basic shall-issue plan at a set cost, similar to the Swiss system.
Insurance companies would then be free to offer various higher-end plans with minimal requirements. No termination of coverage without patient agreement. Noncoverage of any pre-existing conditions needs to be specifically noted at intake.
I have no objection to federally run insurance plan, as long as it is funded by premiums alone, and not general tax revenue. As long as people are free to NOT pay in (via taxes) and acquire insurance on their own. Any insurance company that can’t compete with the federal government doesn’t deserve to exist. More competition, more options are never bad.
Uninsured/underinsured poor should receive subsidies from the government to purchase insurance by the government, similar to SNAP.
I like to think, but I’m probably wrong, the free-rider problem would be largely avoided in this system. There is no ECONOMIC stop to poor people getting insurance…so I like to think the coverage would fairly high.
I think at that point, we have two options to deal with the people who are rich enough to not qualify for federal subsidy but choose not to afford insurance and the poor that for various reasons don’t acquire the subsidy (destitute, homeless, etc).
(1) Callously turn people away without proof-of-payment. I don’t think this works for a number of practical/moral reasons.
(2) Have the federal government cover their costs directly. Out of the general fund. At least we would have a good tracking of the free-rider problem. Additionally, any identified free-rider could be targeted by the IRS. If your wealthy and to irresponsible enough to not have insurance (and need it) the IRS garnishes your wages and/or seizes your property.
Anyway, my thoughts. But I’m not an expert on this so, feel free to explain why it won’t work. Speaking of work, I have to head in to it, so if I’m unresponsive, I apologize.
Work right after a response to Carlton’s excellent comment.
“Now Im wondering why we don’t see this kind of line-drawing with liberals on the board- something to do with the preponderance of liberals in most of the discussions?”
I would think yes. I live in a fairly liberal area, and while I think I’m pretty moderate, I often end up being the “conservative” in talks with my friends. And since I’m “conservative” and frequently outnumbered in this conversations, I frequently find myself getting saddled with “conservative” opinions of some Fox talking head that was on the Daily Show last night. Sometimes the easiest way around that is to say “that’s not ‘conservative’ for X reason” and move on.
It’s because of stuff like that, that I really don’t like labels, Dem vs. Rep, Lib vs Cons, etc etc. And even just in the US…are Cali conservatives the same as Montana conservatives? What about Mass liberals vs. Oregon liberals? What are the odds that two self-described Oregon liberals agree on all or most things?
They are so broad that they become meaningless. But they carry weight. A “conservative” becomes responsible for “conservative” views. A “liberal” becomes responsible for “liberal” views. I think it’s an unfortunate result of the tribal nature of humans.
I think it artificially restricts the free market.
Can I ask a stupid question?
Why is it preferable for either health insurance or health care to be acquired through a free market?
I don’t know if it is or isn’t better, there just seems to be an assumption that it *is*, and I’m curious to know where that comes from.
it’s not fundamentally different from the ACA.
So, I guess I’m confused about what the fuss is all about.
russell, the fuss over the ACA isn’t over the ACA. It’s over “Obamacare” — and specifically the first 5 letters of “Obamacare.” This is demonstrated by the fact that, if you poll about Obamacare, and about the ACA, changing absolutely nothing about what you ask other than the name, suddenly the numbers in favor go way up. (And that’s before the favorable numbers that you get when you actually talk about what is involved in the ACA.) It’s feally a tribute to a great marketting campaign.
We will continue to hear all kinds of comments about what is wrong with the ACA, especially the implementation so far. And lots about what might be done different and better And much of that will be well taken. But “all the fuss” is really not related to any of that. Just the name and the man associated with it.
Here’s one step towards a conservative health care plan. Provide information so that people are aware of how to get around the fact that an individual will get rejected for a “pre-existing condition.” All you have to do is set up a group (LLC, typically). Even if it just has members of your family as members of the group. Then, you can buy group coverage. No check for pre-existing conditions. No basis for rates beyond age and gender. And all it costs is your state’s annual license fee for registering your company/group.**
All the government has to do is make that information publicly available. No other action whatsoever. And suddenly, nobody is uninsurable.
It’s not a complete conservative solution. But it is a big step in that direction.
** Obviously, I have been down exactly this path. And it is amazing how different a group, even of just two spouses, gets treated than an individual. Simply amazing.
I received great health insurance through my wife’s (school teacher) policy at no cost to us but also a good policy from my employer. Was denied a request that my employer stop with the insurance and just pay me a little more money. So for about 15 years somebody (taxpayers?) was paying twice what I needed. Employer based heath care can be screwy.
Russell:
I don’t think that’s a stupid question. It’s an assumption on my part. I freely admit I assume free markets have advantages and serve the consumer better. I’d be willing to be convinced otherwise…but I think that’s a really hard thing to know.
I want to be clear, that doesn’t mean I think lack of regulation is always the right choice. A completely unregulated market frequently leads to monopoly. That isn’t a free market. (I know, the ideal free market doesn’t exist, grant me a little leeway on phrasing).
If I have only one option for healthcare, or anything, that option doesn’t have to optimize for my needs. If I have many options, (a) I can choose the best choice for me and (b) options that are poor for everybody will face market pressure to improve or fail.
Those are assumptions I’m making, I’ll admit. But I don’t think they are crazy ones. (a) at least I have direct experience with. If my employer gave me the money they spend on my benefits, even after taxes, I’d be able to afford a plan I prefer from Kaiser, a provider I like more than my current HMO. And have some money left over. Even in the shambles that is the US health care system, not in some ideal-libertarian-free-market-that-will-totally-reduce costs-someday.
I also assume it would have the effect of reducing costs due to these market pressures…but that’s a lot hazier.
Following wj’s comment re: information. Something that always bothered me is due to the free-rider/insurance system we have, providers don’t have a fixed price schedule.
I know they have a price schedule, because that’s how accounting works. I’d really like mandatory publishing of a provider’s price schedule. Yeah, I know it’s not simple $10K for a hernia surgery. But the breakdown in terms of meds cost this much, surgery theaters cost this much per hour, emergency surgery teams cost X much per hour, interpreting radiographs cost X much /15 min. Etc.
I was in the middle of a negotiation between a hospital (emergency appendectomy) and my insurance. Initial cost: $29K. Insurance wanted to pay 15K (I think). There was a settling ~20K and I had to foot 2K or so. Not the biggest problem in the health care field, but one I always found frustrating.
Similarly, I had friend w/o insurance who broke/sprained her ankle. Couldn’t get any information about how expensive an xray was from local hospitals. Was willing to pay but really wanted to know roughly how much it would cost (not to fix it, just get an xray). No-one would tell her. Ended up going to a free clinic. Not an efficient system.
But “all the fuss” is really not related to any of that. Just the name and the man associated with it.
Not to pick on WJ, but is this considered insightful on the left, “They don’t like ACA because it’s Obama’s program”, the subtext being, “they are all racists”?
Jesus.
Why is it preferable for either health insurance or health care to be acquired through a free market?
Because every element of healthcare, from the provider to the MRI machine to the rubber glove I’ve come to know too well has a real cost driven by unavoidable market factors and when someone imposes costs or limits prices, you get something like what you see in Venezuela if it goes far enough.
Or, because no one has found out yet how to consistently deliver an infinite stream of acceptable quality goods and services for less than the cost of said goods and services.
You can artificially hold down prices for a time, or you can subsidize goods/services, but it can’t last–people are involved and they want to be paid. Manufacturers, new product and drug inventors, they want their efforts rewarded. Doctors, they want some return on the time they spent in school and the difficulty of the work they do. Eliminate risk/greater reward or deferred gratification/greater reward and they will pursue other paths. Not next year or the year after, but in the long run.
“They don’t like ACA because it’s Obama’s program”, the subtext being, “they are all racists”?
that subtext might be all up in your imagination. i certainly didn’t see anything in wj’s post to suggest it. and polling says that he’s right. “ACA” polls better than “Obamacare”:
unskew that poll.
Eliminate risk/greater reward or deferred gratification/greater reward and they will pursue other paths. Not next year or the year after, but in the long run.
fnck em. relax the onerous immigrant doctor requirements and let the market run. there are thousands of doctors from other countries who would be happy to take the place of all those Galtian brats.
McKinney,
The question was about “either health insurance or health care”. Health insurance is a financial service. How much more innovation can we stand in financial services? How do private-sector health insurance companies, innovating all over the place, motivate “manufacturers, new product and drug inventors”, etc, thus keeping us from becoming Venezuela?
–TP
Tony:
Those things aren’t always separate. HMOs, for example, are involved both in the financing and the execution of health care. Kaiser Permanente has been held as an example of how to reduce costs due to better managed care (http://www.nytimes.com/2004/10/31/business/yourmoney/31hmo.html?_r=0).
Of course, that’s not “new drugs” but a lot of things go into improving patient care and reducing costs.
Not exactly what you were talking about, but maybe related. Or maybe completely unrelated. shrug.
Thanks, cleek.
McTex, No doubt some people do hate Obama because they are racists. Equally without doubt, some people simply hate Obama for reasons unrelated to race.
But when “Obamacare” gets signifcantly worse polling than “ACA,” with zero other information offered about what either consists of, it is hard to argue convincingly that this isn’t about Obama.
But when “Obamacare” gets signifcantly worse polling than “ACA,” with zero other information offered about what either consists of, it is hard to argue convincingly that this isn’t about Obama.
You are assuming that everyone knows that ACA = Obamacare. ACA is widely known as Obamacare. It is not so widely known as ACA. That’s how I unskew that poll.
How do private-sector health insurance companies, innovating all over the place, motivate “manufacturers, new product and drug inventors”, etc, thus keeping us from becoming Venezuela?
We can be well above Venezuela and still have a much crappier system than we currently do. But, to answer the question: health insurance companies negotiate fee contracts with provider groups that fix costs for a stated period–by agreement, not by fiat–that in turn permits better actuarial and thus better pricing analysis by the insurer.
fnck em. relax the onerous immigrant doctor requirements and let the market run. there are thousands of doctors from other countries who would be happy to take the place of all those Galtian brats.
As long as you, the Congress, the Senate and the President are required to use exclusively those overseas trained and licensed physicians, fine. I like the much higher end, US trained physicians. Particularly board certified specialists. So, thanks, but I’ll pay more for domestically trained docs.
Not to pick on WJ, but is this considered insightful on the left
Not to pick on you, but if I’m not mistaken, wj is a self identified small c conservative who feels the Republican party has left him. I realize that the whole conversation about racism and conservatism is fraught, but trying to put it in a drawer labeled ‘left’ is not going to make it disappear.
McKinney: Finally, the issue of pre-existing condition/otherwise un-insurable person. First, the two are not the same. For example, if you are over 40, you most likely have a pre-existing degenerative spine, hips and knees. It’s the aging process. OTOH, you can be bedridden and unable to care for yourself. Somewhere between the two extremes you have the obvious gray area that will require some degree of judgment. On one side, the default is the assigned risk pool, on the other, the default is a max added premium of X percent.
I don’t understand what your solution is here, McKinney. The fact is that over 80% of people support non-denial of coverage for people with pre-existing conditions. That has to be paid for with more than philosophizing about “the two extremes”. There are people all over the actuarial map with pre-existing conditions. That’s the whole point of the mandate, etc.
And I still don’t get your obsession with legislation that consists of a lot of pages. If you work with the legislative system at all (state and federal), you know that those kinds of acts exist in every legislative session.
You are assuming that everyone knows that ACA = Obamacare.
Actually, I’m assuming exactly the opposite. People have a negative opinion of Obamacare, without really knowing anything about it. And they have a less negative opinion of the ACA, not because they know more about it, but just because it doesn’t have Obama’s name attached.
And I unskew the fact that views are even more positive when people discover what the ACA/Obamacare actually includes this way. The things that they think that they hate about it are things which simply are not true. In short, there has been some great (negative) marketing done here. But trying to say that people hate what the ACA actually includes will only work by ignoring reality.
LJ, I take some amusement at McTex (or anyone else) assuming I’m on the left. I suppose I should introduce them to some of the folks I know who really are on the left. (Although I suppose it says something that their reaction when I point out that I’m a conservative has been “Oh, but you’re a tolerant conservative!” Like that’s almost a contradiction in terms.)
Not to pick on WJ, but is this considered insightful on the left, “They don’t like ACA because it’s Obama’s program”, the subtext being, “they are all racists”?
