Let’s Have A Real Health Care Debate (UPDATES)
Using highly questionable data sampling, the New York Times today self-righteously proclaimed majority support for a plan for a government-provided health insurance plan that, using the inherent ability of the government to subsidize itself and punish its competition, would inevitably devolve into a single-payer government health care system. And this sort of rhetorical short-circuiting of the process of debate and analysis promises to seriously damage our ability to craft serious health care reforms.
This stridently dishonest approach has been eagerly embraced by the ideologues of the left, who prefer slogans to debate. A characteristic example is TMV’s Kathy Kattenburg, with her no-discussion-tolerated demand “We Need Single-Payer Public Health Care — NOW“. Kattenburg’s post does identify a legitimate problem that requires reform (the practice of “rescission” — the arbitrary denial of coverage using flimsy and even dishonest excuses), but its willingness to only consider one possible solution and its intolerance for any discussion of problems or alternatives makes it a dangerous diktat rather than a progressive proposal. (Unfortunately, the general TMV policy of refusing to even respond to critics exacerbates the problem — one can peruse TMV threads essentially forever without finding an example of its authors seriously engaging a single critic. While its across-the-board application to all issues at TMV is not shared everywhere, this no-dissent-allowed practice is tragically quite common specifically among advocates of single-payer health care. Like Kattenburg, they tend to view their proposals as good-versus-evil rather than as exercises in coming up with pragmatically workable solutions to real-world problems.)
If single-payer health care were the nirvana its advocates claim it to be, this wouldn’t be a serious problem. But continuing experience in Canada, for example, shows that serious problems with availability and rationing in critical care areas such as cancer treatments persist in single-payer systems. The hostility to debate and discussion among single-payer advocates like Kattenburg is thus revealed as more than simply self-righteous arrogance — it is a serious threat to the viability of a future post-reform system. Refusing to discuss potential problems may marginalize and disempower opposition, but it will not prevent those problems from occurring in reality. And the economic logic that causes rationing is impervious to proclamations from high atop a moral white horse: Providers in a single-payer system can only expect to receive whatever the government’s political process deems an “appropriate” payment. Since those payment levels will inevitably remain fixated solely on present costs, there is no room left to invest for the future. As a result, investment in new equipment and technology is slow and unreliable and, as a result, available capacity inevitably lags behind demand. The outcome in the end is that cancer patients and other patients who would benefit from immediate treatment have to wait in line and, inevitably, some of them die while waiting.
But, of course, such matters are of little interest to self-righteous purists like Kattenburg. All that matters to them is demonizing the other side enough to score an easy rhetorical “win” before blithely moving on to the next item on their infinite list of political vendettas. Actually making the system work is Somebody Else’s Problem. And, after all, any problems that do crop up can always be blamed on Republicans, conservatives, or “the rich”. A big advantage of refusing to even talk to your critics is that you can continue that same practice to evade accountability later on as well.
Fortunately, not everyone embraces this vicious and irresponsible approach. Moderate Democrats in the Senate are eschewing the temptations of the extreme purists and are trying to craft a compromise that might address some of the legitimate concerns about single-payer health care. Whether such proposals can gain steam in spite of the dogmatism of the purists remains to be seen, but the willingness of pragmatist liberals like Justin Gardner at Donklephant to actually recognize and discuss legitimate concerns about purist approaches to health care reform is a very hopeful sign.
The bottom line is that the choice is entirely in the hands of liberals. Partisan Democrats dominate the entire political playing field, from the Congress to the elite media to the blogosphere. If they choose to embrace the intolerant purism of their Kathy Kattenburgs, then Americans may have little more to look forward to than a dreary march to technological stagation, rationing, and the decreased quality of care that results from decreased timeliness of care. The fact that enlightened liberals will have “won” over evil insurance companies will be of little comfort to the breast cancer patients who see their tumors metastitize while they linger on the waiting list for radiation and chemotherapy treatments. But if they instead adopt the willingness to compromise of Senator Kent Conrad and Donklephant’s Justin Gardner, a centrist consensus might just be possible.
UPDATE: Newshoggers’ Ron Beasley is even more direct in rejecting all compromise and all debate in favor of a Manichean crusade against “the Oligarchs”:
And what does he need to do?
1. Go to the nation
2. Be LBJ. So far, Lyndon Johnson has been the only president to defeat American Medical Association and the rest of the medical-industrial complex.
3. Forget the Republicans. Forget bipartisanship.
4. Insist on a real public option. It’s the lynchpin of universal health care.
5. Demand that taxes be raised on the wealthy to ensure that all Americans get affordable health care.
6. Put everything else on hold. As important as they are, your other agenda items — financial reform, home mortgage mitigation, cap-and-trade legislation — pale in significance relative to universal health care.
It is fascinating to behold the shameless hypocrisy here. Leftist purists are using the exact same kind of good-versus-evil rhetoric that they excoriated George W. Bush for using regarding the threat of terrorism. Apparently, those who would blow up huge buildings in the pursuit of an extreme religious ideology are no where near as threatening as “the Oligarchs”, eh, Ron?
But even if we “get” those nasty “Oligarchs” and put them up against the financial wall, Ron, the ones who really pay the price may be the cancer patients who must wait months or years for their treatment due to rationing. Why do you refuse to even debate the issue?
I guess your campaign of rhetorical and financial vengeance must be important enough to sacrifice their lives in the process?
UPDATE 2: In a move that is hyperbolic even by their standards, FireDogLake compares the campaign for health care reform to the fight against slavery. The same lot who used to complain about the Bush administration’s rhetorical excesses is showing that Rumsfeld and Cheney can’t hold a candle to them. Next up: Anyone who questions single-payer health care is a Nazi terrorist.
UPDATE 6/22: Kathy Kattenburg has responded with a respectful post at TMV. (It is a hopeful sign that at least some at TMV may be willing to respond to critics.) Unfortunately, her response continues to evade key points of contention, including the propensity of many public-health-care advocates to immediately reject all proposals for compromise (Paul Krugman adds his voice to the purist chorus today) and the problem of how to handle rationing and equipment-investment problems that occur in publicly-funded systems like Canada’s. Hopefully, at least some on the left side of this issue are willing to sustain a debate as it moves into details.
UPDATE 6/22 5pm: Well, Kathy Kattenburg’s respectfulness didn’t manage to last the day before she returned to the purist approach of misrepresenting and demonizing all opposition. This is the dysfunction that seems likely to continue to plague the health care debate in this country — self-righteous purists who believe in win-at-all-costs actively destroying debate from the left and know-nothing purists refusing to even offer debate from the far right. Meanwhile, the moderate majority stuck in the middle can look forward to paying the higher tax bills for a poorly designed system built on ideology rather than analysis.
Fair enough that there might be an inherent problem coming from the capability of the government to be an advantaged competitor or alternative, but is there any other way to get universal coverage?
Also, I think there must be some way to keep the inventions and improvements on medicinal technology to be a feature even in a revamped plan. How, I have no idea, but it must be featured.
It’s always good to remember that no system of delivering payments to private institutions serving millions, tens-of-millions, or even hundreds-of-millions of people will ever work completely smoothly. But, just like the people it condemns, this article also only focuses on one side of the issue. If single-payer really does force Canadians to wait for treatment, it begs two questions. First, are Canadians clamoring for US-style health insurance as a result? And second, are the delays and the rationing simply a factor of so many people being able to seek medical treatment? (That is, does our private health insurance system solve that problem by running a system where so many people either lack coverage or lack enough coverage to clog our hospitals?)
If the answer to the first question is “No,” if Canadians prefer their system despite it’s problems, then adopting it would at least be a step in the right direction. It would be silly to stay with a broken system just because the alternative is not 100% flawless.
If the answer to the second question is “Yes,” if the delays come from Canadians’ better access to health care resulting in more people seeking medical treatment, then the problem isn’t with single-payer but with hospital infrastructure and the number of doctors. Now, I have no idea whether or not a government run system will be able to support the construction of more hospitals and encourage more people to become doctors. However, if the private insurance system is any good at it, then our infrastructure will easily be able to handle the increased number of patients if we switch. If not, then Canada’s inability to do better shouldn’t condemn their system anymore than it should lead to people praising ours.
And either way, it is difficult for me to support a system that keeps wait times to receive medical procedures short by limiting the number of people able to get medical care at all.
Finally, the concern that the government will decided what constitutes an “appropriate” payment for medical treatment is absurd given that private insurance companies already do this. (It’s the reason why a majority of doctors support single-payer health care.) In any system overseeing large numbers of people, there will be bureaucrats following sets of rules established by their higher-ups who make payments, sign off on procedures, and just generally push papers around. This is the case in all government agencies and all private businesses. Bureaucrats are always needed to manage systems involving large numbers of people. (The only way to get rid of them would be to ban all insurance and to have everyone just pay cash for all medical procedures.)
There are, however, two differences between how government bureaucrats would likely determine “appropriate” payments for treatment and how corporate bureaucrats would do it. These doubtless wouldn’t be procedural difference. They would simply be based on circumstance. Corporate bureaucrats have the premiums of a few million to tens-of-millions of people to draw from, having the authority to spend the money that hasn’t been appropriated as salaries or bonuses for the executives. Government bureaucrats have the entire tax base to draw from and will have the authority to spend all that comes in. This not only drastically increases the amount of money coming into the system (the larger the pool paying in, the easier it is for an insurance-like system to work), but it would also cut out the billions wasted on paying a handful of executives.
Serge,
Many Canadians find themselves forced to seek care in the United States due to rationing and delays. I see some of the evidence of this first-hand when I see hospital and clinic parking lots (I live near the Canadian border and have close relatives working in the health care field) filled with cars with Canadian license plates.
Nonetheless, I am not arguing against all reform. In fact, I specifically concede the need for reforms such as preventing abuses like rescission. I actually like what little I have seen thus far of Kent Conrad’s compromise plan.
Your assertion that we should adopt the Canadian plan just as a “step in the right direction” is thus seen as part of the problem — presenting a purist choice as if it were the only choice available rather than being willing to discuss and debate alternatives. Surely our only choices are not to (1) do nothing or (2) embrace Canadian-style rationing that condemns chemo patients to higher death rates, is it? If some form of control on access is required, let’s learn the lessons from other systems’ problems rather than blindly embracing them because of some ideological crusade like that pursued by Kathy Kattenburg and Ron Beasley, ok?
“This not only drastically increases the amount of money coming into the system (the larger the pool paying in, the easier it is for an insurance-like system to work), but it would also cut out the billions wasted on paying a handful of executives.”
But while there is much money spent on paying off the executives, the fact that all the people involved in the companies make more money if they make more of a profit ensures their commitment to make thing run smoothly. Under government administration there is no profit motive, which might lessen effectivity.
OTOH, the insurance companies are able to turn a profit by taking every step necessary to actually not have to provide HC to their paying customers, while this option is not available to the government.
Kastanj : …”but is there any other way to get universal coverage?”
Who says Universal Coverage is wanted by the Majority of US citizens. Oh, I think most of us agree that there needs to be some reform, (in the existing public and private plans), but certainly not “Now”.
Serious, lengthy, multi-faceted debate must take place, (not just a the progressivs likes it, the conservatives opposse it) but details, and in the public forum, like where can the current public and private plans reduce waste (like in not paying for *illegal* aliens) And where are these countries that have “pretty good” as Obama put it in government run single payer systems? he could have at least told me the countr(ies). (And what;s with this one sided ABC network Soviet-Pravda style sales pitch)?
In my opinion, the next time I feel we should hear we should be doing anything drastic “now” at a Federal Government level it should be the makings of a disaster movie, and real proof should be provided, not the “there’s no time to show proof method as we did with the last slew of bailouts..meaning we either we need to assemble a team to take out rogue asteroid with earth in its crosshairs, or north of the 45th parallel is about to freeze over in the next few days and we need to evacuate south (which would then promptly evoke “told ya so’s” from the progressives as to their “guess of the decade” as to where their “climate change guess-o- meter” pointer is aimed.
I have travelled to several countries with one payer/government medicine and have been surprised at the positive attitude towards the system. The waiting times described in emergency rooms etc were actually less than what I have experienced in the US. They found it horrifying that in the US that the uninsured could be pushed back on the streets once stabilized without followup treatment. Waiting for treatment seems better than no treatment for such things as cancer, heart disease, high blood pressure. The lower per capita cost, greater longevity and higher birth survival rates seem to indicate in objective statistics based on the purpose of healthcare insurance that one payer is performing better.
