« You Voted For Obama: How Do You Feel About a War in Afghanistan, Banker Bailouts, No Public Option and No Single Payer? | Kali Star's Blog | If No Public Option, I'll Be Working for a Third Party Candidate in 2012 »
Study: The Importance of a Public Option
The Urban Institute has published a study about the importance of a Public Plan Option. I think the single payer plan has absolutely no chance. However, it does help establish a negotiating position for a public option.
Public option is the last stand. Without it, Obama shouldn't sign the bill. He should be making that clear right now.
Public option is the last stand. Without it, Obama shouldn't sign the bill. He should be making that clear right now.
Advertisement
Very interesting report.
It starts off describing the reasons why the insurance market is not competitive, but instead of offering suggestions on how to improve competition between private insurers it advocates inserting a public option in the middle of that marketplace.
So we'll have insurance companies in a broken marketplace all compete with the public option, subsidized by tax dollars. Great thinking!
And given Barney Frank's admission that the public option is a foot in the door in preparation for the eventual takeover via single payer, it's clear that anyone talking about "competition" doesn't really mean it and is not really serious.
July 31, 2009 8:56 AM | Reply | Permalink
The problem with regulating a recalcitrant, anti-competitive insurance market is that such regulation has been shown to wax and wane at the whim of the administration in power. And it seems that deregulation happens a lot faster than reregulation.
If private insurance's business plan is to exclude a large percentage of the populace as not profitable enough, then it only makes sense to take care of those people with a government-funded plan. The market has been given a chance, but has failed, indeed has chosen to fail to serve a large and growing percentage of Americans.
In essence we would only be replacing emergency room care, and charity care, like RAM, with a public option.
July 31, 2009 10:21 AM | Reply | Permalink
" The problem with regulating a recalcitrant, anti-competitive insurance market is that such regulation has been shown to wax and wane at the whim of the administration in power."
Utter bullshit.
- First of all, proper regulation is not supposed to "wax and wane". A politically-driven regulation probably would. But thanks for tips on the Obama regulation of financial markets, I know what to expect now.
- Secondly, your statement is factually weak and probably wrong. I have no seen any evidence of "waxing/waning" of health insurance market regulation. If you have facts - show them.
- Thirdly, the premise of the "independent report" (and the spin by Pelosi and others) is that introduction of a public option will make this market somehow competitive. So, somehow the public option must be seen as an alternative form of regulation by its supporters. But, as your comment makes abundantly clear, it amounts to applying a band-aid to a wound without treating the condition.
The mere fact of the public option is not going to fix a broken, anti-competitive health insurance market place. It doesn't change the playing field in any way other than prepare the ground for the government takeover of healthcare.
You'd be better off abandoning the false slogan of "let's make it more competitive" and sticking to the true and pure "let's remove competition and have government run things instead".
Otherwise, comments like your make no sense whatsoever.
July 31, 2009 10:49 AM | Reply | Permalink
"First of all, proper regulation is not supposed to "wax and wane"."
Nevertheless that's what happened with environmental regulations, financial regulations and others over the past several administrations. Even our supposed constitutional protections have generally waned.
"I have no seen any evidence of "waxing/waning" of health insurance market regulation."
I have "no seen" any evidence of effective health insurance regulation against rescission at all. If my policy can be rescissed, "for light and transient causes" just when I really need it, then what's the point of having private insurance?
"The mere fact of the public option is not going to fix a broken, anti-competitive health insurance market place."
Maybe, but it might mean life or death for those of us that can't get or rely on private insurance. As I said, the market has had it's chance.
And do you really think insulting me is going to strengthen your arguments?
July 31, 2009 11:30 AM | Reply | Permalink
"that's what happened with environmental regulations, financial regulations and others over the past several administrations"
- Your point is that regulation is inherently unstable because it depends on the ideology of the government in power. I'm not sure how this supports the argument to put 100% of healthcare into government hands, using "public option" as a trojan horse to get there.
"I have "no seen" any evidence of effective health insurance regulation against rescission at all."
- Are you talking about the absence of such regulation? If something doesn't exist, how can it be efficient?
"As I said, the market has had it's chance."
- I think this is what we're arguing about and I disagree. I'd be the first to admit that the insurance market is broken. However, the overwhelming majority of Americans have health insurance and do not necessarily agree that we should pick the most expensive and most complicated way of fixing it.