Not to pick on McTex, but is it considered insightful on the right to invoke racism and then claim that the other guy is playing the race card?
when someone imposes costs or limits prices, you get something like what you see in Venezuela if it goes far enough
Let’s observe that a defender of free market versus government intervention in healtcare probably does not want to go offshore looking for examples. It’s a bad precedent for your position. Yes, there are some &$^#ed up countries that have &$*#ed up economies. And then there’s basically every other advanced industrialized country in the world, providing excellent healthcare at much lower rates than we do.
Shorter: let’s not go that far, let’s just go far enough to get a healthcare system like Germany or Sweden or France…
Or, because no one has found out yet how to consistently deliver an infinite stream of acceptable quality goods and services for less than the cost of said goods and services.
However, we have found a way to deliver those goods and services at a much higher cost than other countries. This is called “market failure”.
btw, not sure why the stream has to be ‘infinite’, even a finite set of goods and services has a cost. I think you’re getting overexcited.
You are assuming that everyone knows that ACA = Obamacare.
I am not sure how to logically process this- if we assume this is true, then there is no reason for the poll numbers to diverge. Right?
McTx: “… health insurance companies negotiate fee contracts with provider groups that fix costs for a stated period–by agreement, not by fiat–that in turn permits better actuarial and thus better pricing analysis by the insurer.”
“Better pricing analysis” means what, exactly?
Do insurance companies compete with each other by negotiating LOWER prices with doctors and hospitals? Or HIGHER ones? And which of those leads to more new drugs, better devices, or smarter techniques? And how?
–TP
I don’t assume that the discrepancy between those who like the ACA but dislike Obamacare is caused by racism. It’s caused by people being exposed to dishonest Republican sources that tell them lies about death panels, socialism and “big government” misusing their private information.
In other words, the individuals who are scared by the lies, like the exchanges, like access to insurance for people with pre-existing conditions, and like people being able to keep their students on insurance through college.
Remember the article about Kentuckycare that was posted here a while back? That same phenomenon is happening all over, which is exactly why the Republicans in Congress did the government shut down.
In another five years so Obamacare will be established and popular. That’s the big threat.
I like the much higher end, US trained physicians.
Pure 100% crap. An untruth. A lie. US physicians are a classic guild that, under any other circumstance, McKinney would be howling and flinging poo against the walls for “restricting the supply of labor” (cf. hatred of unions). If McKinney truly believed in a ‘free market’ he would promote policies to allow any qualified foreign doctor to practice in the US—-or would allow US citizens to participate in other countries health care plans. Free trade, right? Liberty!!!!
They support restricting the power of the largest buyer of medical services to negotiate prices with the private sector (Bush Medicare drug benefit), a clear violation of free market principles.
Tex, and his conservative brethren, do not advocate remedies for these clear violations of their professed free market ideals. They support their constituencies collecting economic rents. They assert the guild setup of the AMA is just dandy. They like restricting free trade in medical care. They support granting infinite patents (a government granted monopoly) for minimal innovation. They like insurance companies skimming dollars off the top of the healthcare market so they, not the government, can be ‘death panels’ and allocate scarce resources in such a manner as to satisfy the insatiable greed of their shareholders vs. satisfying the needs of We The People.
THEY LOVE SUCKING OFF THE HATED GOVERNMENT TEAT.
They are shameless in their greed. They know what they want. They want f#cking everything.
I don’t think McTex is a greedy person. I think he’s a bit doctrinaire (but so are most people) and it’s a doctrine that tends to reward greed, but I don’t think that’s the as being personally greedy.
Laura,
I agree. I have not idea how greedy Tex is. But he does play golf…. 😉
However when it comes to labor markets, many conservatives and their glibertarian brethren vehemently assert that “if you don’t like the job, go get another one.”
They throw this line in the face of collective bargaining supporters always. They call this “Liberty!”. They tend to get rather red faced an angry about it.
Yet, when it comes to doctors, why, suddenly everything changes….these poor, poor creatures. Why, if Medicare keeps squeezing them, they will simply close up shop and go away…then what will we do? Pity those poor physicians.
They never said this about good factory jobs. Never.
The convenient disregard of their espoused free market principles when it suits their political interests is well neigh total.
Lit up as I am on the evil bourbon, I’m also pretty god damned tired reading stupid tirades about ‘Obamacare’ being 1,500 pages long.
Do you know how long the Defense Appropriations Act of 2013 (H.R. 4310) is, Tex? It’s 681 ‘effing pages long, and it doesn’t change a whole lot of policy…just allocates dough.
I’m sure every GOP Congresscritter has read each and every page, right?
Christ on a stick. Give it a #$#$@%ing break already.
McKinney: Doctors, they want some return on the time they spent in school and the difficulty of the work they do.
It should be noted that this claim is essentially a classic regurgitation of Marx’s Labor Theory of Value, a concept that has been fairly well demolished by the legion of Marx’s critics.
Damned communists!
Damned communists!
Indeed. It’s fun to imagine this quote with other professions:
School teachers, they want some return on the time they spent in school and the difficulty of the work they do.
Social workers, they want some return on the time they spent in school and the difficulty of the work they do.
Community organizers, they want some return on the time they spent in school and the difficulty of the work they do.
Nurses, they want some return on the time they spent in school and the difficulty of the work they do.
no one has found out yet how to consistently deliver an infinite stream of acceptable quality goods and services for less than the cost of said goods and services.
That’s true, but it doesn’t answer who pays and how.
It also assumes that what we have now delivers the desirables for the lowest reasonable price, which I think is not in evidence.
Eliminate risk/greater reward or deferred gratification/greater reward and they will pursue other paths. Not next year or the year after, but in the long run.
Not everyone in the world is motivated exclusively by return on investment.
Look, here is a very short, off-the-top-of-my-head list of things that are delivered to me, and to most or nearly all of us, through channels where price-setting is not done exclusively, or even mostly, by market forces.
Gas (natural gas to the house, not gasoline)
Electricity
Water
Auto insurance
And yet, all of the people involved in getting all of those things to me make a living.
So, I’m puzzled as to why goods and services related to health care can only be provided via a ‘free market’.
And the quotes are intentional, because quite a number of the goods and services that make up a health care market basket aren’t really a good fit for market-based price setting.
It might be the case that market forces, allowed to operate without intervention, will provide something like (a) concierge medicine and (b) the ER.
Would that be an acceptable outcome?
If not, than do all of us who (a) can’t afford concierge medicine and (b) would prefer to not go to the ER every time we have the flu get a voice in things?
I think it is a definite indication of greed that corporations like Walmart expect the taxpayers to help pay their employees via Food Stamps. And I think it is a definite sigh of self-induced stupidity though excessive doctrinaire thinking that some many people on the political right are knee-jerk hypersensitive about some slob who doesn’t deserve Food Stamps, but unsupportive of labor unions that fight for a living wage and tolerant of corporations that suck up more in undeserved subsidies than any welfare recipient ever dreamed of. One of the reasons I never finished medical assistant school was my discovery that many med assists don’t have health insurance!
But on the subject of keeping the doctor’s money in his/her pocket: single payer is the way to go for that. With a single payer system the doctor could layoff the med assists who spend their days bird-dogging insurance claims. Do you all have any idea how long it takes doctors to collect? And how much they have to write off because of insurance carriers deliberately lallygag on payment, hoping the doctor’s office will give up on collection?
I took a whole class in bill collecting for doctors. Insurance companies hate to pay their bills, except for Medicare and Medicaid.
So single payer, easier more efficient bill collecting, less staff, more money for the doctor. How about that as a conservative idea?
The full text of the ACA. I don’t know how I found the thing, secret as it is. Be the first to read it:
http://www.hhs.gov/healthcare/rights/law/
If Lincoln were a boy, he’d be sitting against a stump in a meadow reading it to prep for Civil War and his surround-sound theater-going experiences:
The full text of Obamacare:
http://www.hhs.gov/healthcare/rights/law/
Ha ha! Both the same, but which one did y’all click on?
Anyway, for those whose Food Stamps have been cut to 88 cents per meal by the literal bean counters, the full text of the law, eaten at a rate of two pages per day, will supply one’s daily requirement of roughage and residual sausage scraps.
The savings for the food stamp recipient, over time, will permit purchase of a rice cooker, at which point Paul Ryan will find a passage in “Atlas Shrugged” warning darkly and verbosely of efforts to get around bean-counting for the poor by substituting rice.
Just noodling (another substitute starch) around: here’s something about the historical rates of doctors per capita in the United States going back through the last century:
http://www.washingtonpost.com/blogs/wonkblog/post/we-have-more-doctors-per-capita-than-ever-before/2011/12/16/gIQAKIfByO_blog.html
The up slope in doctors per capita, after declining for decades looks like it started in the early 1960s and has gone on since. Let me see, what happened in the 1960s that could have had something to do with that?
You’d think the AMA would have sent out a memo at the time suggesting different career paths for would-be doctors. Come to think of it, they did.
Now, of course the geographic distribution of doctors is out of kilter now, and we seem to have a shortage of GPs and a surfeit of specialists — I have a separate doctor for each finger, two audiologists (one for either ear), and an entire committee of specialists whose only job seems to me to be to tell me “No” when I request an MRI.
I insure with Kaiser and have for 35 years. I’m completely happy with it — but I’ve been healthy pretty much, with the exception of knee surgery over the years.
Laura wrote:
“Insurance companies hate to pay their bills, except for Medicare and Medicaid.”
I have a feeling the exception of the two M’s here is considered a flaw/bug by conservative thinking, not a feature.
In fact, the current dysfunction of the ACA federal website (which will be fixed, just as the trot out of Medicare Part whatever under the Bush Administration went so unswimmingly that John Boehner himself had to stand a microphone at the time and give reporters a pep talk about how the kinks would be ironed out) is viewed with barely disguised glee by Republican members of Congress and they are wondering how they can import the crash feature into other Federal and State websites, like medicare, SS, unemployment insurance, food stamps, and agricultural subsidies (except for their brothers’-in-law)
Russell mentioned:
“will provide something like (a) concierge medicine and (b) the ER.”
If I was poor (I am by some standards) and had to go to the hospital emergency room for my care, I think while I was biding my time reading the March 2007 issue of
Medicare Capitation Weekly (the Enema Issue), and if were ambulatory, which I must be because I would walk there to save money, I’d stand near the door with my cap in hand and show folks to their gurneys and fluff their pillows for them concierge-style, and hope for tips.
Laura also wrote:
“I think it is a definite indication of greed that corporations like Walmart expect the taxpayers to help pay their employees via Food Stamps.”
What you do is have a connection on the loading dock and skim needed food items, or shoplift. To stay under the 88 cents per meal Food Stamp allowance for propriety’s sake, I’d stick with oatmeal, eggs, and the ramen substitute with edible packaging.
Leave work with a fake limp.
A “conservative” healthcare market would be promoted on FoxNews and the Wall Street Journal.
That’s it. The ACA is a fundamentally conservative approach to health care reform, because it relies so much on private insurance companies. Obamacare was basically developed by conservatives, it was their baby.
But conservatives (really “conservatives, these days — most are much more reactionary than conservatives) are owned by the Republican Party, and the Republican Party is owned by FoxNews. FoxNews doesn’t want policy agreements and negotiations, because they make for bad TV. FoxNews wants the fire of battle, stalwart opposition and heroic fights, failure is not an option! — Because that makes for exciting TV.
FoxNews’ ratings (and profits) have never been higher. You have always been at war with Obamacare.
“because it relies so much on private insurance companies.”
In the sense of the government treating them like finger puppets, instead of shutting them down, anyway. Dictating the exact details of what they must sell, to who, for how much.
The DMV is almost as “private” as health insurance companies are under the ACA.
Dictating the exact details of what they must sell, to who, for how much.
Seriously, Brett:
The ACA sets prices on health insurance policies? Really?? Cite please.
The ACA does require insurance companies to sell a policy to anyone who’s willing to pay their premiums. They don’t get to turn you down because you had cancer or a bad back or a hangnail. But it also gives them millions of new customers.
The ACA dictates a minimum level of coverage, not “the exact details of what they must sell”. You talk as if requiring cars to have seat belts and brake lights is the same thing as designing auto makers’ cars for them.
Try harder next time.
–TP
“The DMV is almost as “private” as health insurance companies are under the ACA.”
And the DMV works.
Everyone in the country who wants and tests (meaning just about everyone) for a driver’s license and tags has both.
The websites work well too and conveniently, as will the ACA’s, unless the give-up caucus shoves a spaniel in the works, the worms.