As far as cost is concerned, the one payer system seems to perform with better results for half the money currently being spent on US healthcare.
Waiting occurs in both private and one pay systems but approval rates appear to be higher when profit is taken out as the primary motivator. And who has the ability to shop or discuss prices when you are in the middle of a medical emergency? Medical treatment is not a free market when your life or a loved one’s is in the balance. Why must so many choose between life and poverty? Do I die because my company no longer needs my services and I no longer have or can afford medical coverage? And once I am ill and lose coverage, who will cover me?
I believe our private insurance companies high cost, disapproving treatment and claims, and excessive co-payments are the leading cause of citizen bankruptcies, loss of homes and retirements, and lack of treatment. This is the greater threat to our economy and quality of life, greater than the change required in going to a one payer system.
In our private system, fewer and fewer businesses and individuals can afford the premiums for even more limited coverage and still maintain resources necessary for their daily survival. Do I pay rent, put gas in my car, pay my electric or buy insurance? Do I purchase raw materials for manufacturing, pay for transport, or offer health insurance? These are real choices made by individuals and industry.
The lower per capita cost, greater longevity and higher birth survival rates indicate in objective statistics based on the purpose of healthcare insurance that one payer is performing better. Having seen the success of the one pay system in place for the US military, veterans, congress, government employees, the poor (Medicaid), and senior citizens (Medicare), I am highly in favor of extending this same coverage to all our middle class citizens and other ineligible groups. A universal one payer system would give a better spread of the risk that will increase for all individuals as they grow older and significantly reduce administrative costs. Finally, surveys of other countries one payer systems show better results on a per capita basis for half the money currently being spent in the USA.
I think most people agree that we need policy reforms. But there is big difference between policy reforms and trying to design a national health care SYSTEM, which is what a lot of progressives suggest that we should try to do. I usually stay out the health care debates because they tend to involve very technical policy matters and I’m just not qualified to argue on behalf of one national system or another. The thing is, though, the experts are not qualified to design a national system, either. Nobody is.
It is impossible for human beings (or computers programmed by human beings) to design a top-down national health care system that will work. Too many variables. The problems are astronomically complex. In theory, you could eventually develop a workable system by starting with a best guess, then constantly testing it and making adjustments. In practice, though, the most brilliant minds in America would not be up to the task.
It is up to us non-experts to demand that health care reform avoid the hubris of attempting to achieve impossible goals and therefore cause far more harm than good. Us non-experts have one advantage in this debate: we’re not invested in any particular approach and we probably have a better view of the big picture.
Here’s a few observations from a non-expert:
Demands to create a national health care system NOW! are absurd. Ask yourself, why are they in such a hurry? Like in the global warming debate, the experts have a tremendous diversity of opinions, analyses, recommendations. Be mindful of policymakers saying, “we need to listen to the experts.” Which ones?
Serge, we don’t have a “system” right now. No one is “keeping” or “limiting” anyone from gaining access to care, other than costs, which will ALWAYS limit access to ANYTHING. Right now, people who need emergency care but do not have insurance will receive it. For the most part, they will also receive critical care, too. If you accept the sleight of hand that what we have now is a system, it is easier to accept the idea that it can be replaced by something that really is a system.
Watch out for proposals to centrally plan & manage the health care industry: not only are these doomed to failure, they erode freedoms.
The big underlying problem: rapidly increasing medical advances + rapidly increasing expectations = rapidly increasing costs. Normally, prices for innovative products and services will decline over time due to competition, which would correct for this problem. However, health innovations are like whack-a-mole: finding treatments or cures for one set of diseases or ailments prolongs lives long enough to suffer from other diseases and ailments. Obviously, we all want to live as long as possible. But we have to be careful not to enact policies that give us more access to innovations now if it means fewer innovations in the future.
Almost every Canadian I’ve ever met dislikes the Canadian system, but I will play along. Let’s assume that the Canadian system is functional-to-good. The thing is, the Canadian system is free-riding on the U.S. system, which generates much of the innovations. If you introduce policies that curtail innovation here, the Canadian “system” will fare considerably worse.
The moral imperative of having health care for all is not in question.
I do not believe it ever has been.
The question is how to properly employee its advantage in a society that is free market, captialistic in which companies that hire Americans and pay them good wages take the risk in insuring those same Americans and offering them a valuable benefit for their dollars.
How best to install this program in this system? That is the debate. How to prevent these companies from going out of business. How to prevent the government from taking over.
My brother goes to the VA hospital. The care there is quite good. It was not so good many years ago. Its now facing funding shortages today because of the recession. In other words the quality of care ebbs and flows with the times. Private insurance does not do this because you essentially have a contract which states your eligible for this…that…or the other.
Health care is subject to review because doctors tend to be sued a lot. They are afraid to misdiagnose a case. They tend to over prescribe treatments and second opinions to insure that they do not get sued.
1. Government mandated Cap limits on doctors being sued should be instituted. Hence Doctors still have to pay malpractice insurance but the insurance company and the doctor is capped on liability. Say one million dollars. The federal government then creates a fund in which the uppper limits of this is in escrow to pay out any additional awards above this limit. That would prevent doctors to a certain extent from over prescribing treatments, tests and drugs.
2. Balance the budget and pay off the debt. The interest savings alone would pay for the cost of government run health care.
3. National sales tax adopted that would be used ONLY and by law dedicated to ONLY pay off the national debt, and to pay for national health care. This would be by law a tax of between 3-6 percent.
4. Everyone who pays into medicare and Social Security would have their taxes raised 1 percent this year. Another 1 percent next year and the third year an additional 1.3 percent to fix the social security issues.
5. Private health insurance companies are solely responsible for coverage. All companies must meet certain coverage limits up to an including a certain lifetime maximum with the federal government kicking in after this lifetime maximum is met.
6. Health care is put on cost control evaluation in which the cost of goods, services and fees cannot exceed an annual rate of inflation plus 2 percent increase. Thus a hospital room that costs 600 per night cannot raise to 1000 per night next year but can rise the cost of inflation plus 2 percent next year….etc…etc….yes complicated but price controls are absolutely necessary on the medical industry….they are bandits because they can be.
Nothing is free. People can pretend that health care is free, or that its not going to cost anything to put it in place but thats a lie. Obama and the democrats want to put a plan in place and then beg, borrow, steal or print the money to pay for it but they know that ONCE its in place then its forever.
Confront it up front…you want health care….balance the budget…pay it off and use the 400 billion a year we save in interest payments to pay for health care in full each and every year without huge taxation, borrowing or PRINTING MONEY.
A few random comments.
1) Those opposed to significant health care change should be honest. The majority of Canadians (and for that matter the majority of English, French, German citizens etc) are satisfied with their health system
2) At the same time, those favoring large-scale health care change need to be honest. While the majority of Americans are in favor of significant change, the majority of Americans are satisfied with their own health care.
3) We spend far more on health care than any other country without signficantly better outcomes AND with significantly fewer citizens covered.
4) To address item #2 most proposals for change have not challenged American citizens to “consume less health care”. In fact the major rallying cry against reform is losing “choice” (a proxy for cost)
5) So oddly enough since we are distinguished by spending far more than any one else with no better outcomes, we strive to improve our healthcare system by …. (wait for it)…SPENDING MORE!
Don’t you know that moving to a “single-payer” system will still require that doctors, hospitals, and clinics be paid? The government is not a magic money tree — they are going to have to increase revenue to fund the payments. So it is possible that the move to a single-payer system could simply change the cause of bankruptcies (from health care bills to tax bills) without changing their impact. Also, government bureaucrats can disapprove treatment just as easily as insurance company bureaucrats, and experience from other countries indicates that they do so quite willingly. I personally knew someone who was disapproved for a desperately-needed hip replacement in Britain purely because she did not meet the arbitrary minimum age that the government had set for the operation. Apparently, in Britain, if your hip goes out before you are 50, you aren’t allowed to fix it.
The illusion that “the rich” are some kind of inexhaustible source of infinite available revenue is dangerous. Raising taxes on “the rich” can simply serve to terminate investment as there becomes no incentive to take risks for wealth-building once the government promises to simply confiscate the wealth.
There is a serious argument to be made for the idea of expanding coverage, but my point all along is that we should not ignore the potential problems. Sugar-coating the solution — as single-payer advocates seem to do constantly — risks making our financial AND health care problems even worse than they already are.
The government is not a magic money tree —
Seriously In my points above I proposed some ideas. They are all in and of themselves almost impossible to implement and are costly to boot. Trying to do all of them will be impossible and extremely expensive to everyone.
NOTHING is free. The government cannot afford national health insurance.
WE CANNOT without huge sacrifices. Ill trade you a balanced budget and a paid off national debt for FREE national health care….
We cant do both…have a huge money grubbing debt and national health care.
Nothing in life is free…..the sooner people realize this the sooner they will start demanding the sacrifices needed to get what they want.
Absolutely. Both the Dutch and French models achieve universal (or near so) without a single payer system. Both of those models are much more likely to be adopted in the US than is a single payer system. Obama’s proposal looks much more like the French model.
We do have a system. It is a hybrid public/private system in which the government pays for between 40% and 60% of health care costs (depending on who you read). The option supported by the president and the option most likely to pass is also a hybrid public/private system but with closer to French levels (70%-80%) of government support. We are really talking much more about changes in degree rather than changes in kind. Both sides seem averse to admitting this.
The private system ebbs in hard times as well. The mechanism is people losing their jobs or full time status and so losing their coverage.
I wish that were true.
That would entail quite a bit of government control and coercion. Much more in fact than Obama is proposing. I can already hear the howls from the right about our loss of freedom if he tries to float that.
Who says that? This is a debate about who pays, how they pay, and what coverage is universally provided. Currently it is about half government paid, most of the rest is employer paid, and a small remainder is individually paid insurance. With that payment plan we cover most emergencies and ~87% of the population with something more.
Single payer is not my option of choice, but it does offer significant savings on administrative costs. All information I have seen puts HMO administrative costs north of 20%, generally north of 25%. Conversely all the information I have seen on single payer systems and Medicare indicate administrative costs south of 10%, generally south of 5%.
Perhaps, but not at all likely.
Do you have any information on the relative rates of denial of coverage? I have seen dozens of anecdotes of HMOs denying coverage for reasons of cost or for claimed pre-existing condition. Virtually every anecdote I have heard of coverage denial in a universal care country comes from either the UK or Canada. I think there is less than a 1% chance that we will model our health care system on either of those.
I do think that there is long term cost savings to be had by instituting a universal care system with mandated coverage. Potential administrative savings are in the 10%-15% range and there could be some coraling of cost growth. This is not enough to bring health care costs out of their unsustainable arc. Prices cannot be brought under control without addressing the primary cost, wages. Wages are radically increased due to systemic controls on supply. The issue of supply must be addressed and that requires taking on vested interests. Our supply of doctors is currently controlled by a guild of doctors who paid considerable money to get where they are and whose interests are served by preserving the status quo (low supply and high price barrier to entry). The result of this is among the lowest doctor:population ratio in the developed world*. However you cut it low supply means rationing. In the UK it may mean that some people are less likely to get a hip replacement. In the US it can mean that as much as 13% of the population gets virtually no care unless there is an immediately life threatening condition, at which point they are stabilized and released. The answer is simple enough, we need to increase supply in order to contain costs. We are already harvesting doctors from developing nations to fill (inadequately) our shortfall in supply. We need a long term strategy to increase our supply of doctors and nurses. This will require more medical schools and nursing schools and probably some federal funding, particularly for education of GPs. There is a lot more to it but I am already running long.
* Coincidently Canada and the UK are two of the very few developed nations with worse ratios.
The thing is that bipartisanship is not by default a good thing unless input from the other party will surely improve the proceedings, lower obfuscation and lead to a better bill. Many congressional representatives of the GOP seem to either be just as bad as the more insulated and ideological parts of the DNC, or even worse. The ones that are working together with these approval-stamped centrist democrats happen to be retired.
The anger from some left-wing voices could be partially understandable once you compare the demands for a window of input with the poor quality and lack of good faith of the input. If (and that’s an “if”) the main body of the GOP is mostly concerned with doing whatever it takes to win a perceived battle of ideology rather than provide the best possible solution for Americans, is the noble path of bipartisanship still sensible?
You think that your lack of knowledge about legitimate criticism and practical alternatives from Republicans is because none exist.
I think that your lack of knowledge about legitimate criticism and practical alternatives from Republicans is because those that DO exist are ignored in favor of an easy and politically convenient ideological stereotype.