As for insults - apologies, they are not intentional.
July 31, 2009 11:57 AM | Reply | Permalink
"I'm not sure how this supports the argument to put 100% of healthcare into government hands ..."
It wouldn't have been my first choice, but the more I peel away about private insurers, the better government looks.
"Are you talking about the absence of such regulation?"
Either absence or neglect.
"However, the overwhelming majority of Americans have health insurance and do not necessarily agree that we should pick the most expensive and most complicated way of fixing it."
What constitutes an overwhelming majority? We have about twenty percent not working or severely underemployed, hence they and their families are either without health care or will be once their COBRA runs out. We have some percentage with very bad healthcare, and some percentage paying for health care that may well be rescinded.
I have fairly good health care, but I care about that 20+% that don't, and I think it would be more cost-effective to invest in their health rather than let them cut pills in half and be rushed to the emergency room every few weeks.
July 31, 2009 12:10 PM | Reply | Permalink
In that case, why not cancel Porkulus and use the money to enroll each one of these Americans into the Congressional plan or its equivalent - as Obama himself promised during the campaign?
Because Democrats in Congress already exempted themselves and federal employees from everything in the law they are trying to pass.
What a disgrace.
I hope you weren't thinking along the same lines when you said you're fine with your plan but you want something for the uninsured.
http://online.wsj.com/article/SB124536864955329439.html
July 31, 2009 1:57 PM | Reply | Permalink
My plan only works because my employers make up for the large deductible themselves. I think something else would be necessary to serve people that might not be working.
BTW linking to the WSJ opinion pages is a waste of time. I read the rest of the WSJ, but the opinion pages are drivel.
July 31, 2009 2:16 PM | Reply | Permalink
I agree and propose again to enroll them into the Congressional program.
As for WSJ opinion pages, we can easily remove opinion and focus on the facts themselves (Section 3116).
July 31, 2009 2:39 PM | Reply | Permalink
So you are advocating single-payer?
July 31, 2009 2:41 PM | Reply | Permalink
Of course not. I'm advocating for a targeted program for those with incomes too low to afford healthcare, for a regulatory reform that fixes the worst (and not the best) and for keeping the government as far away from making individual personal decisions about health, life and medicine choices as possible.
July 31, 2009 2:45 PM | Reply | Permalink
I'm advocating a targeted program for those with incomes too low to afford healthcare, for a regulatory reform that fixes the worst (and not the best) and for keeping the insurance company as far away from making individual personal decisions about health, life and medicine choices as possible.
July 31, 2009 2:56 PM | Reply | Permalink
Looks like you both, at the end of the thread, are more in agreement than not. Isn't politics ironic?
July 31, 2009 7:45 PM | Reply | Permalink
Donal, your statement: "... but it might mean life or death for those of us that can't get or rely on private insurance. As I said, the market has had it's chance." is the essence of a most-convincing argument for the public option.
As one who is looking at both sides of this debate carefully, I find myself agreeing with the principle of covering people who could previously afford insurance and were therefore denied access to adequate care.
As far as the competition question goes, it could go either way. Maybe lalo has a point. But the Urban Institute report linked above is quite convincing, although it would require lengthy research to confrim. We might as well pass the public option and hope for the best.
Great comment, Donal. I, for one, am slowly being convinced.
July 31, 2009 3:31 PM | Reply | Permalink
I can only refer you again to Nobel Laureate Kenneth Arrows seminal paper "Uncertainty and the Welfare Economics of Medical Care", which explains why the health care market does not benefit from competition, as other markets might due to 'information assymmetries in healthcare goods and services, (the seller of such goods and services has access to disproportionately more information than the buyers).
July 31, 2009 10:52 AM | Reply | Permalink
Miguelito: But many if not most of the "issues" raised in that 1963 seminal paper are easy to solve, especially the information, and a great deal of these "issues" deal with health care DELIVERY, not insurance.
July 31, 2009 11:06 AM | Reply | Permalink
You're ahead of most economists if you can solve those issues without heavily regulating the market. If insurance isn't the delivery system for healthcare, what is?
July 31, 2009 11:48 AM | Reply | Permalink
I lost all respect for Krugman when I read in his blog from several years ago that Alan Greenspan should have invented a new asset bubble to fix the economic crisis of early 2000s. That was before he became an anti-bubble crusader, of course, in tune with the fashion of the day.