This resort to comparing all government programs ad nauseum to the DMV is a tired conservative oasis with a dry waterhole.
Move your humpless camels on to wind and solar power. Oh, yeah, those work too, in their niche.
The only times is my state that the DMV falls down on the job is during republican administrations when they cut the DMV’s budget and staff to prove some verminous, scum point that a starved government doesn’t work, the filth.
And, no, I don’t need a Starbucks or ESPN on the cable feed or fries at my DMV.
Read a book, whiners.
BTW the exchanges are working fine in my Democratic state.
I’m seriously worried about the effect that over heated Republican lies have had on some people, though. One of my Facebook friends posted a pic of a grave stone with dates and the slogan “United States Killed by Obama”. She followed that with a pic of a quote about the necessity of fighting back (the quote meant literally fighting) when an evil is being done that necessitates a violent response. My Facebook friend isn’t going to shoot anyone or blow anyone up, but she has male relatives that could go that far.
The lies from the Republican party are beyond irresponsible. It’s one thing to discuss a policy as a policy and to disagree even strongly. It’s something else altogether to engage in the-end-of-America type of rhetoric. And that kind of rhetoric has been typical of Republican politicians for years now on Obamacare and other issues. This is why I don’t have much respect for the party leadership or its politicians. Bunch of nasty dishonest irresponsible rabble-rousers.
“The ACA sets prices on health insurance policies? Really?? Cite please.”
Sure. First, by having price controls at the level of the exchanges, and secondly, by mandating that prices not increase more than three fold between ages.
Obamacare And Price Controls
Brett, I can read your Jan 2011 Forbes article, but I can’t read your mind.
WTF are you talking about?
–TP
I can’t get through the link to the article,
Apparently you can’t read my second paragraph, either.
Obamacare sets prices in two ways: First, if they don’t like your prices you can get kicked off the exchange, and getting your insurance no longer averts a fine. It’s not so much that that the prices aren’t controlled, as that they aren’t explicitly controlled. The Forbes link went into this.
Second, they have set a limit on the price differential between policies. You can read about THAT here.
I assume you’re already familiar with the mandate to take people with existing conditions, and the controls over what will be actually covered, since you didn’t take exception to that.
So, who you have to sell to is controlled.
Who must buy from you is controlled.
The price you can charge is controlled.
The product you must sell is controlled.
This isn’t keeping a market. It’s turning insurance companies into the government’s finger puppets. It’s pretending to keep a market, it’s a ‘market’ consisting of companies which have had all their important decisions made for them.
That is nothing that a conservative would recognize as “relying on private companies”. Its closer to taking over private companies, its one step short of nationalization.
I don’t buy your theory that the exchanges are one step short of nationalization (seems like a way, way, overstatement), but if we pretend for a moment that they are–so what? This is my sticking point. I don’t get how people can assume that some idea in their head is a Divinely Inspired Objective Truth That is so Indisputably True That it Must be the Basis of Policy.
Doctrinaire thinking isn’t thinking. It’s believing. Faith-based, like a religion.
Granted everyone starts from their assumptions. My assumption is that the government does have a responsibility to make up the gap between those who are trying to help themselves and what is realistically achievable by that person. I don’t believe that a working person should be forced to go without insurance due to not being able to afford it. It’s a pretty widespread religiously-based assumption that we are supposed to give a shit about each other and not live like piranhas fighting over a piece of meat. Or be indifferent. My assumption is that we are a “we”, not a bunch of separate individuals who all live in one nation, divided, with liberty and justice only for those who are winners in the Social Darwinist competition.
So I definitely have assumptions.
But I’m open to all kinds of ways to achieve the goal of affordable insurance. To me, the issue is how to do it most efficiently and practically and fairly, within the framework of the Constitution, of course.
But the response I read or hear from the rightwing (the responses that aren’t mere mouth-frothing such as one hears from Cruz) is the recitation of doctrine. It has to be done this way because of a doctrine or it can’t be done at all because of a doctrine.
That’s a much narrower way of thinking about the problem of unaffordable insurance. It’s not a way of thinking that precludes the acknowledgment of the problem, but it is one that in the minds of some people precludes any solution at all, or precludes any solution that doesn’t fit within the doctrine. So it’s a narrower way of thinking.
The doctrine dictates the choices. Practicality is subordinate to doctrine. The doctrine is treated like something immutable that exists outside of human experience or belief, independent of cultural values which change over time.
This thread is supposed to be about a conservative approach and I’m getting the impression that that IS the conservative approach: recite the doctrine. It doesn’t matter if the doctrine works when applied to the real world or not. It doesn’t matter if a non-doctrine approach solves the problem–if the solution is non-doctrine, then the solution is wrong!
Who must buy from you is controlled.
The price you can charge is controlled.
The product you must sell is controlled.
The crocodiles cry.
The standard issue conservative response is this: Nobody forced you into the insurance game. Take that capital and invest it elsewhere. Don’t let the door hit you in the ass on the way out.
This isn’t keeping a market. It’s turning insurance companies into the government’s finger puppets. It’s pretending to keep a market, it’s a ‘market’ consisting of companies which have had all their important decisions made for them.
And yet, the private companies will be cashing the checks and making money.
That is nothing that a conservative would recognize as “relying on private companies”. Its closer to taking over private companies, its one step short of nationalization.
Disagree on the “nationalization” part, I would say it is many steps short of nationalization.
“Nationalization” means the public OWNS it, which means when the checks get cashed, the money flows to public coffers.
What is true here, and where I think we sort of agree, is that this is not a market, in the economic sense of the word.
We are, by law, delivering a big crop of new consumers to the insurance companies. We are placing requirements on what they sell, and imposing boundaries on what they can charge. We are imposing requirements on who they can NOT sell to.
In short, we are regulating almost every aspect of the private transaction between the buyer and seller of health insurance.
Which moves health insurance, and probably some aspects of health care delivery, further into the category of goods and services that are seen as being sufficiently important that we prefer to not rely on an unregulated market to make them available.
That category includes (in most places) things like water, natural gas, electricity. In some places it also includes things like trash collection and transportation.
What most of these things have in common besides being pretty much essential is that they are not particularly good matches for being delivered via purely market forces. The things that are essential for an efficient market don’t apply to them. Either the capital costs present a very high barrier to entry, or the infrastructure required makes them naturally monopolistic, or some other inherent aspect of the good or service makes them poor candidates for provisioning via unregulated markets.
There are lots of things like that, most of them aren’t essential, so we sort of leave them alone. Others are more essential, so we tend to intervene at the public level.
There are some essential things – food for instance – that ARE by nature good candidates for delivery via unregulated markets, so there is less public intervention.
What I observe in the health insurance market leading up to the ACA is that, in an environment where everyone over 65, everyone who is truly poor, everyone in the military – in short, many of the highest risk demographics – were handled completely on the public dime, private insurers were unable to deliver an insurance product AT ALL to about 15% of the population, and only a limited product to lots of other folks, and still found it necessary to engage in crap like recission and refusal to issue to people with pre-existing conditions.
Maybe that’s because what we had leading up to the ACA was already so bollixed up with regulations that it screwed up what would have been a perfectly acceptable private market. I can’t tell you, because absent traveling down some alternative-universe wormhole, there’s no way to know.
It’s speculation.
What is obvious is that, in fact, the private market under the existing regulatory scheme DID NOT deliver the goods.
I am not a conservative, or really a doctrinaire anything at all, so it does not bother me at all for the public sector to intervene in order to make important things happen. I’m absolutely fine if the necessary thing happens without public intervention, but I have no problem with public intervention if not.
But I can see why conservatives object to the ACA, because the conservative position is generally that regulations on private commercial transactions are an infringement on freedom.
But what I’m not seeing in any of the conservative proposals in this thread or anywhere is an explanation of how an unregulated market in health insurance and / or health care goods and services address the existing failure of the private sector to actually deliver the goods.
The reply tends to be that if an unregulated market doesn’t make it happen, then it shouldn’t happen. And I find that answer unacceptable.
Sorry for the rambling reply. It just seems like the answers on offer to the question of “what does a conservative health care system look like” seem to describe a system that is congenial to conservative preferences, as opposed to a system that ADDRESSES THE SALIENT PROBLEM.
Can anyone describe a proposal that is both congenial to conservative preferences, and gets us to affordable near-universal coverage?
Because IMO if it doesn’t get us there, it’s not a solution.
I don’t see access to health care as being like buying a car, I see it as more like access to water or electricity. Perhaps the disagreement is at that point.
in an environment where everyone over 65, everyone who is truly poor, everyone in the military – in short, many of the highest risk demographics – were handled completely on the public dime, private insurers were unable to deliver an insurance product AT ALL to about 15% of the population, and only a limited product to lots of other folks, and still found it necessary to engage in crap like recission and refusal to issue to people with pre-existing conditions.
Just to expand on my already over-long comment:
The reason for the above – the reason that the private offerings were not getting the job done – is that the COST OF HEALTH CARE is, and has been, rising faster than inflation.
Not the cost of the insurance, the cost of the actual goods and services.
If that trend continues, it doesn’t matter who is paying for what, or how, or under what regulatory scheme if any.
Health care will become unaffordable for many if not most people. It’ll be concierge medicine, and the ER.
This single item is also the biggest threat to the ongoing solvency of the US, period. The real difficulty in controlling spending is in the so-called entitlements, and the the problem child in entitlements is health care.
If there is a conservative plan that addresses the increase in the cost of health care, plain and simple, that would be of interest. To me, anyway.
The insurance stuff is kind of a sideshow, it seems to me, other than the degree to which the insurance regime is driving costs up.
i believe that the conservative response to the problem of ever-increasing health care cost is that markets cannot fail, but they can be crippled by outside forces. and in this case, if the govt simply removed all regulations in and around health care and insurance, the market would be free to work as it should.
oh sure, that would require getting rid of Medicare, Medicaid, the VA, all safety and pricing regulations. if would also require (but they’ll never admit it) getting rid of limits on malpractice lawsuits.
but, once the market was unfettered, a thousand ponies would bloom.
go ahead, conservatives, have all your candidates propose that.
Brett: That is nothing that a conservative would recognize as “relying on private companies”. Its closer to taking over private companies, its one step short of nationalization.
Not to change the subject to a horse that’s been beaten before, but the term “private companies,” if Brett is referring to incorporated entities, is an oxymoron. Corporations exist because of government. They are protected because of government. Unless they’re willing to assume the risks of private partnerships, it should be a given they need to act under the terms that government requires.
The concept of “privatization” needs to be reevaluated. The financial reward system of our economy isn’t so simple as “private” versus “public.”
Unless they’re willing to assume the risks of private partnerships
Even private partnerships are enmeshed in public laws and policies, and are able to exist because of them.
Who you take to the prom and who you invite to dinner on Thursday are private matters.
Commercial transactions, especially anything involving a contract or other formal agreement at all, are not private. The government may not be a direct party to them, but they are not private.
Nor have commercial transactions been immune to regulation by the public sector, ever, in the US. Nor in the various colonial era governments that preceded the US.
Nor in any other government I can think of, of any kind or flavor, ever.
Just to set the context.
Who must buy from you is controlled.
The price you can charge is controlled.
The product you must sell is controlled.
Let’s see. If, for example, you are a seatbelt manufacturer, every auto maker is required to buy from you. If you sell almost anything, you are forbidden to collude with others who sell the same thing to set the price. If you sell food, the product you sell is required not to contain poisons.
Oh yes, and if you own a lunch counter, you are required not to discriminate in who you sell to based on race, religion, etc.
Now Brett may be a purist libertatian, who thinks all of those are also intolerable infringements on freedom. But let’s be clear that the same sorts of infringement occur everywhere in our economy, in one degree or another. Nothing particularly novel here in the ACA. So why the exceptional hysteria over this one? Really curious.
Russell:
“It’s speculation. What is obvious is that, in fact, the private market under the existing regulatory scheme DID NOT deliver the goods.”
Sure. The question I guess was the regulation getting in the way, not getting in the way? A mix of both? I think the question isn’t where we are, it’s how we get out.
“The reply tends to be that if an unregulated market doesn’t make it happen, then it shouldn’t happen. And I find that answer unacceptable.”
I could have missed it, but I don’t think any conservative on this thread has taken that position? I think there is a lot of faith in unregulated markets, perhaps too much, but I can’t find a reference to, if loosening regulations on the market don’t work, then throw up our hands and despair. Maybe they did.
