Under Laffer’s outline for patient-centered approach would replace the tax exclusion for employer-provided health insurance with an individual deduction. Along with expanded HSAs, the above employee would find employment that paid him $92,000 a year; he would likely buy his own NON-CADILLAC insurance coverage; he’d pay for many routine costs out-of-pocket, which would make him less likely to demand things that might be a poor investment but, heck, since they’re “free” might as well use ‘em (like name brand meds instead of generic, a nuclear stress test at age 43 without being symptomatic, etc.). This family would be better off while contributing less to health care cost inflation.

As for lower-income families, most would be covered by the vouchers that would replace Medicaid. I admit that you might end up with a lower-middle income segment falling into a “blind spot” but perhaps they could qualify for a small voucher (such as the bartender I mentioned above).

The government DOES dictate Medicare and Medicaid payment rates, though. We can infer from providers’ responses to those payment rates what would happen more generally if the government gained dominance as the primary payer in the health care system more broadly.

Where in my comments do you get that I am advocating government gaining dominance as the primary payer? It is easy but not very worthwhile to tackle straw men.
Consider also that virtually every OECD nation has greater government involvement in dictating medical pricing structures and that almost all of them have greater numbers of doctors per capita. That seems to run counter to your thesis.

This is only true if you assume that lower pay combined with the same risks of exposure to lawsuits will result in an increased number of people wanting to become doctors in the first place.

Your position assumes that med school berths are not being filled and that reasonably qualified people are not being turned away. As long as reasonably qualified candidates are being turned away it seems obvious that more medical schools will mean more people attending medical schools and consequently more doctors.

Mere assertion on your part does not consistute an argument. Try again.

Right back at ya with regards to your original critique of my position.

Yes, I agree. Any massive extension of coverage is going to require substantial and sustained government investment.

You have stateded in earlier posts that the problem of the uninsured is one that needs to be addressed. If you agree that it is a problem that needs addressing and you concede that addressing it will require substantial and sustained government investment then your critique of my position applies equally well to yours. The how will most likely need to involve a number of measures including cuts to other programs, finding savings within the current system, and some new taxes or fees.

Or was your original comment snark using a too-easy rhetorical target instead of a real point about qualifications for getting into medical school?

In part it was an easy target, but the larger point remains that GPA and testing requirements for medical school are not on par with the requirements to be successful in medical school or medicine. Just getting in to medical school is frequently cited as the most difficult part of getting a medical education. That absolutely should not be the case. Do you disagree?

I notice that you did not address the debt incurred to become a doctor. Do you think that this does not need addressing?

Based on your past responses, I gather that you would like to act more quickly, but can you honestly tell me that you would support Senate compromise package in its current form (as reported yesterday in the Washington Post)?

I would have to finish reading it to say. I can say that it is not my preferred option, but I cannot yet say that it is on balance better or worse than the status quo. My point in earlier arguments was not so much that it needs to be pushed through now or sooner if possible, but that many of those who are calling for more time now are precisely the ones who are responsible for putting off the debate until now.

Jeb, I don’t think that HSAs would only benefit the middle class and wealthy.

The professions you cited are all middle class. I don’t have a problem with HSA and I don’t object to them being included in health care reform, but they do little for the lower middle class and the poor.

Instead of penalizing companies for offering “Cadillac” plans, the patient-centered approach would make it so that employers and employees would have to pay for the true value of these coverages in the marketplace, which means they’d probably replace the Cadillac plans with other compensation.

How would that work?

If we’re actually talking about reform, Medicaid is rife with waste and abuse.

Rife seems strong, but there is certainly waste and abuse. Waste and abuse are endemic to large bureaucratic operations (both government and HMOs). I have seen no evidence that the waste and abuse in HMOs is greater than for Medicare. I have seen evidence of higher administrative costs in private health plans, some of it to combat waste and abuse.

The issue about how to deal with state mandates is an anguishing one for anti-statists like me, but yes the feds would have to override state mandates to encourage more interstate competition.

That is indeed a tough pill to swallow.

As for pre-existing conditions: 1). It is assumed that the transition to a patient-centered approach would be phased; 2). I have no objection, for example, to the government providing emergency vouchers in special cases to pay out-of-pocket, but (uncompromised) enforcement of contract law should take care of most abuses.

1) it is a current problem as well so whether the transition is phased or immediate is not primary.
2) enforcing contract law does little to help when insurance contracts specifically prohibits coverage of pre-existing conditions. It could help in some cases where the claim of prior condition is invalid, but does nothing for the person who switches carriers for whatever reason (job move, carrier drop, etc) and still needs treatment. Some sort of government vouchering might work but I think the better solution is removing that proviso from health care contracts.