This link and the Arrows essay accept issues (cost, doctor supply, etc) as things that simply cannot change and then point to them as proof that market economy doesn't apply to health care.
I have no problem with HEAVILY regulating insurance markets - I support it. In fact, they are HEAVILY regulated today. But there is a difference between right and wrong, effective and ineffective regulation.
July 31, 2009 12:11 PM | Reply | Permalink
I couldn't agree with your last sentence any more than I all ready do. Expecting the Prima Donnas in our legislature to develop that kind of regulation may be a long shot, but I'm satisfied if they make an honest attempt. They can hardly do worse than the system we have now. As former editor in chief of NEJM Marcia Angell said, "If we had set out to design the worst system that we could imagine, we couldn't have imagined one as bad as we have". Our dialogue here was my effort to explore your original complaint about not "offering suggestions on how to improve competition between private insurers". There is no incentive for efficiency in a system that allows costs to just be passed along the line to the end user/policy holder, and no market force aimed at controlling those costs. Insurance companies have shown themselves to be incredibly resistant to instituting any changes in fairness either as shown by their inability to live up to any of the promises they made in that regard following their last dust up with these efforts on the part of our legislators in the early 90s.
I for one don't expect whatever the pols come up with in this bill to be a panacea for solving our healthcare 'problems', but rather see it as a first step in what is bound to be a contentious and 'zig-zag' transition to a less costly and more fair distribution of healthcare goods and services as we figure out much of how to bring costs under control as we go along. As I said in my last blog, the US health care market is the size of Britain's entire economy, and we can expect plenty of resistance to changing a status quo which affords as much waste as our healthcare system embodies. There is too much money to be lost or made depending on one's perspective for it to be otherwise.
July 31, 2009 12:55 PM | Reply | Permalink
"There is no incentive for efficiency in a system that allows costs to just be passed along the line to the end user/policy holder, and no market force aimed at controlling those costs. "
- But that's precisely my point!
Any business enterprise brings with it both good and bad things. The good things include the profit motive, which compells them to innovate and compete with each other for customers. The bad things include using things like monopolies, unfair business practices and the like - anything that distorts customer-oriented competition model.
Effective regulation, in my view, would work to create an level playing field, restrict any unfair actions, prevent dominance through corporate mergers (as opposed to dominance through cost and quality), etc.
The mere fact that there is no regulation on the books today to prevent patient dumping is a testament that our current insurance framework is broken.
But we are now acting as a bus driver who decides to fix flat tires by painting the bus in bright new shiny colors and adding an electric engine to the existing one.
July 31, 2009 1:23 PM | Reply | Permalink
How about some of them "facts" as to all the regulations that the health insurance industry labors under.
Medicare reimbursment restrictions and limitations don't count. Just try to appeal a denial of a legitimately necessary service through that system.
The pitiful and easily manipulated state regulatory schemss don't count.
And the employer friendly federal ERISA doesn't count-employee/insureds under ERISA health plans have virtually no recourse to benefit plan decisions that usually, imagine this, benefit the employer self funded plan or the health insurer funding such plan.
July 31, 2009 2:00 PM | Reply | Permalink
You know, bad regulation and over-regulation go hand in hand. You point out some good examples.
Here's some more - on FDA regulation of a cancer vaccine.
http://online.wsj.com/article/SB10001424052970204886304574306693989102298.html
July 31, 2009 2:36 PM | Reply | Permalink
Yet the FDA approves, and many governments started mandate, Gardasil seemingly overnight. Good story.
August 1, 2009 9:18 AM | Reply | Permalink
July 31, 2009 7:48 PM | Reply | Permalink
Oh, I'm skeptical Jason. I just think designing an efficient single payer system is actually easier than regulating, bringing costs into line with reality, and streamlining our multi-payer system, and therefore more easily accomplished.
July 31, 2009 8:12 PM | Reply | Permalink
"an efficient single payer system"
- This is so Orwellian.
July 31, 2009 9:05 PM | Reply | Permalink
You got me to belly laugh on that one lalo! I'm off to dinner, keep fighting the good fight. ;)
July 31, 2009 9:26 PM | Reply | Permalink
You too and thanks, today was good.
By way of warning re: upcoming future debates, I devoured a big plate of spaghetti carbonara for dinner. Featured lots of bacon. So, you have been warned, mister.