So it is your choice — you can continue to pretend that no legitimate opposition exists so that you can feel morally superior but contribute nothing to the debate, or you can seek out and engage serious critics who actually have arguments.
But given your track record, I have no illusions about which you will choose.
Republicans own a large share of the blame for this. The preferred line of attack has been to call universal health care socialism and to breathlessly point out coverage issues in the UK and Canada. If the Republicans want to be taken seriously by the American people in regards to health care they need to push a plan of their own that consists of more than a 4 page broadsheet. That is a beginning position and they have come to it quite late (almost as though they were backed into a corner and had no other choice).
Neither side will deal with the primary cost issue, kicking that can even further down the road.
I looked over this before
This is not a fair line of attack. Wait times for almost all procedures in the US and almost all universal care systems in the developed world are comparable. Focusing on joint replacement wait times in the UK and Canada to the exclusion of the mountain of countervailing evidence is not accurate or instructive.
Which ignores the fact that the chances of the US modeling our system on Canada’s is virtually nil. The most commonly discussed model on the left is the French model, not the Canadian or UK model. It is disingenuous to continually flog the failings of systems that we are not going to adopt.
Virtually health care debate I have seen features someone extolling the (apparently unalloyed) virtues of the French system followed by someone pointing to wait times for hip replacement surgery in the UK or Canada. It is nauseatingly pointless.
That is true of some of them. It is not true of ALL Republicans or ALL critics of single-payer health care.
The choice of WHICH critics to give attention to have consistently been made in favor of the more idiotic critics by liberal bloggers and media analysts. And I think that practice amounts to dishonest stereotyping, especially from Kastanj (who has been corrected so many times on his misrepresentations that their continuation is obviously intentional).
The issue of cost does remain the most serious challenge with regards to health care reform. Many liberals assume that cost savings from nationalization will be automatic and massive, but there is little evidence that they have done ANY actual analysis of how that is or is not true. It is simply assumed. That is a major part of the rush to short-circuit debate that I have been criticizing.
I would need to see the evidence for this claim, as it conflicts with what I have found thus far.
The kinds of issues I am talking about are general, not specific, such as the general decrease in incentives for innovation and equipment investment in any single-payer system. And the infrastructure issue requires us looking at an example of population distribution more like Canada than France.
But I am completely prepared to hear about how France has avoided the problems of the UK and Canada and how we could learn from that system. As I have repeatedly said, I am not opposed to reform, I just want to stop the hasty rush to judgment advocated by many (and not just by conservatives).
Jeb: I’m not familiar with the particulars of the French health system, but I’ve read that it has very serious cost issues of its own – that it has recently run large deficits. That in spite of France having very high tax rates and spending much less per capita than the U.S. on national defense.
When I wrote that the U.S. does not have a health care “system,” I meant that it was not planned as a single scheme or system – as one functioning unit. It evolved over time into, as you say, a hybrid public/private “system.” I would not yet describe it as a centrally planned system like France has, although we do seem to be moving in that direction. Medicare sets approved amounts that hospitals, doctors, rescue services, etc. are legally forced to accept. Employer provided health plans are subsidized by tax exclusions. State governments set different insurance regulations and coverage rules. Industry lawyers have assisted policymakers in writing many of the laws. For better or for worse, all of these things distort the markets.
It’s tempting to argue that many of our problems are related to having a hybrid mishmash of a “system,” that we should just move solidly in one direction or the other: a mostly private or a mostly public system – i.e. major overhaul, rather than incremental reform. However, the cost management problems do not go away under public systems, they just put government bureaucrats – instead of price mechanisms – in charge of making the tough choices about access, affordability, and quality. On the other hand, while market-oriented reforms would be a much better direction, they would have to be implemented gradually over time.
Most the House and Senate leadership and the prominent conservative talking heads have apparently taken that tack. These are the people who can move real proposals from conservatives to the fore. They have failed at this. This is primarily their failure rather than a failure of the media.
I lost my OECD paper link, but look at exhibit 2 in the below article. There is a row for wait times.
http://scienceblogs.com/denialism/2009/05/what_is_healthcare_like_Neth.php
The article offers a brief analysis of the Dutch system.
The French and Dutch systems are not single payer. These are the models that most on the left are looking to. Obama’s proposed plan looks to be modeled on the French system and is not single payer. Comparisons to single payer systems like the UK and Canada are not apt when what is actually being proposed is a hybrid system like those in France or Germany.
That has been the call since before 1993. We are approaching a second decade of avoiding a rush to judgment.
BTW Some sort of preview function would be great for format and other error checking.
All health care systems are running into financial troubles as health care expenditures increase faster than GDP. The real comparison here is relative expenditures and rates of growth. The US system pays much more (1.5x – 2x) for near parity in results (perhaps worse) and if memory serves our rate of increase is higher than any OECD nation other than Luxembourg.
Those problems will never go away regardless of system, or lack thereof. The goal is to minimize the problems. A single set of rules should save on administrative costs and administrative costs are lower than in the US for all OECD nations I have seen info on. Cutting admin costs from our near 30% to their near 10% would be a step in the right direction.
Again though the biggest problem with health care in the US is cost and that is primarily an issue of supply. We have less than 2.4 doctors per 1000 pop as compared to more than 3 per 1000 pop for most of the developed world. The countries with cited problematic wait times are actually worse off with 2.2 (UK) and 2.1 (CA) per 1000.
Increasing the number and allowed duties of nurses should also be a priority. There is currently a 2 yr wait list for nursing schools in the Bay Area. That should be unacceptable, but it is typical.
This would seem to be a clear supply side position for conservatives to take. Increasing supply should decrease costs. Why is no one in power doing anything on this front?
As far as systems I would like to see implemented. I like the Dutch system better than the French system and the French system better than ours and am torn on our system v the Canadian or British systems.
“You think that your lack of knowledge about legitimate criticism and practical alternatives from Republicans is because none exist.”
After I have mentioned the retired GOP congressmen who have done good work in providing decent input rather than just posture and fear-monger?
“I think that your lack of knowledge about legitimate criticism and practical alternatives from Republicans is because those that DO exist are ignored in favor of an easy and politically convenient ideological stereotype.”
Guess who brought these retired congressmen to my attention and compared them favorably to “socialist”-labeling klaxons like Gregg? The New Republic.
“And I think that practice amounts to dishonest stereotyping, especially from Kastanj (who has been corrected so many times on his misrepresentations that their continuation is obviously intentional).”
Am I to become a symbol comfortably in reach now?
Another thing I’m wondering is whether it is the business of the US government to preserve the competitiveness of insurance companies to begin with. In Arkansas one such company has three fourths of the market – how is that satisfying from a free-market perspective? Insurance premiums have risen much much faster than wages, and lest we forget these companies make more money if they can somehow deny their customers the service, lumping tax payers with the costs associated with the ensuing situations. Forcing them out of business should be avoided, but the fact that the government will be too advantaged a competitor might not find much traction even among the people who already have insurance (not that it can be called that when few people are really sure of their coverage when push comes to shove). I bet you many of your laudable “centrist” democrat senators are mostly stalling due to the tight embrace of insurance company lobbyists in their respective state.
There are conservative voices that are important because they have perspectives and information that is necessary to provide the basis for an “optimal” bill and revamp. But their existence doesn’t mean that democrats have to await for all right-wing voices to be satisfied, especially when 4-page spreadsheets seem to be what the GOP side of congress is ready to stand behind. Many democrats are indeed self-aggrandizing fools who only see the bureaucrats in the insurance companies as a problem and won’t consider the big picture. But what good will it do to bring in the people who *only* shout about putting a “Washington Bureaucrat between the doctor and the patient” (TM)? You can’t reach a satisfying equilibrium by countering manure with dung.
50 percent of self-identified republicans *do* see the attraction of a public option. Is it really bipartisanship to expect democrats to have to appease the remaining half of the party that has lost all branches of government? The full-on stonewalling by congressional republicans is not representative of the entire party once you look to the non-politician members – the ones that don’t have complete coverage as a perk. So ignore the ideologically obsessive GOP congressmen and invite some sensible right-wing voices that actually *aid* the creation of a better bill, showing the “socialism”-shouters as the unreasonable fools they are, distancing them from independents.
The resistance to listening for right-wing input is partially understandable after the stimulus “debate” – how many on the GOP are actually interested in providing their POW on a bill they’ve seen as unavoidable, and how many are merely playing for time, wanting to prevent their enemies from getting anything through and thereby cowardly hide behind the idea of bipartisanship?
Of course not. No reasonable definition of bipartisanship and compromise requires 100% agreement with all elements on the other side. But it does require doing more than imposing an artificial deadline of October 15 for unconditional surrender from the other side. Yet that is exactly what is policy of the Obama administration, the Democratic Congressional leadership, and supported by the overwhelming weight of the left-leaning media and blogosphere.
There are serious practical issues to be dealt with in a comprehensive overhaul of 20% of the entire economy. But your insistence on treating it solely as a partisan issue where the bad guys (always Republicans) have to be unconditionally defeated and humiliated and where the good guys (always Democrats) should suffer exactly zero scrutiny of any kind makes it unlikely, even impossible, to ever deal with those real issues.
But WHY, Jeb? I would suggest this points towards two of the problems that single-payer purists are extremely resistant to addressing: Medical malpractice reform and low payment rates for Medicare doctors. Who wants to spend a decade of incredible overwork becoming a doctor when the government will refuse to pay you enough to cover your student loans and equipment costs and then also allow anyone who doesn’t get a miracle cure to sue you into bankruptcy at the same time?
And, of course, while Democrats will yell incessantly about the campaign contributions of insurance carriers, they go deaf and mute at the merest hint of talk about the campaign contributions of the trial lawyers.
“But it does require doing more than imposing an artificial deadline of October 15 for unconditional surrender from the other side.”
The HC problem has been growing for a while and the first attempts at a revamp where put on the backburner in 1993. Now the congressional GOP let’s their retirees deal with the opposing party while procuring spreadsheets shorter than some of my gymnasium essays, despite the growing problems and the time they’ve had to think of something decent. Why isn’t October a decent deadline? Surely the concept of a deadline must be acceptable considering the GOP can’t make the democrats wait indefinitely?
“But your insistence on treating it solely as a partisan issue where the bad guys (always Republicans) have to be unconditionally defeated and humiliated and where the good guys (always Democrats) should suffer exactly zero scrutiny of any kind”
There are some republican voices that seem interested in discussing the issue in good faith rather than try to defeat and humiliate democrats, *and they’ve been given a place at the proceedings*. The congressional GOP does not seem serious or capable of relenting and the DNC congressmen who think 60 isn’t enough aren’t necessarily seeing things that way due to concern for US voters of either side.
Here’s the latest foolishness from a congressional republican, blabbering and grandstanding just as badly as the FireDogLake example.
http://blogs.tnr.com/tnr/blogs/the_treatment/archive/2009/06/22/i-want-to-believe-in-lindsey-graham-really-i-do.aspx
We don’t invite left-wing bloggers to the congressional discussions and commisions, so why is Graham entitled to input when he isn’t even aware of the content of a bill he has endorsed?
If they allow the GOP to get what they want there won’t be a public option plan, and that will probably do more harm than good, while the republicans no doubt will try to come off as having no part in the creation of the resulting revamp. Looks like there’s a pretty narrow group of people who have anything to gain by letting the right-wing voices beyond the grassroots get their say.
Because it is not possible to evaluate all the relevant issues and tradeoffs in that period of time. You appear to think it a good deadline simply because your dislike for the Republicans makes them deserve it. I’m saying that screwing the Republicans should not be the goal of health care reform. Creating a good system should be the goal of health care reform. And your partisan obsession is a barrier to creating a good system.
If instead of a deadline, Democrats wanted to create a nonpartisan working group tasked with evaluating all the relevant issues and tradeoffs and tasked with producing a comprehensive report and recommendations in early 2010, that would be acceptable. It would not require that they wait forever for Republicans to get on board, but it would allow them the institutionalized opportunity sufficient time for a more thorough evaluation of the issues. And, most importantly, it would be more sincere than the blatant surrender-or-die deadline of Oct 15. It would also allow the issue to be debated in the context of elections instead of rammed through by a partisan majority insulated from accountability by short memories and a hopelessly biased media.
Really? Where? Show me. Because all I see from the left side of the Congress, media, and blogosphere is EXPLICIT rejections of even the IDEA of bipartisanship.