“describe a system that is congenial to conservative preferences, as opposed to a system that ADDRESSES THE SALIENT PROBLEM.”
I think the system I described would work. I would guess both McK and Brett feel their suggestions are valuable. And there’s been discussion about the problems, which is good. But for myself at least (maybe not “conservative”), things that are “congenial” to my “preferences” are that way because I think they would work.
So let’s talk about the salient problem, which you expanded upon in your next post. The cost of healthcare. Which the ACA does what for, exactly? http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/115xx/doc11544/presentation5-26-10.pdf. You also mention medicare/medicaid as working (and it certainly provides care) but the cost is continuing to increase (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/proj2010.pdf). We all recognize the problem. If we don’t get a handle on healthcare costs, we will cripple the economy.
Now, this doesn’t mean the ACA is bad. Not solving all problems isn’t the same solving no problems. And the ACA at least according to the CBO, does help. Just not very much, and not enough to put us on a sustainable path. And there have been a few criticisms of the CBO analysis…I’m sure you can dig some up if you want to. But it’s a good starting point I think.
I don’t think Ds or Rs are sitting on a magic bullet, here. Rs, bluntly, haven’t really brought much to the table. Healthcare cost control is going to be a crippling problem for our nation unless something changes. And right now, I don’t think anybody has hard data (or at least I can’t find any) on a solution.
I like competition. I think it breeds innovation. I think innovation is what we need. I think examples of this, even in the crappy market we have now, are places like Kaiser, which invests in preventive care and research. And this can keep costs down. Old article in the BMJ but I think still relevant (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC286244/).
I would also note, on the flip side, much of Kaiser’s research funding comes from competitive grants from federal sources such as the NIH. I can’t find a source for exactly how much, though. I support competitive government grants for research, which probably makes me a communist.
wj:
“But let’s be clear that the same sorts of infringement occur everywhere in our economy, in one degree or another. Nothing particularly novel here in the ACA. So why the exceptional hysteria over this one? Really curious.”
As someone who doesn’t really like the ACA and thinks there are any number of reasons to change it…I think the answer is pretty clearly politics. Political point-scoring. Politically, I think the republicans have had any number of times to propose meaningful changes to the law…or propose a better one. And they haven’t. They’ve voted to defund it dozens of times. As far as I can tell, none of those included a comprehensive package to replace it. To me, it’s pure uncut black tar gamesmanship (everything I know about drugs I learned from tv!).
Hysteria helps them fundraise. For the moment. Those winds are changing. http://www.bloomberg.com/news/2013-10-18/republican-civil-war-erupts-business-groups-v-tea-party.html
You know it’s politics. I know it’s politics. But the question in my mind was whether those who are objecting so vigorously would acknowledge that it was politics. Ot, if not (which I thought likely), what their alternate rationale would be.
Sorry! Didn’t realize I was getting in the middle of your quest for truth and approximations thereof.
Just not very much, and not enough to put us on a sustainable path.
There is absolutely no evidence for this assertion beyond simple linear extrapolations of the past into the somewhat distant future.
As they say in the investment game, past performance is no guarantee of future results. Also please see the absolutely dismal CBO record of forecasting the bankruptcy of the Social Security disability fund. Kinda’ leads one to believe that anything they put out is pure unadulterated BS.
Furthermore, the rate of increase in underlying health care costs seems to have slowed down significantly….now why is that?
I could have missed it, but I don’t think any conservative on this thread has taken that position?
not on this thread, but for example here.
Even private partnerships are enmeshed in public laws and policies, and are able to exist because of them.
Well, I’m not sure about “able to exist because of them”. In a Libertarian Paradise, I might be able to freely gamble on people’s health (which is what the insurance healthcare market is doing, in a highly regulated way). In a Libertarian Paradise, I would not be able to set up an Anthem Healthkeepers, which is highly regulated, but also highly protected.
In any case, i agree. In the United States, because of its Constitution (and therefore the Commerce Clause, the dedication to equality under the law, to due process, to protection of property, etc.) there are a whole lot of reasons that the “State” is involved with “private” conduct.
But corporations aren’t private. They, as of their birthdays, just aren’t. So Brett’s discussion of a “private healthcare market” is lunacy if it has anything to do with corporations.
“There is absolutely no evidence for this assertion beyond simple linear extrapolations of the past into the somewhat distant future.”
And I’m assuming you have better evidence that you’re willing to share?
“Furthermore, the rate of increase in underlying health care costs seems to have slowed down significantly….now why is that?”
But the rate of increase is still positive (i.e. growing). Why? I don’t know. Some people have attributed to structural changes from the ACA, the downturn, and a number of other things. Since I can’t read your mind, perhaps you’d like to share what you think it is, and why?
thompson: If we don’t get a handle on healthcare costs, we will cripple the economy.
This kind of talk is bad for my health. It makes me pull out my hair and throw things.
So, thompson: The Economy includes the “health care sector”. What Americans spend on “health care” is not sent to Mars. It is income to other Americans — just as what Americans spend on “litigation”, or “entertainment”, or “software” is income to other Americans. The “software industry” grows when Americans spend more money buying software. The “health care industry” grows when Americans spend more money buying “health care”. The thing we call The Economy grows when Americans spend more money, period. When The Economy grows, people have more money to spend.
The only way your concern makes sense is this: if The Economy can only be a certain size because Americans only have a certain amount to spend, then all other industries must shrink in order for the “health care industry” to grow.
But you have to accept that “if”. Do you?
If you do, ask yourself this: when cellphones became available, did The Economy shrink because Americans shifted some of their spending away from, say, food? Or did The Economy grow because Americans had something new to spend their money on, and something new to do for an income? Now ask yourself if there’s any similarity between cellphones and pacemakers or hip replacements or MRI scans or cancer cures or even boner pills.
–TP
russell:
“in this thread or anywhere”
Sorry, I really should read more carefully. I have seen that video before, but I appreciate the link.
But the rate of increase is still positive (i.e. growing).
The rate of increase in many things is positive, population, GNP…just to name two. But for some reason many righties and so-called centerists are very selective as to which ones are “unsustainable”.
To make the case for “unsustainability” you will have to do better.
And what Tony P. said.
“This kind of talk is bad for my health. It makes me pull out my hair and throw things.”
Well, we certainly don’t want that. It sounds painful, for you and those around you. I apologize, this concept of rising healthcare costs not being a problem is new to me, and my brief googling hasn’t point me towards any enlightening literature. As long as you’re throwing things, could you throw some in my general direction?
Because from the president on down, containing costs has been a talking point and an objective for both the left and the right. Russell even said it would be a problem for the solvency of the US upthread (parapharse, sorry if I’m mischaracterizing your statement, russell). If an insolvent US isn’t a problem for the US economy, crap, I got nothing to say.
By the way, unsustainable isn’t my word, it’s Doug Elmendorf’s and the CBO’s. Which bobbyp doesn’t like, but honestly, I kinda have to go with the team of economists, unless you have some contradicting analysis by another team of professionals?
Re-reading my comment, I’m worried it might come off as a little glib. I apologize if so, and I want to reiterate that I am serious about any analysis you can point me to about the growth of healthcare costs not being a problem. Seriously, it’s not a concept I’ve come across before and I can’t find anything on the net about it.
Growing healthcare spending and growing healthcare cost are not necessarily the same thing.
I did not claim that increasing health care costs was not a problem. I merely point out that assuming that health care costs will continue to grow faster than the economy over the infinite future is meaningless. Throwing in terms such as “unsustainable” is just the cherry on top.
What is driving these costs is a dysfunctional private healthcare sector abetted by some ineffectual public policies. Here is an article with a lot of click through links that could be the basis of a meaningful conversation: http://www.washingtonpost.com/blogs/plum-line/wp/2013/10/21/washington-is-still-stuck-in-the-wrong-conversation/
See also Dean Baker on this topic.
CharlesWT has it right: the cost of health related services does not equal the price for health-related outcomes. Based on comparisons with other national economies, the actual cost for the health outcomes Americans obtain comes to about half the total health services outlay in the United States. As American conservatives remind me sometimes, Americans pay as much in taxes for health services as most people in OECD countries pay in total, for the same outcomes.
What’s the conservative solution? Some blend of the system in Canada, France, or Switzerland: a system of private or community providers with strong government involvement or regulation. Conservatives in the Burkean sense understand that society consists of a huge tangle of messy and often inconsistent relationships, and government exists to mediate these relationships, not to apply some consistent and elegant ideological solution. To judge from their behaviour, doctors as a class do not want to operate in a rough and tumble entrepreneurial environment. They show some fairly strong evidence of valuing their sense of themselves as a profession, dedicated to quality public service. A (Burkean) conservative response would respect that while having governments or representatives of civil society with large scale purchasing power balance the economic monopoly power of the medical profession. Something like Canada. Or France. Or Britain. Or just about any OECD country with the exception of the US.
How would an ideologically motivated “free” market true believer address this problem? Milton Friedman proposed an approach: dismantle the medical monopoly, allow anyone to offer health care services with nothing but a ban on fraud and false advertising, and let the market work. So far, none of the states that have conservative legislators and governors (looking at North Carolina, Wisconsin, and Texas) have taken any stops in that direction that I can discern.
Right now, the United States has the worst of both worlds, and outside the Affordable Care Act the will to remedy the problem appears absent.
thompson,
Not to worry. Your comment was not glib at all, and I still have most of my hair.
Quite honestly, I cannot point you to anybody more authoritative than myself on the subject of “health care spending is GDP, after all”. I’m not saying I am in the least authoritative, mind you. Neither am I saying that I, an amateur, have some brilliant insight that has escaped professional economists. All I’m saying is that the argument I laid out is not a rehash of something I read somewhere on the web.
It’s true that many people talk about “unsustainable growth in health care spending” in various contexts. But they often do not make clear what the context is. For example, there is a difference between the federal budget (much of which is spent buying health care) and the national economy as a whole.
–TP
Well, I’m not sure about “able to exist because of them”.
I was referring to partnership as a form of corporate organization. So, C-corp, S-corp, partnership, sole proprietor.
My point being that even though ownership in partnerships and sole proprietorships (and most S-corps) is not “public” in the sense that it is in a C-corp, they are still creatures of the public sphere, because their existence is a function of law.
John Spragge, false advertising is protected free speech according to some SCOTUS decision iirc.
Tony P., actual improvements in health services delivery grow the economy. Rent-seeking by providers and financial services around health care does not. Since the United States has about the same health outcomes as most OECD countries but Americans pay twice as much, I’d have to say the evidence suggests that American health system has problems that rent seeking and inefficiencies generally.
I posted this on the “A Conservative Healthcare Market” thread as well.
I find debate with most of the conservatives at OBWI to be a far superior experience to debating the “conservative” memes (nice words for lying horsesh*t) wurlitzered by the right-wing media.
By which I mean nearly all of the conservatives here argue in pretty good faith, even if I do disagree with them in every detail for the most part, though their opinions of the way I present here may differ (I’m an acquired taste).
So, we are stuck with conservative opinions about what conservative healthcare marketplace might look like and real world examples of the conservative healthcare marketplace in action in our faces.
I give you Texas, which I’m using as the worst and most vocal example of a state run by conservatives who I gather aren’t particularly viewed in a favorable light by the Texas conservatives who comment here.
You see the disconnect. It’s one thing to consider decent conservatives’ opinions about health insurance coverage and yet another to actually live with the crap that the “conservatives” who have taken over the Republican party in these latter days of the Republic provide on the ground.
What the Texas State Republican Party has wrought (with no little help from the Texas State Democratic Party):
http://www.window.state.tx.us/specialrpt/tif/healthcare.html
But look:
http://www.wfaa.com/news/health/Thousands-line-up-in-Dallas-for-health-insurance-info-229408491.html
Agh, so much good stuff and so little time to post. Bobbyp, the more I read your links the more I think we talk past each other some time. I agree with so much yet come to a completely different conclusion.
For the record, either the initial link or one of the click-throughs made the point that not getting a handle on costs is a problem. Which you seem to agree with, but think I’m being to extreme and/or to broad in my phrasing? Again, the phrasing came from the CBO, so I don’t think I’m way out in left (right?) field.
There was a concentration of various clickthroughs to a thinkprogress link about the slowdown in health costs which you mentioned earlier. Here is an example of another analysis attributing it mostly (77%) to economic factors and not structural changes (http://kff.org/health-costs/issue-brief/assessing-the-effects-of-the-economy-on-the-recent-slowdown-in-health-spending-2/). I have a CMS report that comes to a slightly different number (I think 55% economy, some other factors) but I can’t find it right now. Also, I think they ultimately pulled their numbers from the CBO (again, can’t pull it up so I can’t be sure).