:-)
July 31, 2009 9:50 PM | Reply | Permalink
Seems like a pretty big risk to take, like taking chemotherapy to cure a mole.
August 1, 2009 9:19 AM | Reply | Permalink
Look, we don't have to re-invent the wheel here. Didn't we once have the Public Health Service?
When we had the PHS (a public option), private health care providers thrived, private health care insurance thrived, and the price for health care remained BELOW the inflationary rated. Ah! those were the good, old days.
But six months after the PHS was abolished the price for health care started raising above the inflationary rate, and a few months after that, private health care insurance. Now why do you suppose that happened?
Those who complain that the "public option" is going to kill private health care or private health care insurance have no concept of just how bad the PHS was, nor how bad government heath care is going to be today.
Relax. I can assure you, government health care, irrespective of the promises being made today, will quickly degenerate into a public health care system of last resort for the poor, desperate and the hopelessly ignorant. But if history can be our guide, a "public option" will reduce costs, which is what I suspect all the screaming is about from the private health care sector over the "public option".
ex animo
davidfarrar
July 31, 2009 10:16 AM | Reply | Permalink
Just a note. Howard Dean sounded upbeat this morning saying that his information is that there will be a public option. He said that it will differ from Medicare in that it will have different standards than Medicare so that it does not 'interfere with competition'.
I do trust Howard Dean. We shall see.
July 31, 2009 10:17 AM | Reply | Permalink
I like the public option. I really do.
That said, if a bill comes along that improves the current situation (e.g., by making it illegal to rescind coverage to those who have been paying premiums and filled out their insurance forms in good faith), then it seems like a bad idea to veto the bill just because we're wanting a better bill. Why not sign that bill and then push for a better one?
July 31, 2009 11:10 AM | Reply | Permalink
I don't think we will ever get one without breaking down some part of insurance company profits. Americans have to experience a change in which insurance companies lose. And hopefully taste blood.
Insurance companies have a plan for the "no preexisting" clause. They cut benefits and raise premiums. They will be more than happy to settle for that. Half of the democrats will say that we got something, while the another half will just drop out from exhaustion, and the Blue Dogs will get the Republican votes and MONEY they are after. They aren't democrats anyway.
July 31, 2009 11:25 AM | Reply | Permalink
Won't that still be progress though? At least then, the true cost of the insurance would be better understood. Right now, the majority of American are happy with their insurance policy. The majority of them have also never made a major claim. I think those two things are related.
Again, I do hope the Democrats continue to fight for a public option. However, if a bill crosses Obama's desk that doesn't have the public option, but that is an improvement, I still think he should sign it.
July 31, 2009 11:54 AM | Reply | Permalink
"Right now, the majority of Americas are happy with their insurance policy."
Taking the downside, which is more and more how I feel, check back with me in ten years when those "happy people" have either lost their insurance or pay half their income for reduced benefits.
Going with the "it won't get better until it gets worse" idea, I'll throw in the incidents of cancer that the "happy" group will deal with as they drink more hormone-laced milk and eat toxic chicken. Then there's the "happy" people who will lose their jobs because this country will finally descend to its real roots --a profit-driven society without concern for anyone.
You know what? Screw it. Let the whole thing come down. Obama ! Sign a bill with no public option.
You see, I know we really need a single payer plan. I'm already on my proverbial knees with this public option compromise. That's what having a foot on your neck does to people.
July 31, 2009 12:14 PM | Reply | Permalink
That's exactly my point. People are happy with their insurance because "ignorance is bliss". That is, until you need to pay the piper. If forcing insurance companies to stop rescinding coverage to consumers who have acted in good faith causes the insurance companies to raise their premiums, then at least a little ignorance will have been removed. That's an improvement, in my book.
I'm not sure why you're arguing against it, other than that if you can't get everything, settle for nothing (which is what refusing to sign a bill gives you). We should fight for the best bill we can get, but we shouldn't scuttle the possibility of incremental improvements in the meantime.
July 31, 2009 12:21 PM | Reply | Permalink
I'm taking the position that Obama should sign a bill with a public option. Without a public option, the improvement isn't worth the risk that nothing will have been taken from the insurance companies. In fact, they will make money on the deal. Drug companies too.
Signing a bill that has no public option sends me completely the other way. Do nothing. Let things get worse. Sit back, lay low, and wait till the machine dies of its own sickness. Looks like that could happen in ten years if there is no real change in health insurance. And I'm stretching things to say that a public option represents "real change." The insurance companies have to lose something.