More to the point, I don’t even CARE about bipartisanship. I’d rather that they took the time to actually consult with experts — doctors, insurance providers, tort lawyers, etc — rather than ramming through an ideologically pure plan that won’t work.
Here you go treating all Republicans as if they were a monolithic whole intractably opposed to everything and lumping me in with them. You’ve already said yourself that there are lots of Republicans who are willing to compromise and consider a public option. Kent Conrad’s compromise proposal (rejected out of hand by Democratic purists like Krugman and Kattenburg) is an explicit outreach to them. Why not endorse giving that a run instead of just coming back to your old partisan demonization themes over and over and over and over and over and over???
Could it be because that is the only ammo you have and that you are incapable of discussing ANY issue in detail except as it relates to partisan combat? In short, could your partisan obsessiveness be merely a shortcut for covering up your ignorance about the details of actual issues?
That explains a LOT, come to think of it. Wow. Going back over the history of your comments in my mind, this is an outright revelation.
The short answer is because our supply of doctors is controlled by a guild of doctors.
Medical malpractice litigation is abused and is a problem, but a small one in the grand scheme of health care costs. Liberal estimates have direct costs less than 3%, most estimates I have seen are less than 2%. Single payer could actually immediately lower this cost. It is after all more difficult to sue Uncle Sam.
Low payment rates for Medicare doctors is trivial in regards to supply of doctors in general. It accounts for doctors who can make more elsewhere choosing to do so, it does not significantly reduce supply. If low pay due to government fiat were a limiting factor then we should have more doctors per capita than most of Western Europe, instead we see the opposite.
We should not require 72 hr shifts for interns and medical students should not routinely graduate with 1/2 a million in debt that requires an exorbitant compensation to repay. Increase supply with government help and intern shifts could be reduced to a more sane level and debt load for new doctors would be much lower. They could then afford to work for less which is good because increased supply would mean that they would be paid less.
and the inverse can be said about their opposition. Partisans do play politics even in Washington.
Of the two, the insurance carriers are the larger fiscal problem, but both will stand in the way of needed reforms.
Because that would remove the divide and conquer politics from the equation. If this is debated in the context of an election then we will see and hear nothing but distortions from both sides. Positions become campaign promises and compromise becomes even less likely. The likelyhood of good legislation coming out of that process is less likely than it is in the relatively short window in between.
You say that as though people haven’t been doing this for over a decade now. Clinton’s first stab at this was over 15 years ago and she has been active on it ever since. Many in the Congress and Senate have been active on the issue for years and it has been a issue for Obama from the beginning of his political career. McCain laid out the skeleton of a plan when he was campaigning. Everyone in the House and Senate has known this was coming for years (by 2006 at the latest).
Most with political power on the right in America are/have been opposed to the amount of government involvement in health care as it stands now and will oppose any extension of that involvement on principle. When the debate is over how to provide universal care, their contribution is/has been that isn’t government’s job. They have done everything within their power to prevent further government involvement in health care. Now after 15 years or more of stalling for some of them they have been backed into a corner (some form of universal care is coming) and they are now calling for time for a reasoned debate.
I trust that your call is based on an honest desire to see this hashed out in the best possible way, but I don’t see that happening with the current or foreseeable political dynamic. Few on either side will engage meaningfully and regardless of compromises made there will be minimal Republican support for any universal health care bill(s). This will be the same in October of this year, or next year, or likely the year after that, or the year after that… It could just be that my cynicism has gotten the better of me and another year of study would change this, but I very much doubt it.
Jason,
I understand your history at The Moderate Voice wasn’t a good one. But your statement here is just downright wrong:
“(Unfortunately, the general TMV policy of refusing to even respond to critics exacerbates the problem — one can peruse TMV threads essentially forever without finding an example of its authors seriously engaging a single critic. While its across-the-board application to all issues at TMV is not shared everywhere, this no-dissent-allowed practice is tragically quite common specifically among advocates of single-payer health care. Like Kattenburg, they tend to view their proposals as good-versus-evil rather than as exercises in coming up with pragmatically workable solutions to real-world problems.)”
TMV has over 20 active authors (me included). And to be lumped into a group because you disagree with my fellow TMV colleague Kathy Kattenberg shows some immaturity on your part. And where is this “general TMV policy of refusing to respond to critics”. It’s an author’s choice to respond. Because a few authors may have not responded to you doesn’t make it a “general TMV policy”.
And what is the endgame here? To make TMV leave the blogosphere (not happening)? To cause hits to drops (doing just fine thank you very much)? To make someone cry (well that’s an entirely different issue)? To lose weight? Drink less? Taste great, less filling? Ollie Ollie Oxen Free? Pecan or apple pie? I don’t get it.
How about you disagree with a TMV author without lumping us all into the same boat. I think that is fair and quite balanced! What say you?
More random comments:
Yes, administrative overhead is an issue but keep in mind these two points. 7% of our total health care expenditures goes to administration (that’s all payers). If we are at least 50% higher in cost/capita than the next highest nation then eliminating ALL administrative overhead will not get us to where we need to go. Second, you need to consider how those administrative costs are related to overall health care expenditures. By that I mean if Medicare (WARNING: hypothetical numbers coming) has only 3% over head but sees a double digit increase in health care expenditures annually but “Medicare Advantage plan B” has an 8% overhead but keeps year over year expense increases to less than 2% which is doing a better job with its administrative functions?
An interesting comment for two reasons. I hear very few authorities suggest we have an undersupply of procedural or surgical specialities and yet our costs for these types of care have sky-rocketed. The Dartmouth Atlas has pointed out over and over again that more hospital beds leads to more hospital admissions and more cost. Now I would agree that our balance of primary care/specialty care is grossly out of whack. “Successful” systems in developed countries generally have a 70/30 (primary care to specialty care)ratio of docs. We have a 30/70 ratio.
Finally, I do have concerns for “the public plan”. If the adminstration pursues the “Medicare +10″ route this options would clearly “underprice” the nearest private competitors. As a small business owner I would then gladly tell my employees “Tell you what… I’ll give you all another $150 a month and you can go out and buy that new government plan” Competition actually shrinks. We saw this with the expansion of S-CHIP. And that’s not to mention the uncomfortable reality of having “one of the players” also be the “referee”. If you consistently overbill a private plan you may lose your contract with that plan. If you consistently overbill Medicare you have committed “fraud” and may be liable for “treble” damages.
Tyrone, it is interesting that you know some version about my supposed “history” at TMV but you never bothered to get my side of it before presuming the truth and completeness of what you may have heard from others. I suspect that skew in the information you are relying upon may be part of the reason you think I am making unfounded charges when I think I am merely reporting from my own experience in receiving (and seeing forwarded copies of) directives to not respond to comments and to blacklist certain individuals and sites.
I do maintain that TMV is generally unresponsive to criticisms, in particular about objections to its parading itself as “the internet hub for moderates, centrists, and independents” when its actual content is overwhelmingly skewed to the left side and eagerly features every anti-conservative meme that becomes available while consistently giving liberals a pass on similar issues. Also, TMV keeps publishing contributions from individuals like Kathy and Shaun and Michael that are so immoderate, extreme, and downright abusive as to raise legitimate questions about its advertising itself to be THE leader of the moderate or centrist blogosphere. When you put yourself out there as a flagship, you can’t expect everyone to just shut up and accept it without comment when the reality diverges blatantly from the advertising, eh?
Also, it would be a lot easier to differentiate among TMV authors if they weren’t so frequently in ideological lockstep with both each other and the Democratic National Committee and if the few (supposedly) right-of-center voices on TMV weren’t forced into a perpetual apologetic crouch about it.
But I do appreciate your and other TMV admins’ assistance today and I made a point of defending TMV on one of your own comment threads today regarding that issue. And I have no desire to drive anyone out of business or drive their hits down. Unlike TMV’s policy at times in the past and possibly present, we don’t do blacklists here. We prefer open debate with our critics, providing of course that they are themselves willing to come out into the open about it. I would suggest that perhaps TMV can stop asking people to shut up about their doubts about its claim to be the flagship of the centrist blogosphere and start trying a little harder to actually BE centrist and moderate in both its content and the way that it deals with others. What say you?
Nonetheless, it was perhaps an unnecessary distraction to put in a post, though I would defend myself by pointing out that it is a frustration to not have ANY alternatives available for communicating these objections to TMV’s continuing pattern of poor execution of its self-proclaimed leadership position in the moderate/centrist blogosphere.
Well Jason, TMV’s editor-in-chief has things flowing a certain way and I respect that. I still think it’s wrong that you say that TMV as a whole tells people to “shut up about their doubts” but hey, I don’t want to continue to hijack your thread. Take care!
” I’m saying that screwing the Republicans should not be the goal of health care reform. Creating a good system should be the goal of health care reform.”
It’s not perfectly apparent that *not* screwing over the minority party is a necessary step to creating a good system.
“Democrats wanted to create a bipartisan working group tasked with evaluating all the relevant issues and tradeoffs”
With the ones currently in congress? Their lack of good faith in the entire concept of eking out a solution is quite clear considering they saw fit to throw a tiny spreadsheet out there. That’s not how you give people the impression that your input is of any use. They can talk all you want about bureaucrats between patient and doctor and “Europe” and whatnot. They are good at the media game, so let them play it while the bill gets done over their heads. If they start to show commitment to pragmatic and well-made input then they can use the notion of bipartisanship to demand a slowing of the process.
“It would also allow the issue to be debated in the context of elections instead of rammed through by a partisan majority insulated from accountability by short memories and a hopelessly biased media.”
So you are saying the democrats need to wait until they are less advantaged because the media (who regularly feature right-wing talking heads on this issue) isn’t doing its job properly. I forget that’s the basic rule in politics – democrats are not allowed to earn the advantage.
“Really? Where? Show me.”
I misread the post – they are not invited invited into the house committees (because they are retired, and no longer part of congress) but they have provided a solid document of input rather than just complain, shifting the onus over to the democrats.
http://blogs.tnr.com/tnr/blogs/the_treatment/archive/2009/06/17/what-bipartisanship-might-look-like.aspx
“Here you go treating all Republicans as if they were a monolithic whole intractably opposed to everything and lumping me in with them. ”
I should have said “congressional GOP”.
“Kent Conrad’s compromise proposal … is an explicit outreach to them.”
And it’s another poorly thought-out bill that demands more attention than it’s due under the guise of bipartisanship.
http://blogs.tnr.com/tnr/blogs/the_treatment/archive/2009/06/14/hacker.aspx
Once again, the major impression is that the congressional GOP is emotionally attached to rejecting any meaningful and useful discussion on a working public plan, and are abusing the ideas of bipartisanship and power balance in order to stall and inject as much of their talking points into the discourse as possible. Most don’t seem as if they can be of any benefit to US citizens on this issue whatsoever, but if they start being serious and act in good faith they must immediately be given more attention.
No, the democrats should be swift about this and actually act as if they’ve won (for once) and not allow any input that isn’t up to snuff – for the sake of their constituents and their own political gain (a weakened bill will not be as beneficial, and the democrats will not be able to hide behind the few GOP congressmen they’ll be able to attract with the watered-down bill once this happens). They are in the majority and they have a good shot to actually get a bill through without wharrgarbl rather than wait for the problem to balloon further. The general public will not be merciful if they get cold feet and let special interests take precedence over voters, and the republicans will not pass up the opportunity to blame any ensuing HC problems on them. Not all democrats are welcome voices in the debate but it doesn’t seem as if taking a slower tack will lead to better input from the other side of the aisle. A 4-page spreadsheet does not signal good faith, so putting a deadline on the congressional GOP is a good idea. If they do some actual work like Daschle et al. rather than try the memetic route they will shift the onus further towards the democrats. What does a good bill make, and is that doable? That’s all i am interested in, and if they aren’t interested in talking about exactly that then no one should listen to them. They had six years to touch this problem all on their own.
It appears that you continue to treat partisanship as the only important consideration in the health care debate. 100% of your comment is about partisan winning and losing. 0% of your commentary is about the details of what would create a good health care reform package. I think your priorities (or, at least, your only knowledgeable subject) are clear.
There is no point in trying to debate the issue with someone who just wants to use it as a vehicle for partisan vendetta.
” 0% of your commentary is about the details of what would create a good health care reform package.”