I definitely don’t want to say thinkprogress is “wrong” and KFF is “right” (indeed, the thinkprogress piece heavily cites KFF), but this is a complicated question with poor data at the moment. I’d like to directly quote the thinkprogress article:
“But certain structural changes in the health care system may also be at play, including the “less rapid development of new medical care treatments,” greater reliance on generic drugs and more efficient provider practices.
The Affordable Care Act will further encourage these reforms. In fact, a ThinkProgress analysis of the Kaiser data found that the rate of growth has slowed since the law’s passage in March of 2010, though it is impossible to directly attribute the cost trend to the new law.”
That assertion (The ACA will continue reforms) is far from concrete and indeed, two sentences later they say it is “impossible to directly attribute” the slowdown to the ACA.
Forgive me if I’m not floored by the implications and immediately abandon CBO projections and verbiage as severely flawed. This is staggeringly complex, and even experts aren’t expert enough. At the end of they day the data isn’t complete and we’re going to step into the unknown based on biases and assumptions.
But even so, I agree intemperate language is rarely helpful and besides I’d rather focus on where we agree. We agree healthcare spending is a problem? We agree that this is due to a dysfunctional industry operating in a dysfunctional regulatory environment?
My understanding of where we disagree is what to do about it?
Tony:
Thanks for the response, glad you have plenty of hair. I’m going bald myself and wouldn’t wish to accelerate someone else down that path.
Yeah, healthcare spending is GNP, but that doesn’t necessarily mean it’s a good thing. Someone else touched on rent-seeking behavior and relative spending US vs. other OECD and I have little to add.
I will say I convolve national spending and government spending, perhaps improperly. I view them as pretty linked, at least for the time being…if health care costs go up, the government will spend more, and that will threaten solvency. I get the impression you disagree with that assessment and I’d be really interested to discuss why.
Finally, I’d say it’s not just the growth of spending, it’s the growth of spending as a proportion of GNP. Of course, maybe the trends will continue to decrease due to the ACA and this conversation will become irrelevant. I’m not rooting for failure, to be clear. I’m just not convinced the ACA has solved the problem.
thompson,
When you say “if health care costs go up, the government will spend more, and that will threaten solvency” I suppose you mean the federal government’s solvency.
But I also want to be clear on what you mean by “health care costs go up”. Maybe you mean prices go up, maybe you mean “more medical services are purchased”. Those are two different things, though not mutually exclusive.
If we are to discuss this stuff coherently, and reach agreement on whether “ACA has solved the problem” or not, we need to be clear in our terms.
–TP
I come at this from a slightly different angle, because I think the discussion of costs is too narrow. The fact that the US is the only fundamentally developed country with the system (or lack of one) that we (or should I say y’all) have suggests that the US are out of step and it will cause problems. Right now, Japan is a ‘pioneer’ in the sense that their demographics are skewed towards the aged, but other developed countries are right behind. I’m sure someone will cite parental admonitions about jumping off a bridge with everyone else, or the more excitable will scream ‘Freedom!’, but I think one of the problems is that Americans often don’t realize how they really have no freedom from fear when they are a medical emergency away from bankruptcy. Perhaps that ability to not think about it is gives demagogues the ability to fearmonger about the possibility of change, but when I think of those times when I went blithely around with no insurance, it is like the ‘be afraid, be very very afraid’ tagline for a horror movie.
This, from Russell, “The reason for the above – the reason that the private offerings were not getting the job done – is that the COST OF HEALTH CARE is, and has been, rising faster than inflation.
Not the cost of the insurance, the cost of the actual goods and services.
If that trend continues, it doesn’t matter who is paying for what, or how, or under what regulatory scheme if any.
Health care will become unaffordable for many if not most people. It’ll be concierge medicine, and the ER.
This single item is also the biggest threat to the ongoing solvency of the US, period. The real difficulty in controlling spending is in the so-called entitlements, and the the problem child in entitlements is health care.
If there is a conservative plan that addresses the increase in the cost of health care, plain and simple, that would be of interest. To me, anyway.
The insurance stuff is kind of a sideshow, it seems to me, other than the degree to which the insurance regime is driving costs up.”
Is the most intelligent and salient comment on the thread.
Insurance companies have performed a unit cost decreasing role in that they are able to negotiate lower prices in the provider networks they assemble and contract and, conversely, an overall cost increasing role in that the presence of insurance ensures that medical technology and services based on it will expand. Insurance finances this and the fact that consumers of services (read patients) are divorced from the cost of the services at the point of consumption ensures that a bludgeoned mess is made of anything resembling a free market/invisible hand.
I am a conservative. I think the ACA is thinly veiled Marxism and nothing more. Obama is willing to let the unwashed masses choke to death on bread and circus. That is his legacy. Why? Go back and read Russell’s comment that I quote. More insured people means more financing for expansion of medical technology. The ACA does nothing to address the cost of health care, only the cost of insurance.
A conservative approach actually already exists. High deductible (say $20K) catastrophic coverage coupled with an HSA. The HSA allows healthy people to save (it’s only 2.5% to 3% of the risk pool that incurs costs in excess of the premiums they pay in) and it creates price/cost awareness at the point of purchase; bringing free market forces back into the system.
The chronically seriously ill would receive Medicare, regardless of age, but services would be capped. They would only receive treatments with proven benefits and the amount paid for those services/treatments would be set at a level where marginal cost = marginal benefit.
They would only receive treatments with proven benefits and the amount paid for those services/treatments would be set at a level where marginal cost = marginal benefit.
As determined by death panels, I assume?
BTW, would you prohibit those insurance companies that would sell you “high deductible catastrophic coverage” from having their own free-market death panels? I bet not.
So, government death panels AND free-market death panels?
Incidentally, nobody can stop you from setting up a “health savings account”. Your bank would gladly open an account for you and let you call it anything you like. But I suspect what you want is a “tax advantaged” account. That’s a different kettle of fish.
I should stop being snarky, though. You make the excellent point that
and I agree with you. Without the insurance called Medicare, it is quite possible that some of the medical inventions of the past half century might not have happened. Invention is an expensive business, and there are only so many elderly multimillionaires; to amortize its costs over them alone, a company would have to charge them each an arm and a leg. Luckily for those elderly multimillionaires, they get to buy their pacemakers and their hip replacements and their boner pills at the far lower prices that a much wider market makes possible.
The Conservative line on Medicare was that it would destroy medicine and crush freedom in America. The Conservative line on Obamacare is pretty much the same. Conservatism is nothing if not consistent.
–TP
“I am a conservative. I think the ACA is thinly veiled Marxism and nothing more.”
Mark down illiteracy as one of the qualities of conservatism we’ve been compiling here.
Got quote from Marx on the ACA?
It does steam me, in a pleasant way, that Russell gets a thumbs up from all comers, regardless of ideology, but the man talks sense.
” They would only receive treatments with proven benefits and the amount paid for those services/treatments would be set at a level where marginal cost = marginal benefit.”
The Death Palin meets the ACA meets Chico Marx goosing the chorus girl in the catwalk above the set.
I have an Alzheimer’s-stricken mother and a pillow.
Policy without the f*cking math.
What Tony P. said.
Tony:
Thanks. I did mean the federal government’s solvency.
I think there are two things, price is going up AND potentially more services are purchased. More purchased services can be good (people getting care is good, certainly), but it does leave someone footing the bill.
In terms of costs going up, I can’t find direct evidence at the moment (although *I think* it’s something I’ve seen hard numbers on…I’ll keep looking) but in the meantime I’d point you to the high cost-of-care-for-similar-outcomes in the US compared to other OEDCD countries.
As to whether the ACA has solved the long term solvency issue…I’m skeptical. I don’t think we’ll know for some time what those structural changes are going to do to that sector of the economy. I’m even more skeptical of the claims that the recent slowdown in growth of healthcare as a % of GNP is due to the ACA…before most of the major provisions go into effect.
Again, not rooting for failure and would be very happy if it stabilized costs longterm.
So, sorry for all that rambling, it’s late where I am. To be clear on the terms (and feel free to tear into them!):
I think more medical services will be purchased (which is not bad, but needs to be paid for)
I think our costs are high relative to outcomes (and I think, somewhere, I have data saying they are growing)
I think the combination of these two factors will threaten the longterm solvency of the federal government (and to a lesser extent the individual states)
I don’t think (largely based on the CBO estimates) that the ACA solves this problem.
I’m interested to discuss why you think it does. Or if you think my terms are off the wall, I’d like to discuss that too.
PS – If I could request a little leniency, I just watched a fairly high stakes football game for me and some friends. Beer *may* be clouding my attempts at careful phrasing.
The HSA allows healthy people to save (it’s only 2.5% to 3% of the risk pool that incurs costs in excess of the premiums they pay in) and it creates price/cost awareness at the point of purchase; bringing free market forces back into the system.
My issue with allowing free market forces to set prices and generally allocate finite resources for health care is that health care is not, as far as I can tell, a good fit for that approach.
There are certain conditions that have to exist before you can have an efficient market. Those, or at least all of them, are not available in the area of health care.
And even if those conditions did exist, all that they guarantee is that the goods and services available, and the prices they would be available at, would be at a more or less arbitrary “optimal” level. Where the definition of “optimal” is not necessarily the same as “good”, “useful”, or “desirable”.
If people can’t go to the doctor, they get sick and die, often for unnecessary and completely preventable reasons.
So, people end up dying from simple infections, or flu, or colds that turn into pneumonia. Diseases that have more or less disappeared because of widespread availability of vaccines will return. Etc etc etc.
Even if the moral ethical and simple humanistic aspects of this don’t motivate you, there is a basic public health issue there that ought to.
Do you want to ride a bus, or airplane, or train, or cab, with somebody who has contagious tuberculosis?
Market forces are an excellent mechanism for price setting and resource allocation *in the most efficient manner*. And, efficiency should certainly be *one* of the things we consider in deciding how to organize our public life.
But they will not automatically create the most DESIRABLE outcome.
We’re free people, we are not required or obliged to employ market forces in any and every case, just as we are not required or obliged to channel all transactions through the government.
Given our history and culture, we might have a preference to do things via market-based means.
But if relying on ‘market forces’ means that millions of people have no access to health care other than the ER (and that only because of a government mandate), then IMO we would be idiots to take that approach.
“…As determined by death panels, I assume?”
What is all of this death panel stuff all about anyhow? Is it a death panel any time a benefit is denied b/c it is deemed either medically unnecessary or to be of little to no benefit given a patient’s situation?
Does everyone not realize that we could spend 100% of GDP on healthcare and people would still get sick and die?
When you’re spending money to give Peter every last treatment no matter how unlikely that it will improve his condition, no matter how far beyond the point of diminishing returns, then Paul will have to go without – or of course we could just print more money to be given to the medical provider sector. Democrats are always OK with printing handout money.
“My issue with allowing free market forces to set prices and generally allocate finite resources for health care is that health care is not, as far as I can tell, a good fit for that approach.”
I agree to a point, but tell me what the ACA does to remedy prices? That’s right, nada. It’s nothing more than a wealth redistribution regarding premiums. The HSA coupled with a high deductible catastrophic plan would force prices down b/c prospective patients would make decisions that would lower consumption.
Say it’s 10:00pm and junior has a sore throat. It’s easy for people under the current situation to say, “F’ it. I pay for this insurance. Let’s just take junior to the emergency room”. However, when the payment is coming out of the HSA it is salient, it is felt right then and there and the decision might be to wait and see the primary care doc or perhaps to just let the sore throat resolve on it own with some home remedies. This is a simple and crude example, I know, but it illustrates the micro-economic thinking involved.
“So, people end up dying from simple infections, or flu, or colds that turn into pneumonia. Diseases that have more or less disappeared because of widespread availability of vaccines will return. Etc etc etc.”
Really? Come on. A doctor visit for +/- $100 and a generic antibiotic or vaccine at +/- $20? Who can’t afford that? That’s hyperbole at the level of death panels.
What is all of this death panel stuff all about anyhow?
yeah, that’s what we’ve been saying for the past five years.
Democrats are always OK with printing handout money.
I’m just going to let that one sit there and be what it is.
Really? Come on. A doctor visit for +/- $100 and a generic antibiotic or vaccine at +/- $20? Who can’t afford that?