July 31, 2009 1:25 PM | Reply | Permalink
We're in complete agreement there.
So are you taking the position here that it is impossible to improve the health system at all without a public option?
Whoa. I definitely can't get behind that. Sacrifice the sick now so that hopefully one day they'll see that we were right?
July 31, 2009 1:30 PM | Reply | Permalink
Here's my position. Small steps that help a few people now will result in greater losses and reduce significantly the chance for real change. There are plenty of people who don't want Obama to sign a bill without a single-payer option, so I don't see that my position is that isolated. It's moving to the middle. Reluctantly. Help a million now (let's say) and, as a result, leave out 40 million for ten years. Standing firm now is more likely to help more people sooner.
July 31, 2009 2:42 PM | Reply | Permalink
Didn't make that clear. Sorry.
Helping a million now and reducing the chances for 40 million is no good. Stand tough(er) now. If one can imagine settling for a public option now as "tough."
The public option IS a tiny bit of socialism. That's the turning point for us. We have to make that first turn on health insurance just as we did once for social security.
July 31, 2009 2:46 PM | Reply | Permalink
The assumption you're making is that helping a million now would hurt 40 million later. I'm not willing to sacrifice the benefit to the 1 million now on that assumption.
Obviously, like you, I'd rather help the 40 million now. That's where pressuring Congress comes into play. If Congress screws up, however, I'd like Obama to make the best of what he's given.
July 31, 2009 2:55 PM | Reply | Permalink
Crumbs or fool's gold. I'm not interested. But, personally, I'd benefit from the crumbs. I fear that this self-interest for so many will be the excuse for taking the crumbs. But I think we're clear, finally, on where we both stand.
July 31, 2009 3:24 PM | Reply | Permalink
One of the false impressions often circulated is that the proposed public option would be subsidized by tax dollars. In fact, it would be self-financing, paid for exclusively by premiums. Therefore, its inclusion in the proposed legislation would serve exclusively as a potent cost reduction mechanism, with no added contribution to federal expenditures.
July 31, 2009 11:33 AM | Reply | Permalink
Fred, if that's so, i have several questions:
- why is CBO issuing reports that say spending will go out of control and add to deficit?
- what is the purpose of the surtax
- what is the reason for the provision in the Waxman draft that the surtax would DOUBLE in 2013 if the "cost savings" are not realized??
July 31, 2009 12:20 PM | Reply | Permalink
Lalo - The costs are primarily those involved in the increasing cost of health care in general (e.g. projected Medicare and Medicaid payments) plus the cost of subsidizing low income families so that they can afford health insurance premiums. The public option, at least in the House bills (I haven't seen the Senate HELP committee draft) is required to pay for itself through the premiums it collects.
Of course, when premiums are subsidized, the government is paying, but those subsidies would be paid regardless of whether the purchaser is buying private or public insurance. If the public option did not exist, then the subsidies would still be paid, but exclusively to private insurers. Since the public option is intended to serve as a cost-cutting competitive measure, it should actually reduce premium costs, and thus the amount of subsidization required.
Finally, the complete package includes mandated coverage. In the absence of mandates, a public option would greatly increase the number of Americans buying insurance, whereas that number would be unchanged if most Americans are required to have insurance whether or not a public option exists. Presumably, therefore, a public option in the absence of a mandate would increase the number destined for subsidies, although that would be offset, I suppose, by a reduction in Medicaid expenditures.
The surtax or other types of tax provisions that are contemplated is destined to cover the costs I mention above. As far as Waxman's "cost savings" are concerned, I imagine that's a euphemism for saying cost increases not quite as astronomical as might otherwise have occurred.
July 31, 2009 2:29 PM | Reply | Permalink
You may enjoy reading this article from rollcall.com.
You may get some additional information out of Peter Orzag's blog dated 7/25/09.
July 31, 2009 2:59 PM | Reply | Permalink
Thanks for the article. An interesting line here:
"According to the Institute of Medicine, the absence of health insurance kills 18,000-20,000 Americans a year..."
Interesting. Somehow seems familiar.
July 31, 2009 3:30 PM | Reply | Permalink
Peter Orzag works for Obama. He has a vested interest in saying CBO is wrong and he is right. I don't recall him saying the same thing about CBO when he was its director. Do you?