That’s because I was focusing on my idea that most of the congressional GOP demanding attention are, in your words, not caring about the details of what would create a good health care reform package. That was the notion I was trying to put forward, so of course I wasn’t talking about the details. The reason I was talking about loathsome winning and losing is because the lack of constructive efforts from the congressional GOP means that there *no longer is a conflict between being utterly concerned with DNC interests and creating good HC reform*. You said the reform shouldn’t be rushed due to a loss of important input, I said that it so happens that the DNC can only focus on in its own gains without denying us improvements of the discussion and the resulting reform because the GOP congress can’ muster more than a measly spreadsheet after *decades* of the problem growing. Satan almighty!
“There is no point in trying to debate the issue with someone who just wants to use it as a vehicle for partisan vendetta.”
You say there is a conflict between democrat partisan interests and the progression towards an optimal environment for the creation of a good HC reform bill. I say there is not because the upper echelons of the GOP no longer represent the interests of their constituents and neither does the scaredy-cat democrats who want to appeal to the few GOP congressional members who might be swayed if the bill becomes impotent enough.
China is going towards UHC, because while they might be ruled by a self-satisfied party of gangsters they change things that do not work. In America too many rich people have become addicted to the current employer-oriented HC system, so naturally there will be much resistance to changing the tax exemption.
There are practical and economic concerns among McCain and Obama voters that all need to be addressed, and they are not represented by Gregg or any of the other GOP congressmen whose addition to the debate so far is an embarrassing spreadsheet and the amusing idea that Washington bureaucrats are bad compared to the status quo even when the status quo is choc-a-block with bureaucrats who have a profit incentive to not be customer-oriented and actually provide HC.
Except for those interested primarily in casting blame or otherwise just “bashing” the Republicans, this would be a complete irrelevant subject to focus upon in the first place. The fact that you repeatedly choose to make it the exclusive focus of your attention (on this as well as all other issues) exposes your true interests. The fact that you ALWAYS continue with that exclusive focus even when other issues or facets are raised (you always change the subject if necessary) reinforces this interpretation. Even after you are called out on it, you keep on with it. That’s a pretty powerful obsession.
It is also just flatly false logic to assume that just because one side of political opposition is ineffective that the other side’s parochial interests are therefore presumed to be good policy. Lack of effective opposition does not make one right any more than a crazy person in the forest stops being crazy by virtue of the fact that no one is around to articulate his craziness. Your emphasized statement is a clear non-sequitur. Of course, for those who presume the absolute correctness of the Democratic Party anyway and the absolute evilness of any dissent from its proclamations, your statement makes perfect sense. It is therefore not surprising that you would fail to see the underlying illogic.
“Except for those interested primarily in casting blame or otherwise just “bashing” the Republicans, this would be a complete irrelevant subject to focus upon in the first place.”
No, because I was trying to refute your claim that the process shouldn’t be pushed through quickly because this will lead to a worse bill when the GOP congress won’t have a say. I said that the DNC could act selfishly (that is, do things on its own and ignore GOP demands for attention) without hampering a constructive discussion for a good bill. You said that the DNC shouldn’t act in its own interests because this would prioritize partisan politics above serving voters, and I said that since the GOP in congress are being no better than the worst representatives of the left there is no reason for the DNC to be noble and abstemious. When dealing with said claim of yours, I’m not going to talk about the details of HC reform, and of course I am going to push for pro-DNC partisan politics if there is no conflict between democrat selfishness and the legitimate interests of all US voters. Since not pushing ahead with reform and not setting a deadline is not conflicting with the creation of a bill that is effective and fair for all US voters, I can safely shake the pompoms for the “far-left” approach.
But if I see some proper input from the GOP, including people who actually serve in congress today, the onus will shift on to democrats to argue as to why the reform should be pushed through. Seeing as they demand attention despite not offering much more than media memes and spreadsheets, it’s obvious that their critical faculty is either as bad or worse than those of the democrat “purists” and partisans. You can’t balance dung with manure.
Yet again we see your bizarre priorities. You assume that the only reason that anyone should try to create good policies is if the opposition is behaving good enough to deserve them. Apparently, the need of the people to have good, workable policies is unimportant to you. Only the question of what is currently the most convenient meme to bash Republicans with is relevant to you.
You are STILL focusing solely on partisanship among 535 Congressional representatives as the determinant of whether good arguments exist and are worthy of discussion and debate. Are you really that incapable of independent thought that you presume good arguments do not exist unless someone else (actually, only Congressional representatives seem to count) is making them?
I’m done with this. You’ve shown the limits of your knowledge and interests. The only think you know/care about with regards to ANY issue is how the parties in Congress line up after which you choose your side (always Democrats) and start up with your standard talking points about how horrible Republicans are. You don’t seem to know/care about any of the actual issues themselves. You are behaving as the very paragon of a partisan hack and as a political independent I have no interest in those petty games. A real health care debate requires analyzing the details of the relevant issues REGARDLESS of whether Republican Congressional representatives (or that subset that you choose to acknowledge when convenient) participate or not.
Except of course when the subject of the post is partisan “inside baseball”, I will consider any of your future attempts to change the subject of comment threads away from actual issues to purely partisan bashing to be off-topic and your comments will be ignored or deleted as necessary.
I have some follow-up questions for Jeb and a few ideas that I wanted to just throw out there, as a non-expert on this subject. This thread may be losing steam now, so I may have to follow-up with this topic is revisted.
Jeb: how are you defining and measuring “parity in results” for purposes of comparing the relative performances of different nation’s health systems? I would be concerned about the difficulty in isolating the most relevant variables. For example, there’s that WHO study, which ranked the U.S. 37th out of 119 in performance. However, the WHO formula produced misleading results. For exmaple, it appears to use a non-standardized measure of life expectancy, which does not account for different rates of poverty, homicides, accidents, tobacco and alcohol usage, as well as differences in dietary habits, culture, etc. If you remove homicide and accident rates from the picture, the U.S. has very high average life expectancy. The WHO study also makes other assumptions about performance that are subject to debate.
The U.S. tends to have more diverse demographics and unplanned immigration, and higher poverty and birth out of wedlock rates than other highly advanced economies. So, while it is a concern that the U.S. has not scored well in terms of preventable deaths, this too could be complicated by other variables. Once diagnosed, Americans have a higher survival rate than any other countries on earth for 13 of the 16 most common types of cancer.
Here’s my “back of the envelope” proposal for health care reform, which I put together in about 10 minutes. Obviosuly, this proposal is a complete stab in the dark, but if someone put a gun to my head and demanded that I predict which proposal is likely to deliver more bang-for-the-buck, mine or the current Baucus proposal making the rounds of Congress, my money is on ME. I actually prefer to take Jason’s advice and insist that our elected officials create a panel to study and debate this issue in detail and then make recommendations no sooner than, say, next summer. But everyone seems to be in a hurry, so here goes . . .
Basic structure = a reverse French model. Instead of a large public plan with a small private supplementary option (sickness insurance, extra prescription drug coverage), do the opposite: a very small public plan that covers ONLY 2 annual visits to a general practitioner primarily for purposes of screening for preventable diseases.
Malpractice reform
Tax reform
Medicare reform: for example, stop incentivizing students to go into specialties instead of general practice.
Increase financial aid to medical students who commit to a certain number of years in general practice.
“You assume that the only reason that anyone should try to create good policies is if the opposition is behaving good enough to deserve them.”
Nooooo. I’m saying that there’s nothing wrong with being a partisan as long as this won’t impede the quality of the reforms, bills etc. The reason I bashed republicans was because the reason I think democrats can run ahead with HC reform is because the GOP congressmen are deserving of bashing. I can happily come out of the closet as an anti-republican partisan, but the reason I pursue my hobby in this thread is because that is my main argument for saying that there is no reason to take things slowly with the reform.
“Apparently, the need of the people to have good, workable policies is unimportant to you.”
BzzzZZT! As I’ve specifically said a couple of times, I think the democrats can run ahead because the rightists who are supposed to create a more diverse and multi-perspectivized basis for reform (that is, those elected to congress) are doing a poor job. Once again; there doesn’t seem to be any conflict between screwing the congressional GOP while cheering the “non-centrist” democrats and caring for all the Americans who deserve a decent bill that has been subject to proper scrutiny. We’re not losing out on any decent advice or input by going ahead, so I’ll gladly be a left-wing partisan supreme here.
“You are STILL focusing solely on partisanship among 535 Congressional representatives as the determinant of whether good arguments exist and are worthy of discussion and debate.”
Things can change. The GOP congressmen can stop sucking at their job, and then the onus will be on the democrats, who then should be asked to take things slowly once again. My position is based on the quality of the input by the congressional GOP so far. *They* are solely concerned with their own partisan gains and narratives, and spend all their time being every bit as nuanced and useful to the creation of a good bill as the average DKos commentator, so why should we assume they’ll shape up as soon as the democrats stop being so mean? If they do give me the impression we could be losing out on meaningful input if things go to quickly I’ll want things to go at a more sedate pace as well. That’s a big “if”. The reason I can only be concerned with the interests of the DNC is because this position does not conflict with the interests of all US citizens regarding this issue. There are good and bad ideas, voices, perspectives and POVs on offer from the entire left-wing political body.
But since the congressional representatives of the GOP don’t seem to be any better than the most partisan and ideological parts of the congressional parts of the DNC, why should the congressional part of the DNC assume the congressional part of the GOP might shape up in the future? 50 % of self-described republicans (not that many of all the US voters) are happy with a public option, and they should be heeded because they will have a more critical eye. Their “representatives”, meanwhile talk about “Washington bureaucrats” in order to keep their insurance lobbyists from competition and change from the comfy status quo, so it is not as if the DNC are cheating some Americans from representation. These “centrist” democrats are only being “reasonable ” because they themselves come from states where one or a few insurance companies have staked out a safe, trouble-free market while not having to bother with pleasing the customer and all that jazz. I wonder why these insurance companies are so important to protect when they can’t even handle actual competition unlike all other successful companies, but I guess one can create an answer to that if one often plays golf with or receive donations from said companies.
I know democrats are never supposed to win or show any backbone, but they are perfectly capable of enforcing that rule themselves.
“I will consider any of your future attempts to change the subject of comment threads away from actual issues to purely partisan bashing to be off-topic”
You say the reform should not be put through quickly without GOP input, I say that since the GOP congressmen are not giving people the impression that they will approach the discussion with good input and good faith they can be ignored and the reform should be moved on swiftly. When the reason I bashed the GOP was in order to refute your claim – the main topic of the thread – how can it be off-topic? The actual issue might be HC, but if you read your article you’ll find that you asserted that it would not be in our interest if the congressional GOP was railroaded. I said that no one will lose out on important additions to the HC issue, because the GOP congressmen are beholden more to their upper-strata lobbyists and ideological purists than the idea of working to create a good bill tested from many POVs.
You set down the playing field, and since your assertion stemmed from your notion that the GOPs in congress might be important to the debate, I voiced my on-topic notion that the GOP congressmen so far haven’t offered anything constructive. But if they stop being partisan “socialist”-labelers they will earn a wider window for giving input. Once again, a big “if”.
“I actually prefer to take Jason’s advice and insist that our elected officials create a panel to study and debate this issue in detail and then make recommendations no sooner than, say, next summer.”
As long as there are some standards as for who should be on the panel, and as long as lobbyist-beholden people like Baucus can’t keep a lockdown on meaningful change. Keep the unions and the insurance company lobbyists out of it, and focus only on getting the best possible C.B.O. score. Also, start changing the reality for hospitals and its employees. As of now doctors can make much more money (which they need considering it costs 170 billion dollars to become a doctor) being expensive specialists with expensive equipment rather than provide care and check-ups.
This line reminds me of Boy George’s infamous apology to a gay rights group in the 1990s for having stayed in the closet so long. The reaction from most of the gay rights group (and pretty much everyone else) was: “You were in the closet?”
I said nothing of the kind. I said that reform should not be put through quickly without input, evaluation, and debate by non-partisan experts. No where does the original post mention Republicans except in their reliable role of boogeyman used by Democratic apologists to receive blame no matter what.
So I guess with you we’re back to lying about what other people did or did not say? Are you trying to get yourself banned again? It certainly appears so and if it continues for another round, I’ll gladly accommodate you.
FYI, here is my quotation on the subject which you have repeatedly ignored and misrepresented in your increasingly desperate contortions trying to explain away your obsessive fixation with partisanship at the expense of actual issues:
Sorry for the mixed metaphor. By bringing so many weapons to the argument, maybe I was trying to stimulate the emergency services sector.