Poor people. Or people who are just short of money at the wrong time.
But, more interestingly, I wanted to add something on the subject of healthcare costs.
Rent-seeking is bad for everyone except those receiving the rent, regardless of the sector in which it occurs. Health insurers and providers are collecting rent, and that certainly needs to be addressed.
That being said, on the fundamental costs of healthcare, I’d suggest not thinking entirely about dollars and thinking a lot more about real resources – the people, time and “stuff” – needed to provide healthcare. What of those things will we find are prohibitively scarce in the future, such that healthcare “costs” are growing unsustainably?
The poster calling themselves “I am no one” raised two points which require an answer. First, they said a health savings account system would make parents think twice about getting care for their kids. I have a newsflash: the parents of sick kids do not behave in an economically rational manner. By having a kid they have made an economic choice of dubious rationality. If your system for restraining costs depends on parents of kids with unknown ailments looking coolly at the economic aspects of their options, you will probably fail. Secondly, you can’t control rent-seeking by a cartel by lowering consumption. Doctors control the supply. If a lowering of the consumption of health services threatens their incomes, they can lower the supply to match.
I wasn’t going to chime in, but “I am no one” is mostly making my argument and I want to add a few things.
A conservative approach would take into account human nature and provide incentives to individuals to keep the cost of care down and recognize personal responsibility. “I am no one’s” account of the ER trip for the sniffles is a good example. When I lived in Alaska, it was darn hard to get a clinic appointment for something moderately serious because of the $5 copays for state and fed workers and “junior has the sniffles” visits.
A conservative approach would provide choice and mandate as little as possible. It would keep the government out as much as possible except in support of the above (e.g. anti-trust to preserve a free market).
That being said, it gets hard to articulate exactly what a “conservative” approach would look like.
HSA’s are perhaps a start. They, for example, require the individual to make important decisions about their own health care and provide incentives to live healthy. To make those decisions, you have to learn about your own health care (heaven forbid!). And you have an incentive to live right. I’ve been on a high-deductible HSA since they were called MSA’s. Most Americans don’t know or begin to understand what HSA’s provide. My HSA provides better coverage (for now!) than a “regular” full coverage plan when something catastrophic happens. And I have paid for five sets of braces pre-tax! No significant balance in the “savings” part of the account, but I have hope for that after braces.
I’d study Singapore’s system. Although not really conservative, it does have components to prevent over-utilization.
I’d consider breaking down the inter-state barrier to insurance to broaden the market. I know that is somewhat too federalist, but it doesn’t have to be by federal fiat. Shoot, there are all sorts of inter-state compacts in the law.
Bellmore’s tax equity point is well-taken. Make the tax savings universal. Broaden the market. HSA’s deal with that somewhat.
Make it portable. Again, increases the market.
Within this framework, leave as much leeway to the states as possible, providing for individual experimentation.
Did anybody read the house “replacement” bill circulating just before the shutdown? I think it expanded HSA’s and did something with the selling across state lines.
I also support doing away with exclusions for pre-existing conditions, with some reservations (said reservations based on how to deal with those that don’t take any sort of interest in their own health and burden the system vs. congenital conditions). How do do that is another question entirely.
Just some thoughts.
Btw, Tony P’s observation that “If health care were less expensive, the arguments over health insurance would be less bitter. The charming notion (held by Libs and Cons both) that proper jiggering of the insurance system would reduce the costs of medicine seems doubtful to me” is a good observation. We need to focus on over-utilization as well.
And McKinney’s comment that “Conservatives would treat adults like grown ups and let them live with the consequences of their own bad decisions, whether that is buying health insurance, riding motorcycles or unprotected sex–have at it, it’s your body” is more of a true conservative approach than what I said above. I’m willing to be less conservative on health care while keeping in mind individual responsibility. I understood the question to be with the underlying assumption that the “conservative approach” had to be aimed at universal health coverage or at least greatly increased access.
Just sayin’.
Say it’s 10:00pm and junior has a sore throat. It’s easy for people under the current situation to say, “F’ it. I pay for this insurance. Let’s just take junior to the emergency room”
by coincidence, 2014 health benefits enrollment at my job starts today. the brochure i just received tells me that emergency room visits will cost me $100 each; primary care visits $20; urgent care $30. none of those count against the annual deductible.
you might say F it. i’d try urgent care, first.
but tell me what the ACA does to remedy prices?
it gave me a whole suite of brand new deductibles, none of which i had last year. it raised my co-pays. and it will increase those co-pays and deductibles in the years to come, not because the company is stingy, but because the company is trying hard to avoid hitting the “Cadillac plan” tax in 2018. it is putting more of the cost directly onto employees, just as conservatives demand.
obviously, not everybody works for my company. but the pressures are the same for all.
I made a reply earlier, it seems to have disappeared. Apologies if this shows up multiple times.
Say it’s 10:00pm and junior has a sore throat. It’s easy for people under the current situation to say, “F’ it. I pay for this insurance. Let’s just take junior to the emergency room”.
The problem with this example is that people with insurance by and large don’t go to the ER for sore throats. They call their GP.
The people who go to the ER with stuff like a sore throat are people who HAVE NO INSURANCE, because that’s all that’s available to them.
And even they don’t like to go for trivial stuff, because the ER is not such a great experience by and large, and they’d prefer to not go if they can avoid it.
Really? Come on. A doctor visit for +/- $100 and a generic antibiotic or vaccine at +/- $20? Who can’t afford that?
If you don’t know somebody for whom an unexpected +/- $100 would present a hardship, you need to get out more.
There seems to be a perception on the conservative side that people “overuse” medical goods and services because they are covered by insurance.
I can believe that there is overuse in the sense of doctors recommending or requiring expensive stuff like MRIs etc, because they’re covered, even when those things might not be strictly necessary.
What I seriously doubt is that people are going to the doctor when they don’t actually need to go at all, just because they can. People by and large don’t really like to go to the doctor. The fact that they have insurance and can take an office visit for $20 is not, I don’t think, sending them there for trivial issues in any great numbers.
I have car insurance, but I think being in an accident sucks, so I avoid them in spite of my insurance. I imagine that’s the norm.
People are not automata, and they don’t think or act like the hypothetical entities in an Economics 101 textbook. They don’t like going to the doctor generally speaking, and they MOST DEFINITELY don’t like going to the hospital or the ER, and they ABSOLUTELY don’t like undergoing uncomfortable intrusive or painful procedures, no matter how little they cost.
Sorry guys, but “i am no one” and bc are illustrating the point I’m making in the next Obamacare post.
When you compare the US to all the other First World countries, our health care spending has been going up *much* faster, for decades. In all the other countries, individuals do *not* have to make the kind of decisions about health care that you-all claim will lead to lower costs. And yet, they have lower costs.
The US “free market” is the problem, not the solution. Yes, it’s a constrained market, not completely free. But to say “30 other countries have been getting better results then we have for 40 years, but obviously we’d be ruined if we tried to do what they do” is to make an idol of American exceptionalism.
And this idol requires *human sacrifice* — at least 20,000 Americans a year die for lack of health insurance. And that’s not even counting the human misery from nonfatal conditions that are left untreated, for lack of coverage.
It seems russell thinks of health care as more of a necessary evil than something akin to, say, a delicious dessert or a stay in a luxury resort in a tropical paradise. Liberals…
Doc. Sci:
And thousands die needlessly even under universal, government-controlled care. Both are overly simplistic analyses, IMHO.
Wow, what assumptions you make, Dr. Sci! No, I am not relying on the “axis” of Fox-Limbaugh-Drudge. I admit to scanning Drudge daily and regularly reading Powerline. Fox News, never (don’t have cable or regular tv; just Netflix and Amazon Prime). Limbaugh? If I’m on the road and forget my tunes, maybe or maybe not and then only for an hour because he is repetitious. I’ve listened on the average maybe twice per year in the past ten years. I also admit to reading Huffpo from time-to-time, reading the NYT (no, not cover-to-cover), regularly reading Sullivan and watching MSNBC in airports, among other “liberal” sources (even Kos!). I am more likely to listen to liberal talk radioon the road because I like to know how others think. But that isn’t often because I don’t get good radio reception in my truck until I’m out of the mountains, which isn’t often. And I regularly read here (but don’t comment as often anymore).
In all the other countries, individuals do *not* have to make the kind of decisions about health care that you-all claim will lead to lower costs. And yet, they have lower costs . . .
But to say “30 other countries have been getting better results then we have for 40 years, but obviously we’d be ruined if we tried to do what they do” is to make an idol of American exceptionalism
Ah, the logical fallacies making any connections to the current situation. Not to mention I didn’t say that.
To be clear, me suggesting ideas that MIGHT be included in a possible “conservative approach” should in no way be read as stating we shouldn’t look elsewhere for ideas or that my ideas would work.
Or that my “facts” come from Fox News. Because my opinions are my own and, I’d like to think, are informed by much more than the axis of evil. But I’m willing to consider that I am wrong.
And thousands die needlessly even under universal, government-controlled care.
that 13,000 estimate was due, not to anything having to do with the govt’s involvement per se, but rather to doctor or institutional failures – things that we already have in our hospitals here (this guy says “40,000 per year”!).
the 20K-45K in DrSci’s linked article are the lucky duckies who can’t even get the care that would put them at risk for dying of a doctor’s error because they don’t have insurance.
Cleek:
I’m not disagreeing with your reading, but I think it is a mistake to read either estimate too broadly. I note that the study Dr. Sci linked appears to have taken a “snapshot in time” approach to the uninsured status. They admit that this approach potentially biased the results. I skimmed the study and didn’t see an adjustment for the reason for being uninsured (e.g. lost job, prexisting condition, can’t afford COBRA, oh crap; or e.g. young, likes to take risks, will never die, takes up skydiving). I am quite sure that the risk of dying for someone who loses coverage due to job loss with a fatal pre-existing condition is quite high. And that the risk of dying for young risk takers (meaning everyone participating in devinsuprtramps youtube channel) is higher than the national average.
I’m not trying to be flippant. Being uninsured has an association with increased chance of death. But to say that is the CAUSE of your death is a bit more problematic. Some people can afford coverage but choose to buy cable t.v., beer, cigarettes and frequent casinos. Some people can afford insurance and choose not to buy, then get hit with cancer and choose to not spend their own money on health care and impoverish themselves to qualify for medicaid. And yes, for some it would be a huge burden to obtain coverage and are caught between being truly poor and affluent enough to buy coverage.
I’m not unfriendly to a public health screening service to catch things early. I’ll bet that alone would help the increased risk. Or maybe not.
And, like I said, I personally like somehow (emphasis on somehow) taking preexisting conditions out of the equation and portability.
bc: We need to focus on over-utilization as well.
What’s “over-utilization”?
I mean, the phrase suggests that there’s some appropriate limit of “utilization”, but I can’t figure out how that limit would be defined — especially from a “conservative” point of view.
If a rich hypochondriac is willing to pay for a daily MRI, is that “over-utilization”? Says who?
The rich are just as afraid of pain and death as the poor. Doctors are no less greedy than any other profession. There will never be a shortage of doctors specializing in diseases of the rich. If there are too few doctors left over to treat the poor, that’s the poors’ problem, right?
Seriously, bc: how do we define “over-utilization”? Would the same definition apply to things other than health care, e.g. energy, or bandwidth, or jewelry?
–TP
It doesn’t seem that overuse is the source of the US’s higher health care spending, at least compared to other wealthy nations:
http://www.oecd-ilibrary.org/sites/health_glance-2011-en/04/01/g4-01-01.html?contentType=&itemId=/content/chapter/health_glance-2011-29-en&containerItemId=/content/serial/19991312&accessItemIds=/content/book/health_glance-2011-en&mimeType=text/html
The problem seems to be that our prices are higher:
http://content.healthaffairs.org/content/22/3/89.full#sec-7
Tried this a couple of times with no luck, once more into the breach.
Some people can afford insurance and choose not to buy, then get hit with cancer and choose to not spend their own money on health care and impoverish themselves to qualify for medicaid.
Can you point me to one person, anywhere, who has actually done this?
Can you point me to one person, anywhere, who has actually done this?
More likely, someone who hasn’t bought medical insurance gets cancer, and goes bankrupt because of the medical expense of treatment, and then is eligible for Medicaid. Not really a plan.