July 31, 2009 5:36 PM | Reply | Permalink
I don't remember any parallel situation under his stewardship. Any thoughts on Bruce Vladek's, former head of US Health Care Financing Admin (Medicare/Medicaid), article in Rollcall?
July 31, 2009 5:41 PM | Reply | Permalink
hehehe, I love chasing you from diary to diary (and I do enjoy arguing with you!).
But no, my point is simply that Orzag has a conflict of interest. This disqualifies his opinion on the accuracy of CBO for me, until this conflict of interest is resolved.
July 31, 2009 5:58 PM | Reply | Permalink
I enjoy discussing these issues with you too lalo, and just to save us more time I'll link to your admission that the CBO's projections are more or less a big pile of steaming crap, so we can move on to the next issue. ;)
http://tpmcafe.talkingpointsmemo.com/talk/blogs/observer2/2009/07/health-care-charts.php#comment-3545818
July 31, 2009 8:18 PM | Reply | Permalink
KKrugman (I know you don't respect him, but I do) hhas his concerns about Doug Elmendorf, the CBO guy.
http://krugman.blogs.nytimes.com/2009/07/29/cb-uh-oh/
July 31, 2009 10:38 PM | Reply | Permalink
Well here's a new thought that might be pertinent. If we just look, for a minute, at cost centers in health care administration. While everybody's talking about the insurance companies and the legitimacy of their methods and profits, here is, perhaps, a more important element of skyrocketing medical expenses:
My wife, the nurse, calls it CYA medicine (cover your a**), and here is the simple, rude truth:
Because of malpractice suits, both hospitals and doctors are forced to order far more medical procedures than are actually needed in most cases. This not only runs medical bills sky-high, but also inflates the billed charges that originate with unnecessary medical procedures.
If you want to get the government involved in cutting costs, have the government cover malpractice insurance and the inflated legal claims that result from "malpractice", which is in many cases nothing more than humans do what humans do, and making a few mistakes along the way. Neither doctors, technicians, nor nurses nor hospitals are perfect.
Get the legal profession out of medicine.
Then perhaps hospitals and doctors can be free to practice medicine efficiently and minimally without constant threat of lawyers.
July 31, 2009 4:09 PM | Reply | Permalink
Although malpractice insurance and "defensive medicine" (excessive tests driven by fear of litigation) increase health care costs, they contribute only in a minor way to the excessive costs of healthcare in the U.S. compared with other nations. The exact fraction is hard to define. Malpractice premiums represent a very mnor contribution. The role of defensive medicine is harder to define, but an objective assessment by the CBO (Congressional Budget Office) concludes that it is relatively small, and that tort reform would not substantially reduce the costs of health care in America -
http://www.cbo.gov/ftpdocs/49xx/doc4968/01-08-MedicalMalpractice.pdf
July 31, 2009 4:37 PM | Reply | Permalink
Carey does bring up a point relevant to current proposals. While defensive medicine appears not to be a major contributor to health care costs, as judged by the CBO, its role shouldn't be neglected. One reason why some physicians offer more tests or procedures than others, or more than may be warranted, is that there are rarely publicized standards to consult indicating which tests or procedures are known to be valuable and which superfluous. If a physician could consult such a standard, and only order from the "valuable" list, he or she would generally be fairly insulated from legal liability.
An important part of the proposed legislation, at least in the House version (the only one I've seen) involves the development of appropriate standards of this type based on evidence. This type of "evidence-based medicine" or "comparative medicine" should both reduce costs and alleviate worries by both patient and physician.
I've seen resistance to these efforts by opponents of the legislation, but most medical experts endorse the idea.
July 31, 2009 5:11 PM | Reply | Permalink
This "valuable" list was tried by the HMOs in the 1980s and the outrage led to state-mandated coverage requirements. That's when the costs started growing again, from the late 1990s onwards.
The only difference between then and what you're describing is that the new "valuable" list is going to be compiled by the government that allocated $1 billion to develop it.
Just as quickly with HMO, rationing is going to become an explosive political issue and it will lead to more and more things being placed on the "valuable" list.
And history will repeat itself.
July 31, 2009 5:30 PM | Reply | Permalink
Actually, Lalo, these lists already exist to a substantial extent, although not to the extent necessary. What distinguishes them from less commendable efforts is that their primary goal is medical excellence, they are developed by medical experts rather than bureaucrats, and most importantly, they are evidence-based rather than reflective of anyone's undcoumented opinion.