I think people like me are more adverse to the idea of ideologues who’ll blame all failures on the democrats anyway get to influence the bill just because they co-opt the idea of bipartisanship. The partisanship here is not dual – it is only meant to exclude the blustering and useless GOP congressmen, not meant to let the DNC congressmen solely dictate what good reform would look like. I don’t have an interest in ideology either, and the more experts that get to steer the DNC’s work, the smaller the chance that the reform will blow up in their faces by the 2010 midterms or later.
I misunderstood: seeing as bipartisanship incorporates “bi” and “party” I assumed this meant that reform shouldn’t be hastened due to the possibly important input from the GOP congressmen, which so far isn’t apparent, supposedly hostile media or no. Any and all experts are more than welcome.
Patrick
I am combining the WHO stats (infant mortality, life expectancy, etc.) with personal experience*. As you mentioned, the WHO stats in isolation place us in 37th place and some of the stats are questionable as we don’t necessarily use the same definitions and our populations have different issues. The WHO tried to correct for this, but who knows how successful they were. My guess based on looking at the data in the WHO report and personal experience is near parity in health care service provided (for those we provide it to). Some of the stats are quite straight forward (doctors, nurses, and hospital beds per capita). We are lagging quite far behind on at least 2 of 3. I think that needs to be addressed.
Re: the wait.
The wait is approaching 2 decades. There has been active engagement and study on this issue going back even further. IMO yet one more study group will not make a dimes worth of difference. The primary opposition’s position is simply, NO! Simple negation is not constructive engagement. Now after actively blocking every attempt at universal coverage for nearly two decades it is time to slow down and create a working group. Pardon me if I don’t take calls for yet another year of delay from those who have been delaying since 1993 without a shaker of salt.
Re: your proposal(s)
I would prefer the Dutch model to the French, but a French model scaled up a bit from where you place it would be better than our current model for delivering quality care to near all of our population. Mandates are a must for this to work.
Malpractice reform is necessary, but the devil is in the details. I think that this is a 2-5% problem, but every bit helps.
I’m not sure how tax reform is related? Are you talking about taxing benefits?
Agreed, but that needs to be combined with an overall increase in the number of doctors. To this end the accreditation process for medical schools might need tweaking. The number of medical schools needs to be increased as do the number of berths in nursing programs. Increase the responsibilities of LPNs and RNs along with increasing their number. We absolutely must increase supply if we are to get costs under control.
* My personal experience with Western European health care, limited primarily to the Netherlands, but bits in France and Germany and input from friends all around Europe, would indicate that any differences in quality of care are minimal. I was always seen the same day and the care received was generally excellent. My friends and relatives that had much more serious health concerns than I was were also quite well taken care of and rarely had to wait and then not for long.
Jason,
The Institute of Medicine for the National Academy of Science has done some excellent work already as have others. The Senate Finance Committee has been hearing expert testimony from a variety of non-partisan sources.
The work you are asking for has largely been done over the past two decades. Most of that work of collection has been done by Democrats, not because of their partisan nature, but because Republicans did not choose to engage in the process other than to say NO and remind Democrats of their failure in 1993.
I am not inherently opposed to yet another working group, but IMO it will provide no information that is not already available, will be used as yet another delaying tactic, and when the report comes out it will change nothing in the final bill.
Wow. You just keep on proving my point for me, Kast. Even your hope for success is motivated by a desire to prevent partisan damage to Democrats rather than health for Americans. I’m sure you want Americans to be healthy also (as a secondary consideration which you will no doubt now claim now that you have been reminded), but your primary interest remains exclusively fixated on the effects that the policy will have on the 2010 midterms and Democrats’ other electoral prospects.
It really is all about partisanship, nothing else, with you, isn’t it?
Jeb, given the huge scope of this change (20% of the entire economy, slated to grow to nearly 50% in the near future), I don’t think it is appropriate to just assume that all the discussion and debating has been done already. Even existing reports and studies can benefit from a comprehensive once-over of the entire range of information, taking into account the interactions between that compiled base of information and current-day demographic, economic, and financial forecasts before we act. Unless, like Kastanj, the only thing we really care about is scoring a “win” for Democrats and a “loss” for Republicans, I think designing a program to improve health care for all Americans deserves a methodical approach EVEN IF that approach might be temporarily frustrating for the impatient partisans and the intolerant purists.
Jeb, one of the advantages to creating a very small public plan is that it would not compete with private coverage. You suggest the Dutch model as an alternative. Apparantly it does not have a direct public plan. However, according to the WHO, the Dutch system is 62 percent government funded, which sounds quite high.
As you have pointed out, health care in the U.S. is considered to be relatively costly. Significantly increasing the ratio of government funding to private funding is very likely to either raise the per capita costs even more or require rationing. Part of the problem now, it seems, is that Medicare is helping to drive more activities in the medical specialist fields than would otherwise occur, and that contributes to the higher costs. In addition, the tax exclusion for employer provided health insurance also distorts the market in that it leads to mismatches – e.g., single professionals in prime health are given the same “cadillac” plans are their married-with-children or middle-aged coworkers. There are other market distortions as well. What happens if we were to layer a Dutch model over the existing public investments in employer provided health care, Medicare, Medicaid, military system, SCHIP, etc.? Or, are you proposing a complete overhaul?
Another issue with the Dutch system is that it mandates coverage. In addition to being simply un-American, that would only exacerbate the cost problems. Twentysomething nmarried singles should have the option of purchasing cheap, very scaled down insurance policies against catastrophic health events, or nothing at all. It is illogical and uneconomical to require them to purchase anything more than that. I could see maybe setting up a cheap public plan for them, where they could check off a box on their tax returns, and for maybe $80/year they would get catastrophic coverage from the feds, with a promise of being placed in the “system” under certain conditions. Then, on top of that, the government would pay for everyone to take up to 2 annual visits to a general practitioner, mostly to screen for preventable illnesses. But again the public plans cannot compete with the private plans, or you end up with the French system whether you want it or not – basically, well off people will buy supplemental plans to cover extras, but the public plans will squeeze out the baseline private coverages.
We really should reform the tax exclusion, but if we were to do that, we should offer a individual tax exclusion or credit to all qualifying taxpayers. Then, from a regulatory p.o.v. we could roughly copy the Dutch: make it so that consumers would have the option of buying scaled-down plans (more scaled down than the Dutch minimums) from anywhere in the U.S., or aborad for that matter, as long as they offered the basics in a satisfactory manner. These plans could be purchased to cover things in addition to the 2 annual general practitioner visits covered by the feds.
Basically, my proposal would be to create a very-scaled down public plan at the same time that we introduce a series of market-oriented reforms. That would have wide support and would be more likely to contain escalating costs.
There is also danger of mandates from the opposition direction from rationing, Patrick. Would the government order me to go to the doctor to receive preventative tests, like a colonoscopy? And if I refused or if I missed a test, would I be committing a crime? Would I be subject to loss of all coverage? What about government mandates regarding health choices like smoking tobacco (marijuana smoking is exempt, of course), drinking alcohol, or unprotected sex? Would the government use the lever of health care coverage mandates to coerce personal behavior in these areas? Might they mandate personal exercise programs?
Some of these scenarios may sound laughable, but only until one looks at the rhetoric and proposals of self-appointed “fitness” advocates who are salivating at the prospects of being able to force those dumb, stupid, self-destructive Americans to shape up.
Of course, some people (e.g. Kastanj) don’t want us to talk about details beyond the partisan talking points, but these kinds of scenarios are precisely why the details are so important. Small changes in the way the program is authorized, funded, and structured can have huge second-order effects once the bureaucrats and activists get hold of it.
As I said I have not inherent objection, but doubt that it will uncover any new information or meaningfully shift policy. I also am near certain that regardless of how much time is spent and research done the chorus calling for more time and study will not substantially diminish.
Well, Jeb, assuming that ALL critics have bad intentions that will never be satisfied is certainly a popular method among liberals these days of avoiding dealing with ALL criticism, but I don’t think such assumptions should form the basis of a healthy policy development process.
“Even your hope for success is motivated by a desire to prevent partisan damage to Democrats rather than health for Americans.”
If you want to fill in the blanks any way you want I don’t have any reason to stop you. When i say that the bill won’t explode in their faces due to expert input, am I not also saying that the bill won’t be lacking in efficiency and stability? You can’t have democrat gains here without a successful reform.
“And if I refused or if I missed a test, would I be committing a crime?”
No, but you might be in line for some sort of fine, provided there is a collective option. After all, you can’t expect people to chip in for your HC unless you are ready to check if your skin won’t fall off next year at a great cost for all other tax payers. Here in Sweden no one is forced to undergo anything under the threat of a fine. There is no duty involved, and I’m not sure of any other country with collective paying for the collective HC that demands it.
I guess the idea is that everyone are forced to get insurance considering the bill is footed by them and other tax payers. Considering this system cannot be opted out of, I don’t think the government should impose too much control on people to ensure healthiness. The fact that Americans in general munch too much sodium, sugar and anti-depressants is related to HC and its costs, but if you can’t choose whether to have others pay for you or not, the expectations from the government on you to stay healthy or suffer repercussions should not be higher than in any other nation with a similar system. In the current system your insurance premium goes up by all numbers of factors, so your lifestyle choices and other circumstances already affect you negatively – you are punished for being more probable to be costly in the future. I don’t think a system where everybody have to get HC insurance will be that attractive if you need to visit a proctologist much more often if your BMI isn’t up to snuff. Choosing one punitive life-coach for another is not a choice people should have to make.
No one wants to be unhealthy after all, but it all accumulates. I’m so thin I have to jog around in the shower in order to get wet, and I don’t have any problem paying to have some hypothetical obese homophobe racist get his problems sorted out, and AFAIK he doesn’t have to pay extra because of his destructive lifestyle.
One person could be sitting at home, eating chips and being safe, while the person driving to the gym finds his car wrapped around a streetlight with him thrown out the windshield. Should the fitness expert have to pay more because he drives to places? No, not even if he only drives short distances. Beyond the blatant, clear-cut and logical cases, you can’t put human behavior in a mathematical function and get a fair set of taxes for each person.
Even if the government abstains from punishing people who make bad choices (people already have to pay taxes in order to provide for people who make bad choices regarding their own health, mostly because they lack insurance) there is still the fact that the government might get the idea that punishing some goods and foods will not only bring in more money but will also lower HC costs. Well, there are certain impositions that make sense financially and medicinally, but that is not a good rationale for banning things. I guess that is an important concern – what will happen when the government has a financial stake in keeping people from the hospitals?
Could we like, ban the government from banning or putting new taxes on things?
The only possible inference to take from your repetition of this is that you see successful health care reform not as an end in itself but as mere means to the greater end of “democrat [sic] gains”.
That’s my whole point — that I think your priorities are sickly twisted.
And the authoritarian underpinnings of the left reveal themselves yet again. Next up: Mandatory morning exercises for everyone, monitored by the government through your in-home telescreen. And mandatory weekly blood tests to ensure that no one consumes too much sodium. It’s all for your own good, of course!
I see now why you were avoiding discussing any specifics beyond mere partisan gaming — once your preferences are revealed, anyone who cares even a little bit about personal privacy and freedom will be repelled by your agenda.
I don’t see that added competition as a bug.
The WHO has our contribution at between 45% and 54% if memory serves. In that context 62% isn’t such a high level.
What evidence is there that higher government contribution to health care costs increases per capita costs. That every industrialized nation has a greater % of government contribution and yet all pay far less and that all but Luxembourg have a slower rate of growth in costs seems to be evidence to the contrary.
Re: rationing,
We already have rationing based on ability to pay.
Without this ‘distortion’ (risk spreading) those middle-aged and older workers would be quickly priced out of the market. If we are to approach universal care there must be more rather than less spreading of risk.
That would be my preference, but it will not happen. Given that incremental change is all we will get, the French model might be a better fit. We are not all that far from the French model as it is.
No more than mandated car insurance.
Only in so far as mandates can increase demand by bringing in the previously uninsured.
and if the sceening(s) came back positive? What then for the twenty something that has chosen to forgo coverage? Now they have a pre-existing condition and no insurance company will have them.
That would also require subsidies to those who could not afford coverage. The Dutch minimums do not seem exorbitant to me.
Look to the systems that have been proposed as models (France, Germany, the Netherlands) and at the proposed systems on the table now (Obama’s and those of the congressional dems). The answer to your hypotheticals in all of those cases is no.
“And the authoritarian underpinnings of the left reveal themselves yet again.”