TonyP: over-utilization is simply more healthcare than is necessary. There is a lot of discussion from the doctor side (e.g. certain screenings like mammograms). This is really an issue for insurance or universal care. In a truly private system of pay-for-services it would still exist, but it would not be an issue in terms of the insurable cost.
russel: wow, that was a badly worded sentence. I better start previewing. I meant to say what sapient said, but emphasizing that the person chose not to use their money until they had to and were captured for the study while uninsured and terminal but leading to medicaid coverage in the end.
Lewis: that chart doesn’t adjust for type of system, making it hard to correlate what would happen if there were no barriers at all to getting, for example, a GP visit. Interestingly, I have heard of a study that showed that low copays for the elderly increased costs. I’m not sure that would extend across the spectrum.
“Some people can afford coverage but choose to buy cable t.v., beer, cigarettes and frequent casinos. Some people can afford insurance and choose not to buy…..”
Absolutely. Seriously Russell, if you can’t afford to pay $120 for a doctor visit for, say, strep throat, and you die as a result, you are a hopeless moron that makes really bad decisions in life. One of those bad decisions is not going and out and getting yourself enrolled in the Medicaid/Child Health Plus/Family Health Plus program that you would most assuredly qualify for.
Just as conservatives have their silly myths concerning this debate, liberals do to and the dead b/c couldn’t afford a doctor visit is one of them.
“I mean, the phrase suggests that there’s some appropriate limit of “utilization”, but I can’t figure out how that limit would be defined — especially from a “conservative” point of view.”
Over utilization is utilization where the marginal benefit is less than the marginal cost. Medical directors at insurance companies spend considerable resources determining what that point is and what procedures, diagnoses and cost are involved. They attempt to impose their determinations on the system by a. not covering or b. contracting a lower prices.
Physicians themselves try to do the same thing. There is research published in respected trade journals comparing the value of clinical approaches for conditions and making recommendations a to which approach should be used.
Unfortunately, for various reasons, these controls are not enough.
I would be for a single payer socialized health system *if* prices and benefits were controlled. I don’t think Americans realize the extent to which citizens in those systems are denied utilization – the type of utilization that is deemed as medically unnecessary or excessive utilization by government panels in those systems. Take a moment to read up on the Australian system’s PBS that control which pharmaceuticals are covered.
BTW, Russell, I don’t think your analogy of car insurance and accidents ends up where you want it to if followed all the way. Car insurance doesn’t cover maintenance. If your alternator dies you have to buy a new one and have it installed out of pocket. It is a cost of owning a car. A car accident is more analogous to coming down with cancer. No one is ok with cancer just b/c they are insured. The HSA couple w/ a high deductible catastrophic coverage is comparable to car or home owner’s insurance.
Lewis Carroll, you posted a link that only shows a comparison of doctor office visits. These are not the problem. Office visits are not driving insurance cost. What drives insurance cost is, primarily, inpatient hospital stays; particularly for surgeries (aka admits/surgical admits). These are much more expensive in the US and US they occur much more frequently.
I reiterate that in the socialized systems many of these admits would simply not occur and those that did would be much less expensive b/c they would involve far fewer costly bells and whistles.
Also, childbirth in the US tends to involve longer hospital stays at a higher price than it does in socialized systems.
On the outpatient side, in no particular order, we have ER usage, expensive pharma, expensive dialysis, expensive chemotherapies driving costs.
For a higher level view (approved by this conservative with some insider experience) I recommend this link: http://www.aetna.com/health-reform-connection/aetnas-vision/facts-about-costs.html
I am no one: Over utilization is utilization where the marginal benefit is less than the marginal cost. Medical directors at insurance companies spend considerable resources determining what that point is and what procedures, diagnoses and cost are involved. They attempt to impose their determinations on the system by a. not covering or b. contracting a lower prices.
My original question was not so much “what’s the definition of over-utilization” as it was “Says who?” And the answer appears to be “medical directors at insurance companies”.
My problem with that answer is the obvious one: the “benefit” is to the patient, the “cost” is to the insurance company.
Now, as a liberal, I stand ready to be accused of crushing freedom by telling people what’s good for them because I know better than they do. What I did not realize is that insurance company medical directors are flaming liberals too. And conservatives apparently approve of that.
Well, not always of course: if the “insurance company” were The Government and the “medical director” were a faceless bureaucrat, that would never do.
The conservative proposition, I suppose, is that private-sector insurance companies compete. If Company A’s medical director underestimates the “benefit” its customers (in their own subjective evaluation) perceive, they will take their business to Company B, whose definition of “over-utilization” is less stingy. But it’s not clear to me how this dynamic results in less “utilization”.
It still seems to me that “over-utilization” only makes sense if somebody other than the “utilizer” gets to define it. But if we’re going to take the concept seriously, then let’s keep in mind that it’s not just medical services we can apply it to.
For instance, I say “financial services” (like health insurance) are “over-utilized” in this freedom-loving land. People use more “financial services” than is good for them. If we don’t do something about it, “financial services” will soon be over half of GDP. Oh, the humanity!
–TP
Just as conservatives have their silly myths concerning this debate, liberals do to and the dead b/c couldn’t afford a doctor visit is one of them.
spend twenty seconds with Google, and you should have enough info to convince yourself that this isn’t a myth.
and how could anyone forget this?
It’s the WaPo and anyway, it’s a dentist, not a doctor.
http://www.washingtonpost.com/wp-dyn/content/article/2007/02/27/AR2007022702116.html
At any rate, he would have probably grown up to be a hopeless moron, and we couldn’t have that, could we…
I am no one, you seem to have missed this part:
http://content.healthaffairs.org/content/25/3/819/T2.large.jpg
Can you show me where there is, relatively-speaking, over-utilization in this country of inpatient hospital services that would account for our higher costs? As the other piece I posted showed, our costs are higher because our *prices* are higher, not because we use more of the services per capita. Even the costlier, more intensive services.
I’m also wondering how high deductible HSAs are supposed to be the magic answer when they should have virtually no effect on the use of these well-above-the-deductible expenses.
Seriously Russell, if you can’t afford to pay $120 for a doctor visit for, say, strep throat, and you die as a result, you are a hopeless moron that makes really bad decisions in life. One of those bad decisions is not going and out and getting yourself enrolled in the Medicaid/Child Health Plus/Family Health Plus program that you would most assuredly qualify for.
There are a couple of dozen states in the US that do not offer Medicaid for single people without children.
Many of those people are unemployed, or live on $10/hour jobs.
At what you net from a $10/hour job, you’re gonna work the better part of two days to afford your $120 medical bill. It likely means you will do without something else that is also quite important, like meals or rent or busfare.
That’s a hardship. It’s a sufficient hardship that many many many people are going to live with the flu until it’s pneumonia, or live with a cough until it’s stage 4 lung cancer, etc etc etc.
Have you ever lived on a very limited income? If not then STFU, because you don’t know what you’re talking about.
Hopeless morons who made bad decisions in life. Let them die.
Russell, I do not believe there are ANY states that exclude an individual from Medicaid if that individual falls below the federal poverty line. You’d better check your facts.
Just how many people are we talking about that aren’t eligible for Medicaid and can’t afford $120.oo to save their own life? Come on. This is liberal myth making at its worst (or finest, depending on perspective I suppose).
You’re going to have to back up your emotional statement with some facts.
We don’t engineer ANY social program or ANY market to be PERFECT for EVERY individual citizen.
Just how many people are we talking about that aren’t eligible for Medicaid and can’t afford $120.oo to save their own life?
tens of thousands. look it up.
Russell, I do not believe there are ANY states that exclude an individual from Medicaid if that individual falls below the federal poverty line. You’d better check your facts.
Actually, I am no one, you should check your facts, especially when you are calling people on their facts.
We don’t engineer ANY social program or ANY market to be PERFECT for EVERY individual citizen.
Correct. But, since we’re just looking for some marginal improvement in the aggregate, also not relevant. (Not even all caps could save it.)
sapient, sorry, but I don’t see where your link backs up the statement that Medicaid is not available for single adults without dependents.
“tens of thousands. look it up.”
First off, that’s a pretty small % of people. Secondly, what I am supposed to look up? People that can’t $120 for a life saving doctor visit? Tell you what, since you know so much about it, why don’t you just point me to your source.
All of the money spent on the lame albatross known as the ACA could have taken care of your tens of thousands – assuming they actually exist – through some kind of (slight) tweaking of Medicaid with Federal grants to states.
Just how many people are we talking about that aren’t eligible for Medicaid and can’t afford $120.oo to save their own life?
If you tell somebody who doesn’t have a lot of money that they need to spend $120 or they are going to die, they’ll probably spend the money.
But the situation rarely presents itself in that way.
The situation presents itself not as “you are going to die”, but “you have a cough”, or “you have a weird bump or discolored patch on your skin”, or “you have a headache that won’t go away”.
Poor and uninsured folks, like most folks, are not expert diagnosticians. Also like most folks, they are prone to putting off dealing with stuff that they don’t have the resources to deal with.
So, minor, bearable symptoms are left unaddressed, until they are no longer minor or bearable.
The way that being poor and uninsured kills people is when they neglect things that are not such a big deal, until they become a big deal.
And then, it’s too late.
This stuff happens every day, there is no mystery about it.
And yes, there are something like two dozen states in the US where single adults with no kinds are not eligible for Medicaid, regardless of how much money they do or don’t have. Go look it up, sapient has kindly included a link to the Kaiser Foundations overview for your convenience.
If you can’t be bothered to click through and read the freaking doc, there’s probably little point in our discussing it any further.
sapient, sorry, but I don’t see where your link backs up the statement that Medicaid is not available for single adults without dependents.
Second page, figure 4, entitled “Coverage of Low-Income Adults by Scope of Coverage,
January 2013”. If you look at the key, you will see that the color white means “No coverage”.
No coverage means no coverage.
Or, page 5, table 3, which shows the income limit for Medicaid eligibility, by state, as a percentage of the federal poverty level (FPL). The right hand column lists the levels for non-disabled adults with no dependent children.
If there’s no limit there, it means there is no coverage.
No coverage means no coverage. No Medicaid, no program offering lesser benefits, nothing.
Nothing.
There are 26 such states as of January 2013. I don’t know how many there still are, because I don’t know how many of those 26 have elected to expand Medicaid per the ACA.
Perhaps you’d like to go to some homework, find out the answer to that one, and come back and let us know.
I don’t mean to be rude, but if you’re going to pontificate about people who “don’t know their facts”, or who are “hopeless morons who made bad decisions in life”, you should at least have the most basic and rudimentary facts right.
Which you do not.
Maybe you’d like to get some information and try again.
All of the money spent on the lame albatross known as the ACA could have taken care of your tens of thousands – assuming they actually exist – through some kind of (slight) tweaking of Medicaid with Federal grants to states.
Perhaps you are already aware that this was actually part of the ACA, that many of the states we are talking about have refused it, that this specific point was addressed as part of the SCOTUS decision on the constitutionality of the ACA, and that the SCOTUS decided the states didn’t have to accept the expansion of Medicaid.
So, by and large, they have not.
These informational tidbits are common knowledge among folks who have an interest in the facts. Perhaps you would like to join that club.
What interests me Russell, in all your heart felt compassion for poor people who can’t afford to spend $120, you are asking for young healthy poor people to spend, by law, considerably more than that for insurance they don’t need and will probably not use in excess of premiums in a decade.
What about them and their ability to pay?
regarding states with no Medicaid for single adults with no dependents: you are misunderstanding what the situation is. Such people are still eligible for state Medicaid waiver programs. It isn’t the full Medicaid program, it’s a slightly different program tailored to that demographic. So, no, they aren’t left with no insurance. You are simply wrong.
Dear no one:
Military spending is insurance. I am paying higher premiums for it than it’s worth to me. I’m being forced to subsidize those who “over-utilize” it.
When are you going to shed a crocodile tear for me?
With all due respect (I assure you)
–TP
Young healthy poor people will be eligible for subsidies under ACA.
Look: I think that the concern that taxpayers be billed to subsidize those who don’t need a subsidy is a legitimate concern. I just don’t get why this concern is so frequently raised by conservatives in the context of some hypothetical poor person somewhere (when the amounts of money wasted are small) and never raised in terms of the BILLIONS spent essentially on subsidizing individuals who are already wealthy, like the Koch brothers. Doesn’t it make more sense to be concerned about large amounts of wasted money than small ones?
Besides in terms of health care, how does one decide if the health issue is self-inflicted or not? Are we going to deny Medicare to people who spent their adults lives eating red meat? Or just make an issue of the Medicaid for the low income person who spent too many years living on Top Ramen?