I would support efforts to increase the supply of doctors, nurses, and health insurance options, but as Jason points out, the government is often very clumsy and inefficient when it tries to make that happen.

How do we go about making those changes if not through government?
I think that the current accrediting bodies could remain if additional accrediting bodies were introduced.

I favor decoupling employment and insurance, using the patient-centered approach. Jason makes a good point about employers dumping coverages, but then they’ll be forced to make up the difference in total compensation packages

As alluded to in my caveats for decoupling health insurance and employment, I think that the state mandates for employer health insurance could be replaced with mandates for employer provided vouchers for health insurance. In order for that to be successful other steps would be necessary including some method of consolidation for customers so that economies of scale would still be in play.

employers dumping coverages, but then they’ll be forced to make up the difference in total compensation packages, or they will lose a lot of talented/experienced/good employees to other firms

That is certainly true for the high end and to a lesser extent to the middle. Below that state mandates requiring coverage could be replaced with mandates for vouchers.

The government does not dictate the price of most medical care so Medicare and Medicaid payments are not a likely cause of physician shortages.

The government DOES dictate Medicare and Medicaid payment rates, though. We can infer from providers’ responses to those payment rates what would happen more generally if the government gained dominance as the primary payer in the health care system more broadly. And what we find is that low Medicare/Medicaid payment rates are driving many doctors, especially in rural areas, to refuse to accept those patients. That means that if government’s role increased, either fewer doctors would accept the patients OR, if accepting them were made mandatory, fewer people would endure the costs and risks of becoming doctors in the first place. Either scenario would decrease overall supply of doctors to patients under the government-controlled health care system.

Tort law, at least in some areas is a greater concern, but still all I have read suggests that it amounts to 2-3%. Do you have any references that show it to be a larger component of cost.

I don’t need it because actual cost is not my argument. My argument is that the perceived risk of exposure to lawsuits deters doctors from becoming doctors in the first place (especially in certain specialties, like OB/GYN or GP). The fact that ruinous lawsuits remain a possibility even for doctors that operate in good faith with good professional practices is sufficient to cause the disincentive I talk about.

1 and 2 are about increasing supply of medical professionals (the largest component of health care costs). Assuming again that basic economic principles apply (at least to some degree) more doctors and nurses means lower paid doctors and nurses and thus a decrease in the cost of the largest component of health care costs.

This is only true if you assume that lower pay combined with the same risks of exposure to lawsuits will result in an increased number of people wanting to become doctors in the first place. That contradicts the very most core fundamentals of what we know about individual economic behavior. Lowered pay combined with sustained risk of lawsuit does not, in fact, draw more people into a field. It draws fewer.

That does not follow, particularly with my listed caveats.

Mere assertion on your part does not consistute an argument. Try again.

1) Any plan to cover the uninsured will require at minimum short term costs and more likely long term government investment. Do you have a non-magic pony solution to this that doesn’t involve government investment?

You’re trying to shift the burden by conceding the point and demanding that I provide an answer for you. That’s bizarre.

Yes, I agree. Any massive extension of coverage is going to require substantial and sustained government investment. It therefore falls to those advocating change to provide ideas on where that money will come from. It is not the duty of those criticizing their proposals to do that work for them.

2) Pet peeve: that is not what begs the question means.

Perhaps this is because you believe that the use of that term in formal logic is the only meaning it has. I was using the term in the literal sense — your position of advocating universal coverage paid for by the government begs (for) the question “where will the money come from?”

I have known plenty of people that received a C in freshman comp (or similar) and were/are much better at communicating than most doctors I have been to.

Ok, great. What other academic courses are irrelevant to being a doctor? How shall we reorganize transcript reporting to differentiate between the ones you think are relevant and the ones that are not? Should this be another government mandate?

Or was your original comment snark using a too-easy rhetorical target instead of a real point about qualifications for getting into medical school?

assumes that the doctor shortage results from an inadequate number of medical schools.

The number of medical schools does effect the competition for entry and excludes many who could otherwise be excellent physicians. Also I assume that normal economic principles play at least some part in the cost of medical school. Low supply…

I would argue that low payment rates for providers (which the Obama administration suggests lowering still further) combined with high exposure to lawsuits from a completely out-of-control tort system is a far bigger disincentive to becoming a doctor

The government does not dictate the price of most medical care so Medicare and Medicaid payments are not a likely cause of physician shortages. Tort law, at least in some areas is a greater concern, but still all I have read suggests that it amounts to 2-3%. Do you have any references that show it to be a larger component of cost.
Much larger than either of those two costs is the avg $500,000 debt on leaving medical school (that demands a high income to pay off) and the ridiculous work load of interns.