Yeah, ignore the entire rest of my post while you are at it. If they want to give you a *free* check-up to see if there is anything bad brewing inside of you that could be prevented (such as breast cancer) it is not authoritarian to ask someone to allow doctors to investigate whether you might suddenly become a huge fiscal drain in the future, if you go unchecked. So I get to be chewed out for saddling all of the GOP with a resistance to the public option but I am a representative for the *entire* left? You are way too enamored with your own armchair theorizing.
“Next up: Mandatory morning exercises for everyone, monitored by the government through your in-home telescreen. And mandatory weekly blood tests to ensure that no one consumes too much sodium.”
Don’t forget the nanomachines we put in the polio vaccinations and the agreement with the Betelgeusians to sell of all neocons as slave labor…
When everybody share the same costs, risks and commons, it is not irrational to demand people to come in for *free* to see if there is anything preventable that would not only cost all fellow citizens a lot more in the future if you were left unattended, but would also cause more suffering and risks for you. Having your car checked off and scrutinized is a hassle, but it is mandatory for a reason, and you are punished if you drive around without being having your car green-lighted for safety concerns. There is no reason to think the US government will force any check-ups on citizens anyway, but even if this is the case it is not so sinister and authoritarian considering the shared costs (it would be more costly for everybody very soon if people didn’t have to have their cars okayed by mechanics).
Please stop misrepresenting what I have said.
I have responded to you point by point and have quoted you directly rather than misrepresenting what you have said. It would be appreciated if you would extend the same courtesy.
Now again what I said was,
I have seen nothing to make me think this analysis is incorrect. Do you really think that most of those calling for delay now would not be calling for delay a year from now? or a year from then?
I stand behind what I said — you seem to be resisting the imperative to be comprehensive and methodical in approaching health care reform because you PRESUME that all the critics of health care reform are ill-intentioned and impossible to satisfy and therefore you conclude that any time taken to be careful would merely be coopted as an excuse for indefinite delay.
I don’t think I misrepresented what you said at all, as your rhetorical questions reinforce my interpretation. Please explain how I did so.
Jeb, I’m trying to learn how to use the block quotes, but I’m not yet ready to use multiple blocks in one comment . . .
Most economists anticipate that a susidized, competitive public plan will drive private insurers out of the market. As per a June 10, 2009 NYT article, the A.M.A. opposed creating a public health insurance option for non-disabled individuals under age 65 because it would raise costs while restricting patient choice as private insurers went by the wayside. If we create a competitive public plan, eventually American consumers, like the French, will have the option of purchasing private “boutique” supplemental plans, but the baseline packages will be provided mostly/entirely by public plans. At that point, the government is in the position of having to centrally plan the health care system because there is no longer a market setting prices. Not only would that lead to a system failure; it would have very negative ramifications in terms of individual liberties, personal responsibility, government accountability, civic activities, etc.
Come to think of it, I wonder what would happen to the vaunted European health care systems if there is no longer the huge U.S. market setting some sort of price targets, even if it’s happening now from across the Atlantic. I realize that the current U.S. health care system functions within what is only nominally a private market, which is distorted by various policy inputs, but if the U.S. system were to become unmoored from market pricing mechanisms altogether, who knows what will happen. The U.S. has almost 1/4 of the world’s GDP. The “Eurozone” accounts for almost another 1/4. Perhaps one of the reasons that the E.U. countries have been anxious about the recent direction of American economic policy is that the U.S. market obviously plays a central role in setting world market prices.
Evidence that higher government contribution to health care costs increases per capita costs? That’s a fair challenge, which is unfortunately not as easily overcome as I wish it were. Government can be quite efficient in the short run. Keep in mind also that, in 21st century “corporatist” capitalism, it can be very difficult to untangle the state from the private market. Likewise, I think many proposals to “reform” health care tangles them up as well.
I did notice that you try to have it both ways by arguing that we should not worry about reaching Dutch levels of public funding (62 percent) because we’re almost there now (55 – 60 percent); then you then turn around and argue that every industrialized nation has a greater percent of government contribution and yet all pay far less for health care. What, greater by 5 – 10 percent? Are we to assume that slightly increasing our public funding component will enable the U.S. health care system to pay FAR less to get even more performance?
More likely, you’re suggesting that our current public investments are not well spent. I agree, but maybe you can see why I might be skeptical that increasing public funding will necessarily be an improvement. If the government policy has hitherto butchered things as badly as you have described, why should we now trust government to get it right? Not only that, how will incrementally layering more government “fixes” onto the previous “fixes” result in a better system?
I happen to believe that if you remove the non-relevant variables, the U.S. health system performs as one of the best in the world. The big underlying cost drivers cannot be corrected by the market or by policy: aging population, longer average life expectancy, sky high expectations, the young spending so many years in the educational system instead of paying into the “system,” etc.
If the U.S. had a more true market-oriented system, the rising costs would be less of a problem; however, fewer people could afford access to life saving treatments (although not as many as you think). We do not, and should not, treat healthcare as we do other services and commodities. So, I would never suggest that we go back to a “sink or swim” approach. I am suggesting that existing government policies contribute to the rising costs, whether they are packaged as a “public plan” or not.
Could we “fix” some of the current messes and inefficiencies by shifting to a mostly public system? To a degree, yes. But we have to be careful about what the precedents set today will mean 25 – 50 years down the road. Historically, heavily centralized governments often had a knack for streamlining things and getting the trains to run on time. If you think a relatively free market can be cruel, brother you ‘aint see nothing yet.
Indeed, I think you underestimate the implications of government rationing when you state that “we already have rationing based on ability to pay.” Today, many families have to make tough, anguished, even heartbreaking choices about health care. Under rationing, a government bureaucrat or computer will make the choices that break the hearts of families and, in the process, the government keeps getting bigger and less accountable.
I think I have a solution.
A 20 percent VAT whose money goes directly to healthcare run by the government. The government then purchases health care from Insurance companies. 100 percent free and 100 percent paid.
Employers are freed of the responsibility of paying for health care. This freed up money is then used to stimulate new jobs. Americans do not have to pay for health care but are required to pay a 25 percent VAT on everything.
The taxes on the rich are raised by 12 percent. This money is used to balance the budget and pay down the debt. AT the end of 13 years the debt is retired.
I was offering a piece of evidence counter to the assertion that increased government contribution necessarily equates to higher per capita health care costs. The government share in the US is in the neighborhood of 45-55% and the EU nations are generally in the range of 60-80%. The Netherlands is on the lower end of that spectrum. We are talking about an increase of 10-15% up to in the neighborhood of 60% government contribution to the US health care system. The gap is there, but it is not near so large as most on both sides of the debate pretend. If one were to listen to the talking heads on the subject it would seem that we have a market system in America and we are talking about socializing it. In truth the contrast is much less stark. We have a hybrid system with near parity in contributions from public and private sources and are talking about increasing the public contribution by 10-15%. I am not trying to have it both ways I am pointing out that while there are differences between our model and the European models the differences, particularly to the French model, are not nearly so great as they are made out to be.
No. I think that we can cover more people and that there is considerable potential for administrative savings. Looking at admin costs in the various systems, I would guess that potential savings are in the 10-15% range. By way of comparison, tort reform has a potential savings in the neighborhood of 5-10%.
I am participating in multiple conversations and am not certain at this point what I said where, but I believe I made that clear either in this thread or in another on this site, if not my apologies.
That was not what I was saying, though the moneys could be spent better*. I am saying that we have a haphazzard patchwork approach rather than a unified whole.
* This is equally true of HMOs, so I don’t see it as a distinguishing feature.
We currently have ~13% of the population (~40 million) uninsured, most of those because they cannot afford insurance. These people are effectively rationed out of most common medical care and certainly out of joint replacement surgeries and other treatments that are pointed to as rationing boondoggles in the UK and Canada. We are able to have relatively shorter waits because those who cannot pay are rationed out of the system. If we were to institute a single payer system like that in the UK or Canada (virtually impossible in the US) might there be rationing by bureaucrats? Certainly. Would that rationing be more restrictive to more people than or current price and HMO denial scheme? Who knows.
blockquotes just requite the tag blockquote within the and /blockquote within the carats to close the tag. Bold requires strong and /strong respectively within the carats. It is easy to miss a close tag as you can see from my earlier comment. It would be nice if they included a preview option here so we could check for simple errors.
I think that restricted supply is among the largest cost drivers and it can be corrected or at least mitigated by policies directed at increasing supply of doctors and nurses, coupled with increased responsibilities for nurses. This is an issue that neither party seems willing to tackle. The only reason I can think of is fear of going up against the AMA, though I would love to here a different hypothesis.
No.
1) I have not to this point used ALL either explicitly or implicitly in reference to any group. You added those words not me. It is not an honest characterization of what I stated.
2) I do not accept that the process over the past 15 years has not been comprehensive and methodical.
3) I think that yet another fact finding commission will accomplish exactly what most fact finding commissions accomplish, namely nothing. I also think that it will have minimal effect on any eventual legislation and minimal effect on public perception of any eventual legislation. I don’t doubt that some are sincere in their desire to see a commission help improve the process, but I also have little doubt that those who are leading the Republican party in Washington will seize upon this as yet another delaying tactic and even if it is agreed to there will be some other excuse for delay immediately following, and yet another after that until they are back in power and can simply shelve it again as it has been shelved since 1993.
I also have virtually no doubt that if there is a commission those who disagree with its findings will immediately tar it as illegitimate and argue that its results should be ignored.
As I have said before I am not opposed in principle to a commission. It is possible that it could add a greater perception of legitimacy to the process. I simply don’t think that it will add anything more than that to the process.
A question for you Jason. Why do you think it is that comprehensive health care reform has not been addressed in any meaningful way in congress since the mid 90s? Or do you think it has been meaningfully addressed? If so, when and how?
The application of the theoretical policy frameworks to the specific current demographic, financial, and economic situation. None of these sets of data from 1993 could be useful. Also, medical technology and treatment standards have not been static for the last 15 or even the last 5 years.
I also do not agree that the compilations of activist groups over the last 15 years should simply be presumed to be complete, accurate, and unbiased. It is necessary to submit these to a formal policy development process rather than trying to shortcut the process simply because those activists are ideologically congenial to the political party currently in power.
I’m not suggesting a “fact finding commission” (if you are going to be hypersensitive about adding words, perhaps you should not in the very same message be adding words), but rather a full-fledged policy development process. Health care reform IS going to happen at this point, regardless of whether we presume the evil intentions of Republican critics. Our choice is how to best do it. And my argument is that artificially rushing the process simply to pander to purists OR out of paranoia about powerless Republicans is a really dangerous course of action.
Jeb: in theory, policies that aim to increase supply of doctors and nurses would be beneficial and widely supported. Apparently, the shortages are projected to get worse in the future as baby boomers continue to age. The medical providers offer bonuses to attract new nurses, but I’ve heard that nursing programs are not producing enough graduates in part due to a lack of qualified instructors.
Maybe you can clarify exactly what you would support in terms of health care reform. To summarize your views, as I think I understand them: you’d prefer a major overhaul along the lines of the Dutch model, although you don’t think that’s politically feasible. You would settle for something like the French system that includes a sizable public plan. Is it the Dutch model, or the French model, that would generate 10 – 15 percent savings from greater administrative efficiency? If it’s the latter, it doesn’t sound like we would get much cost savings in return for more government intrusion into private matters (the other cost savings you mention are more likley to be championed by pro-market advocates – tort reform, increasing supply, others?). I’m guessing, though, that you’re also arguing for more government involvement to advance non-economic social equity concerns.
How would the Obama plan improve the current system? How does the Obama plan compare to the Dutch or French models? After negotiations, what do you anticipate is the best incremental reform package that we can expect in the current poltical climate? Isn’t the final Democratic plan likely to contribute even more to the “haphazard patchwork” of a “system” that we have now rather than create a more effective, efficient “unified whole”? If so, and there is very little chance that a relatively unified Dutch, French, or other useful model will be enacted, wouldn’t folks like you be better served by joining with us to concentrate on the market-oriented reforms that we already agree on – tort reform, increasing supply, etc.?
Let me ask you: Would you support a system that delivers only minor improvements across the board – slightly better results and slightly more equity – while very significantly increasing public sector involvement? Please keep in mind that a 50/50 trade, government for private investment, is not really an even trade when you factor in all the unintended side effects.