It’s taking the easy way out to always scapegoat the poor
It isn’t the full Medicaid program, it’s a slightly different program tailored to that demographic.
Here is current the list of Medicaid waiver programs.
You are correct that they are tailored to particular demographics. Those demographics are generally:
I spent some time going through the program descriptions. I looked at each program description for any state that shows up as “no coverage” in the Kaiser paper.
After five pages worth of this, I found zero waivers that apply to adults, with no kids, and who did not have some specific disease that would prevent them from working.
I did find two waivers that match that description, one each for NJ and NM, but those are not among the “no coverage” states.
If you’d like to pick up the legwork and continue from page 5, I’ll be interested to see what you find. There could be some in there, there are about 23 pages of these.
I just don’t have the time to go beyond 5 pages worth right now.
Or, if you can provide any kind of documentation to back up your assertion that such programs exist, that would also be interest.
Short of that, I’ll simply say that based on the information I’ve seen, I don’t believe you.
If you want to press the point, do the homework. I’m happy to concede the point if you can bring some actual information to the table.
http://www.nytimes.com/2013/10/31/us/politics/behind-roar-of-politics-whispers-of-race-persist.html
Besides, fear that money might be wasted on the poor isn’t really about poor people. It’s abut certain people who might or might not be poor.
OK, I’ve looked at every single Medicaid waiver program, for every state that is listed as “no coverage” in the Kaiser paper.
There are waivers for:
There were also some waivers for community mental health, and some for family planning.
But almost none that simply extended Medicaid coverage or anything like Medicaid coverage for non-disabled adults who were not parents or guardians of dependent children.
The exceptions:
So, out of the 26 states, the folks we are talking about might be covered by a waiver if they live anywhere in IN, or in Cleveland OH, Chicago IL, or St Louis MO.
Otherwise, as far as I can see from the list of waivers published on the Medicaid website, nothing.
Your turn, i am no one.
“you are asking for young healthy poor people to spend, by law, considerably more than that for insurance they don’t need and will probably not use in excess of premiums in a decade.”
Those who have any kind of insurance and do not experience an “event” subsidize those who get to enjoy that unenviable experience. Life insurance is a bit different, but the underlying actuarial data is pretty well known and predictable. That is why you cannot find a $250k policy for $25/mo. when you are 80.
However, for the young, life insurance is cheap. For some reason this does not apply in the health insurance realm. Perhaps you could tell us why.
Tony P.,
Are your really trying to tell me the resources dedicated to our military are “over-utilized”, that the Department of Defense’s marginal product is out of line with our marginal costs? Really? Really?
/snark 😉
you are asking for young healthy poor people to spend, by law, considerably more than that for insurance they don’t need and will probably not use in excess of premiums in a decade.
What about them and their ability to pay?
If they make less than 400% of the federal poverty level, their premiums are subsidized.
FPL for an individual is currently about $11,500 in the lower 48, a little higher in AK or HI.
So, if they’re making less than ~$46K, they get a break. If they make a lot less than $46K, they get a big break.
Or, they can pay the penalty, which will probably be cheaper than buying insurance.
So, no tears.
And not for nothing, but evaluating an insurance product in terms of whether you receive benefits in excess of premiums sort of misses the point of insurance.
However, for the young, life insurance is cheap. For some reason this does not apply in the health insurance realm. Perhaps you could tell us why.
Actually, it does apply–or it did. Young people are cheaper to insure than older people for both life and health. Now, health, but not life, is mandatory. And the price for the younger people involuntarily enrolled or taxed is being artificially jacked up, to subsidize insurance costs for others.
This is supposed to be fair and efficient. Stupid young people and stupid conservatives don’t agree. Which is why they are stupid. And that statement Obama made about getting to keep your insurance if you like it, it was actually true, if you are smart enough to understand the context in which the statement was made. Which conservatives are not smart enough to do. Because they are conservative and are not high information progressives. High information, progressives get all of this stuff.
Every tax is a way of making one person pay for something that someone else might be using more than they are.
Progressives do get information from better sources by avoiding the conservative sources. I’ll state that as a fact so long as the conservative sources are the ones listed in the initial post on the subject of information sources.
Besides we have the experience now of discussions of Obamacare being polluted with gazillions of rightwing lies from rightwing sources. Death panels! Twenty-six thousand IRS agents! Socialism! Jeez, don’t pretend all that lying didn’t happen!
As for Obama’s remark, it looks weaselly to me, given that insurance companies have in fact been telling people that they cannot keep their current plan. I don’t think I’m the only one to see it that way, judging from reading the thread. I even gave an example of someone whose insurance got changed.
However, according to Talking Points Memo, this isn’t a case of Obama being a weasel on this issue. TPM says that the laws doesn’t allow the insurance companies to change people’s plans, but insurers are dodging the law by cancelling plans and offering substitutions. If that’s the case, then it is the insurers, not Obama, that are being weaselly.
So I thought the weasel was Obama, but maybe it’s the insurers.
The effect on the consumer is the same, though.
I’m glad for Republicans that after years of making up shit there’s finally a real problem with Obamacare to complain about.
And it is a real problem for some people. My neighbor whose insurance jumped in cost doesn’t qualify for a subsidy and is just barely staying afloat as he struggles to get past a bankruptcy. Paying more for insurance is a real problem for him.
‘There are waivers for:
•disabled people of all ages
•people with specific debilitating diseases
•people with development disabilities ‘
Well good. Those people need it. They’re actually sick and have huge costs.
“But almost none that simply extended Medicaid coverage or anything like Medicaid coverage for non-disabled adults who were not parents or guardians of dependent children.” Hmmm, people that should be working for a living and should be able to pay $120 for doctor visit. The horror! the shear unmitigated tragedy that this small group of typically healthy and low utilizing people might have to pay a few hundred $s a year, tops, out of pocket.
I defy you to explain – using facts please – to explain how or why a national debate and arguably unconstitutional federal law gets enacted based on this group of citizens.
You’ve done nothing to convince me so far (and I’ve read all of the comments) why the ACA is a better choice than free markets and HSA + high deductible catastrophic plans.
This is wealth redistribution for shallow political gain; plain and simple. Tax and spend, tax and spend and print more money. I don’t see how it gets paid for otherwise.
I thought your Nobel Peace Prize winning savior was going to end all of these crazy wars. If he had, the $s spent on brutal nonsense could be diverted to needs at home and Medicaid could be expanded and people who earn a decent wage could chose what they wanted from the free market.
Because Obama! Because rich people suck! Feh.
Any how, thanks for playing.
“This is wealth redistribution for shallow political gain; plain and simple”
I appreciate your willingness to cut through to the substance of your opposition: you don’t like a program that might help someone lower in income than you, especially if it means those people might vote for the party that supported the policy, but, judging by your silence, you are unmoved by the income transfer from the middle class to the wealthy via corporate subsidies.
I kind of thought that was the heart of the conservative position.
Not sure I’m interested in engaging with someone who’s too (? blinded by hate? blinded by ignorance? much of a [epithet deleted.
Unfortunately, “I am no one” has a way too common view. Maybe he’s never had trouble making ends meet. Not sure whether I should congratulate myself for understanding that world (since I lived in it briefly). Maybe I’d be that kind of an a**hole too if I had never had that experience. I sincerely hope not.
arguably unconstitutional federal law
Not arguable anymore. See Marbury v. Madison.
You’ve done nothing to convince me so far
Nobody needs to convince you. The law has already been passed. You need to convince us now.
I don’t see how it gets paid for otherwise.
You don’t see because you don’t look.
No more troll-feeding from me. Night all!
However, according to Talking Points Memo, this isn’t a case of Obama being a weasel on this issue . . If that’s the case, then it is the insurers, not Obama, that are being weaselly.
Obama 2009: “if you like your healthcare plan, you’ll be able to keep your healthcare plan. Period.”
But the ACA sets minimums where it was going to be unlikely that any plan would be unchanged. The issue is that the White House knew that well over 50% of the plans would be cancelled (according to NBC). And then although there was a grandfathering clause, DHHS wrote regs that made it that if any party of a policy was significantly altered the grandfathering was lost. Now, DHHS makes it sound like the change to the grandfather provisions were helpful to consumers. Others cry foul. I haven’t read the provisions, but it seems to me that the large numbers of people finding their plans cancelled speaks for itself.
Not arguable anymore. See Marbury v. Madison.
Wait, we haven’t been arguing over Roe v. Wade since the 70’s? That’s right, it’s just a conversation. 😉
bc: Maybe in 40 years your people will have many cases challenging but failing to overturn the decision upholding the constitutionality of the health care law. Good luck with that! I’ll be dead by then, thank goodness!
According to I am no one, our uniquely high costs were due to ‘over-utiilization’, but not just any over-utilization, utilization of the high-end stuff like acute inpatient treatments / hospitalizations.
Only it turned out that the data I provided showed that, of the OECD nations, the US has either the lowest, or one of the lowest, per capita in-hospital days per annum. So that got conveniently ignored.
Now we’re back to the high-deductible / HSA solution, which would have no obvious effect on those intensive in hospital treatments, since those charges would quickly exhaust even the highest HSA deductibles.
There seems to be a lot of motivated reasoning associated with the idea that unfettered markets can somehow deliver healthcare efficiently and fairly, when we’ve known for about 50 years that it is against human nature to treat it like any other good:
http://www.aeaweb.org/aer/top20/53.5.941-973.pdf
If I were only concerned with my very narrow self-interest I would be grateful for this stubbornness; having been in the insurance business for 20+ years, it’s helped line my pockets.
Young people are cheaper to insure than older people for both life and health
Granted. But I believe I said health insurance for the young is “not cheap”. Pre ACA anybody purchasing health insurance was subsidizing health care costs incurred by those who were not insured. Now it strikes me that if more healthy young people are in the insurance pool contributing premiums, then their insurance costs could possibly come down.
But of course only conservatives and their lickspittle know anything about ‘free markets’.
Well good. Those people need it.
I’ll take that as “Well as it turns out, I couldn’t find any of the waivers I was talking about, either”.
And yes, those folks do need it, as do lots of others. Earth to i am not alone – everyone who is poor and uninsured is not in that circumstance because they are dumb irresponsible hapless dunderheads who can’t tie their own shoes.
Perhaps you have noticed the unemployment rate over the last, say, five years.
Moving on:
What I think this all comes down to is this.
The ACA is, in fact, deliberately changing the health insurance market. By law.
It’s setting a floor on what a health insurance plan can include, it’s requiring some people who otherwise might not want to bother with health insurance to either buy a policy or pay a penalty.
That’s the stick.
It’s making health insurance accessible to a lot of folks for whom it was not previously accessible.
That’s the carrot.
It’s gonna be really good for a lot of folks, and not so good for a lot of folks. I don’t know what quantities belong to those respective “a lot”s, but hopefully it will net out positive.
I suspect it will, because I suspect that when a lot of the folks who are pissed off about stuff like having their high deductible / low coverage plans cancelled actually shop around, they are likely to end up with something that offers them better value.
It’s also possible that the whole thing will crash and burn and be one long extended exercise in futile bureaucratic wankery. I hope that’s not what happens because the potential upside will actually be a truly good thing, if it works out.
I am, personally, astounded it’s gotten as far as it has, because the level of opposition and rancor associated with its passage has been nothing short of astounding, considering what the substance of the law actually is.
It’s just not that alarming or radical a piece of legislation.
It will take a month or two, and they’ll get the website sorted out, because that’s just tech. And no, I don’t say that flippantly, it’s just a lot easier to get a computer to do something than it is to get people to do something.
And over the next 6 months or so, we’ll see if it was all worth it.
And for the record, yes the website sucks, and yes Obama shouldn’t have said that about nobody having to change their plan if they don’t want to. Folks that are pissed off about those things should feel perfectly entitled to be pissed off.
Also for the record, the fact that the health insurance market is being changed is something we should all fall on our knees and give thanks for, because the status quo ante was well and truly FUBAR.
Just saying.
But as sapient notes, however you feel about it personally, it’s the law. It’s happening, and it’s going to continue to happen. If we’re really really smart, we’ll do our best to make it happen as well as it can, and then we’ll see what if anything we need to change.
In any case, it’s not the end of the freaking world.
I defy you to explain – using facts please – to explain how or why a national debate and arguably unconstitutional federal law gets enacted based on this group of citizens.
It is my devout wish that the currently 11+ million unemployed, each and every fnking one of them, waltz up to your front door and lay a canned sales pitch on you for a new vacuum cleaner.