2 and 3 involve substantial costs on the government

1 and 2 are about increasing supply of medical professionals (the largest component of health care costs). Assuming again that basic economic principles apply (at least to some degree) more doctors and nurses means lower paid doctors and nurses and thus a decrease in the cost of the largest component of health care costs.

sounds all nice until you realize how it would work in practice. Employers would simply drop medical benefits from their pay package and dump the whole cost on the government.

That does not follow, particularly with my listed caveats.

again begs the question of where the money is coming from

1) Any plan to cover the uninsured will require at minimum short term costs and more likely long term government investment. Do you have a non-magic pony solution to this that doesn’t involve government investment?
2) Pet peeve: that is not what begs the question means.

Oh, and about the “C in freshman comp”: Perhaps you don’t think that doctors need to be able to communicate effectively, but I disagree.

I have known plenty of people that received a C in freshman comp (or similar) and were/are much better at communicating than most doctors I have been to.
Patrick,
I will address your points when the kids nap.

Instead of penalizing companies for offering “Cadillac” plans, the patient-centered approach would make it so that employers and employees would have to pay for the true value of these coverages in the marketplace, which means they’d probably replace the Cadillac plans with other compensation.

If we’re actually talking about reform, Medicaid is rife with waste and abuse.

The issue about how to deal with state mandates is an anguishing one for anti-statists like me, but yes the feds would have to override state mandates to encourage more interstate competition. Often, federalism can lead to good policy experimentation, new efficiencies, etc., but the barriers to entry when it comes to health care are overriding the benefits from state-to-state policy differentiation. A cynic might sat that it’s more like, in each state, the state governments and big insurance companies have set up self-serving rackets that do not benefit the public at large.

As for pre-existing conditions: 1). It is assumed that the transition to a patient-centered approach would be phased; 2). I have no objection, for example, to the government providing emergency vouchers in special cases to pay out-of-pocket, but (uncompromised) enforcement of contract law should take care of most abuses.

As a classical liberal, I say that the federal and state governments should go back to the basics: enforce contract law and promote interstate commerce (within constitional limits, of course).

As for your first 3 things things: I think we can have a really good discussion about items 1 – 3, which suggest “reform” in the true meaning of that word (unlike some other items I’ve seen). In theory, I would support efforts to increase the supply of doctors, nurses, and health insurance options, but as Jason points out, the government is often very clumsy and inefficient when it tries to make that happen. The government always has a vital role to play in providing hard infrastructure, but when it comes to health care, a lot of the infrastructure is private, and we already have the best health care infrastructure in the world. Well meaning progressives sometimes cause more harm than good when they take very interventionist approaches to improving “human infrastructure,” when a lighter hand would accomplish much more.

I favor decoupling employment and insurance, using the patient-centered approach. Jason makes a good point about employers dumping coverages, but then they’ll be forced to make up the difference in total compensation packages, or they will lose a lot of talented/experienced/good employees to other firms, who might not offer health insurance but they will pay the employees what they’re services demand in the market. Employees will then put their extra salary into the HSAs to buy into appropriate insurance pools and pay out-of-pocket expenses.

In addition to the analysis, the report also outlined patient-centered solutions at the end, which are a little more fleshed out than they are in the op-ed linked above. Still, it is an outline, not yet a detailed policy framework. A lot more work needs to be done along these lines.

We should all agree to have Congress set aside 12- 18 months to develop three general policy tracks in detail and then test these models for projected performance: 1). immediate or transitional (gateway) single-payer; 2). the coop model (gang of 6); 3). patient-centered model.

Based on your past responses, I gather that you would like to act more quickly, but can you honestly tell me that you would support Senate compromise package in its current form (as reported yesterday in the Washington Post)?

This is getting long, so I will try to respond to your specific points after I post this more general response.

I’m shocked…shocked that there is gambling going on in this establishment!

leverages Health Savings Accounts, a low-premium, high-deductible alternative to traditional insurance that includes a tax-advantaged savings account.
OK for the middle class and wealthy.

All of the GOP proposals involving HSAs have included subsidy to lower wage earners to fund their HSA/HDDP. It’s possible that they need to increase the allotments, but I’m pretty damned sure that 47 million people could be given a generous amount and the tab would still come in far less than the cost of the Dem’s reform proposals.