You do seem to be a proponent of a top down, centralized system (“unified whole”), if not a single payer system. I’m a city planner and this reminds me of folks in my profession who argue that too many jurisdictions doing land use/transportation/economic planning make for a messy, patchwork of rules and regs, conflicting interests, etc. They prefer top down regional (or better yet State) planning authorities to streamline the process, increase efficiency, professionalism, rational decisionmaking. However, this approach also reduces individual choices, popular representation, intra-jurisdictional competition, experimentation, and so forth. Plus the regional/state planners end up being completely overwhelmed with data. The jury is still out on whether they produce greater efficiency.
You did not respond to my concerns about a competitive public plan crowding out the private insurers in the U.S., which in turn would eventually necessitate centralized planning to determine prices, and – with the absence of a semi-private market in the U.S. – could create serious pricing problems in the rest of the world. Are you conceding these points?
My (revised) plan: allow taxpayers the OPTION of checking off a box on their returns to pay a relatively low amount (maybe $175/year) for a very downsized public plan: 2 doctor visits per year, catastrophic coverage, plus auto entry into a full Medicare/Medicaid plan in certain cases. So, if a single adult signs up, tests come back positive, they’re now guaranteed coverage. Yes, this would raise the costs of the general pools, but that would be offset by market reforms, and you could then pass stricter rules against rescission. The small public plan would be subsidized but would not compete with private full coverage plans. Combine this with other previously mentioned market-oriented reforms.
I don’t presume evil intent. I see strong ideological disagreement. The primary objection from the right has not been, ‘your not going about it right’ it is, ‘you shouldn’t be doing it at all’.
and you have stated that you feel all the work that has been done toward that end is just so much partisan politics and that a new framework needs to be set up to address it. How do you picture this framework. I am guessing a presidential panel would not suffice since that would still leave control in Obama’s hands rendering it to no more than a partisan document. A congressional health care commission composed of members acceptable to both parties would take months and putting together a report that all of them were willing to put there names to could make the 9/11 commission look speedy. I would be shocked if it were completed within two years. You may find this the most prudent course of action and you may be much more optimistic about the process, but to me it looks like one more delay that in the end will accomplish little.
Something that I think has been lost in this back and forth is that I also don’t agree with setting an October deadline for a vote. I think that the finance committee should continue to hear from experts and continue to gather information to make the eventual bill as good as it can be, but I don’t think that a commission is the way to go about it.
Not the point I was making.
Congress was presented with the problem in 1993.
What did they do about it from then until the last year or two?
Why do you think that is?
I have been teaching in a feeder program for nurses and it is frustrating to see what the students are put through. There is a two year wait list for the nursing schools here in the Bay Area, there is a shortage of venues willing to take on enough student for internships, a shortage of instructors for the nursing schools, a shortage of facilities…
If memory serves both have better than a 20% difference in admin costs compared with us. I doubt we would net the entire difference, particularly since we will almost certainly do this piecemeal. I think with a radical overhaul we could realize 10-15% of that and with the piecemeal approach we will likely end up with less.
If you mean that I think that having ~40 million people in this country without adequate health care is a moral issue then yes.
Obama’s plan takes elements of the French system. The primary similarity is the expansion of Medicare (and like programs) and government employee insurance. Employer based health care will remain for bottom up coverage unlike in France. Also unlike the French model there are tax breaks to buy ground up insurance either from either a private or public entity. There is loss in administrative savings with this approach but most Americans are covered by employer provided health care and like it that way. I think that we would be better off decoupling employment and health care, but I am afraid that is not a political possibility. Pooling employers to reduce costs is an element in his plan and every other plan. Most of the rest is quite specific to our system as it stands now. Some element of tort reform is included, etc.
No. I think that France, Germany, and others along with the wealth of Medigap insurances are testimony to the ability of private insurers to find a way when confronted with a public provider. The public provider is after all taking the business with the lowest margins. Given that any plan for the US in the foreseeable future will leave employer provided bottom up coverage I think that it is even less of a concern.
Add a couple layers of coverage to include more available screenings and some more basic medical care and means test for contribution and we are close.
What will stop employers from simply dumping their health care benefits programs under the assumption that employees could now simply sign up for the “public option”? Doesn’t the argument about cheaper auto manufacturing assume that the auto companies will do exactly that?
Well that’s not because of the evil corporations and insurance companies, though, Jeb. It is because no one has the slightest idea how to pay for a single-payer health care system, especially given the deplorable fiscal state of our country right now.
And let’s not forget that the infamous Clinton health care plan which you apparently believe to have been a fine proposal combined the worst elements of complete government control with “employer mandates” that tried to force business to foot the bill for the 100% government-controlled bureaucracy. It is not, in fact, the case that the only reason that the grand schemes of health care purists have not been fulfilled is because the people who disagree with them are just bad, evil people.
I thiknk they did little to nothing on the truly important parts of the issue because there is no political benefit to actually addressing the practical problems of designing a health care system that can actually be run and paid for. Activist groups have generated rafts of studies for comprehensive health care systems using implausible and ideologically purist hypothetical funding schemes like extreme tax rates on “the rich” or near-total elimination of all military spending, but I don’t consider those proposals to be sound foundations for practical reform.
I think Congress has been doing pretty much what health care purists are doing now — championing the rhetorically easy parts of health care reform when it is politically convenient to do so, but kicking the real problems of paying for it down the road forever. The vast disconnection between what President Obama says his health care plans will cost and what even the Democrats’ own CBO says it will cost if proof positive that the funding issues are not being honestly dealt with even now.
Health care for all is NOT free. Period.
Under the current proposals from what I’ve read the plan will insure the roughly 39,000,000 Americans who dont have insurance now but let another 36,000,000 fall thru the cracks.
So essentially we destroy the American economy and end up right where we are now.
Talking point. I don’t know. I’m not even remotely qualified to talk about health care reform, but I do Know one important fact about life…..NOTHING is free. Everything costs and the plans being thrown out fast and furious after debating this crap for 50 years is junk.
The politicians in DC are trying to give us health care for FREE….well its not free but they are trying the old smoke and mirrors approach to it….hide the cost, delay the fiscal impact and then later on when the PEOPLE begin feeling the real pinch of paying for the poor……..They just all blame it on the other side and the American people buy it because they can’t possibly believe that their favorite Democrat or Republican that they voted for could possibly have messed up.
Nothing is free and this health care fiasco is guaranteed to be the greatest fiasco in a 100 years because we are rushing it thru and trying to hide the impact and cost in double talk.
Among other things state laws.
That is not an argument I have made.
If you look back at my comment you will see my stated reason that it is not a political possibility. Hint, it has nothing to do with evil and is only tangentially related to corporations.
Why do you keep at this ‘evil’ nonsense? I have not once implied evil intent. It is firm ideological disagreement. Please respond to what I write rather than painting over it with what you imagine I mean.
When the party in power is ideologically opposed to the proposition nothing will be done on that front. I submit that the likelihood of a Republican controlled congress or WH passing a universal health care plan is about as likely as a Democratically controlled congress or WH building a complete border fence. Their ideology determined their action, not evil intent. I have been repeatedly explicit about this, yet you continue to put words in my mouth. Again, I would appreciate the courtesy of response to my actual words rather than response to imagined intent.
Come on now. Was it the Republicans’ CBO 3 years ago? No, and it’s not the Democrats’ now.
Where did you come by those figures?
Jeb, you’ve repeatedly indicated in this thread that you see Obama’s plan as an honest proposal for a shift in the private/public hybrid from slightly less than 50:50 to slightly more than 50:50.
I’d be interested to hear your response then to the following videos which indicate that the plan being pushed right now is a thinly veiled attempt to incrementally impose a single payer public health care system.
http://hotair.com/archives/2009/06/12/video-the-public-plan-deception/
http://www.verumserum.com/?p=6413
If the people who developed the current plan, when speaking to friendly audiences (those who favor single payer), admit openly that they know that such a system can’t be sold to the public so they should instead create a Trojan horse of a ‘competive’ model with public and private options- and admitting that this will drive private insurers out of business and ultimately result in single payer system, then why on earth should we believe that Obama and the Democrats who support his plan aren’t attempting to do exactly that?
Yes, it was, and it was certainly treated that way by critics. Yet somehow the reciprocal treatment now is intolerable?
Anyway, any entity which claims to be non-partisan should be treated with skepticism. People For the American Way claims to be non-partisan, as does the National Rifle Association and MoveOn.org. Let’s not be (or pretend to be) naive.
And if you don’t think that the people who work at the CBO know which side butters their bread at any given point in time, I think that’s naive.
This does not mean that the CBO numbers are wrong or intentionally biased, just that we should consider them only as part of the available information and remain open to new analysis or questions about methodology and assumptions. Appeals to supposedly definitive and unbiased sources are usually the province of the intellectually lazy.
CS,
I support a move to a French or Dutch style system because I think those are the best models currently out there. Some may try to move to single payer in the future. If they do so I will oppose it. While the explicit goal is still to move toward a French model I will continue to support it. I think the likelihood of our moving to a single payer system in the foreseeable future is negligible and I am skeptical of slippery slope arguments in general. What legislation is is far more important to my calculus than what may or may not come on its heels.
Advocates for single payer may hope so and some on the right may fear so, but I think that the evidence of systems currently in operation show it to be unlikely. The French have had their system for decades and yet private insurers remain and even thrive. The system proposed here is more limited in scope than is the French system. The same is true in Germany. The same is true for people in this country covered by Medicare.
The quote from Obama expressing support for single payer was from 2003. I think it quite possible that his position has changed in the intervening years.
Later he supports moving away from employer provided insurance to something more portable. As mentioned earlier I think this would be best, but is not a political possibility at present.
His comments (out of context) are interspersed primarily with an activist for single payer with no clear connection to Obama or the legislature.
Two separate points. The fact that the CBO has been quite consistent and has not held back information quite damaging to the party in power then or now indicates to me that they are considerably less partisan than you implied (“the Democrats’ own CBO). The most common political use of CBO reports during the Bush years was by Democrats pointing out the disparity between WH predictions and CBO predictions (this while Republicans still controlled congress). If the CBO reports comported with WH predictions they were ignored by Dems (or dismissed as partisan) and if they strayed from WH predictions they were trumpeted (the inverse was also true). I predict the exact same responses now with roles reversed and lo and behold initial returns look promising for my prediction.
Something else that I think has been lost here is that there are multiple single payer models most of which allow and do have supplemental private insurance and that the usage of this term in the general health care debate is so nebulous that the French or even Dutch systems would qualify as single payer (by the usage I commonly see).
Jeb: several econometric studies have projected that the introduction of a public health plan will indeed “crowd out” the private plans. For a summary of this argument, see recent WSJ article: http://online.wsj.com/article/SB124502127377113741.html
Already there is a lot of cost-shifting from public plans – Medicare and Medicaid – to families enrolled in private plans. Private plans do not compete with private plans on a level field. For example, public insurers can enforce contracts using criminal courts, whereas private insurers must resort to civil courts. Unlike private insurance companies, Medicare and Medicaid cannot fail; they are backed by the U.S. Treasury. Government can use its monopsonistic power to set its own prices, while private insurers cannot.
According to a 2002 study, the French system was more than 76 percent publicly funded. Yes, due to rising health care costs everywhere, private “complimentary” plans are on the rise there, but these are only boutique plans. They do not compete with the government to provide the large “basic” coverages. The public plan has no competition within its domain. Then, private insurers compete against other private imsurers for the leftover, complimentary market.
In contrast, the Dutch model is public funding, paid to private insurers. Again, no competition between private and public plans. I’m still not seeing much evidence that private insurers can compete and/or coexist with government in the same market.
Also, I haven’t seen anyone here make a slippery slope argument, such as “a public plan will inevitably lead to socialized medicine.” Actually, the path to social democracy is being laid out clearly in front of us and health care is moving in that direction: http://www.weeklystandard.com/weblogs/TWSFP/deficit.jpg. But, yes, if the American people have the will, they can go back in the other direction. It’s just that it’s a lot harder to go in reverse than forward.
The French System of health care:
Reimbursement is regulated through uniform rates. The financing is supported by employers, employee contributions, and personal income taxes. The working population has twenty percent of their gross salary deducted at source to fund the social security system.
20 percent of their gross salary JUST for health care. TWENTY percent.
Health care is not free…..and the democrats are going to slip thru a mindbogglingly expensive plan and saddle America for ever with socialism and extremely high taxes.
Frankly America cannot afford health care…Period. We cant balance our budgets so why should we have health care for all? Truth is we cant…not without going bankrupt.