If what is developed in the future follows the same pattern, care should improve and costs should go down, thus reversing our current trajectory of unrestrained cost increases unassociated with a discernible improvement in health outcomes. I see something along these lines as an inevitability because of the current unsustainable growth of costs within the healthcare system itself independent of insurance. The critical question, therefore, is not whether it should be done - it will be - but whether it will be done right. I've already seen some of the evidence-based guidelines, and so I know it's possible, but there will be a clear need to insulate the medical experts from the budget people to ensure that health concerns remain the highest priority.
July 31, 2009 7:11 PM | Reply | Permalink
How do you define medical excellence in the context of cost containment in a goverment system? The same way NICE defines it in the UK.
But we've been there last weekend.
My point is - it doesn't matter how you justify rationing. The fancy sales pitch doesn't matter because the result of rationing is always the same. And just like Americans didn't accepted from the HMOs, they won't accept it from the government.
July 31, 2009 7:24 PM | Reply | Permalink
Re point about rationing from lalo:
If the report of the Urban Institute, linked above in Kali's posting, is indicative of what the public option would entail, it seems that:
Folks on the upper end of the income scale who choose to forego the limitations of the "exchange"--those people will also, by their more expenseive/more comprehensive insurance plans, be able to avoid the limitations of rationing.
Folks on the lower end (presently uninsured) of the income scale whose choices are fewer--these people will be consigned to rationings and/or lists that define the public options.
So in this sense, nothing really changes.("Private plans would continue to serve 161 million Americans." Urban Institute report) The affluent patients still have more choices because they can afford to retain those choices. People on the public option have fewer choices, because some choices are already made for them on the lists and ration schedules.
But at least they're covered!
August 1, 2009 7:26 AM | Reply | Permalink
For a useful broad survey of evidence-based medicine, the wikipedia article and its links are a good starting point - http://en.wikipedia.org/wiki/Evidence-based_medicine
One of the very informative links is the first external link - to the Institute of Medicine.
These types of efforts, while necessary to constrain costs, are equally necessary to greatly diminish the unconscionable level of rationing that now characterizes health care in this country. Because there are limits on how much of its total workforce and GDP a nation can devote to healthcare, some rationing would inevitably remain even after the reforms are instituted, but it would not only be reduced in extent, but also prioritized on a much more equitable basis. Again, if one starts with the wikipedia article and then pursues the links that address this in more detail, the concept becomes clearer, along with its advantages and drawbacks.
July 31, 2009 7:35 PM | Reply | Permalink
Also note that no-one is suggesting that unnecessary or ineffective tests or treatments be prohibited by law. Rather, they should be distinguished on the basis of evidence from those that are effective. Physicians who refrain from the unnecesary interventions would be better protected against lawsuits, costs would go down, and in many cases, health outcomes would improve. The experience of all the other major industrialized democracies, which offer less intervention but achieve better health outcomes, demonstrates that this is not merely a hypothetical result.
Currently, basic private insurance plans very much restrict what is covered for many individuals. With reform, the laws of economics dictate that some of those restrictions would remain, but because less of healthcare would be devoted to unnecessary interventions plus excessive profits plus duplicate facilities and services, more of what actually works should be available to more members of the public. Again, the evidence from the rest of the world bears this out. Their citizens accept and in most cases welcome the systems they have, and I have no reason to believe that Americans wouldn't accept something similar here as well.
July 31, 2009 8:30 PM | Reply | Permalink
"some rationing would inevitably remain even after the reforms are instituted"
- what an exquisite statement
Fred - Wikipedia defines rationing as "the controlled distribution of resources and scarce goods or services". It defines scarcity as "the problem of infinite human needs and wants, in a world of finite resources."
The argument that is often put forward that our current system is rationing is completley untrue.
Rationing depends on WHO DECIDES how these scarce resources are allocated to each individual.
The "public option" is a Trojan horse to a single payer system, where government will take your money and will decide what you can get and what you cannot. The government will invent all kinds of justifications (typically - public good, cost containment, etc), but at the end of the day you will be just another brick in the wall.
The current private system, admittedly imperfect and improvable, makes YOU, the individual, decide. If you don't like the Keiser plan or BCBS plan, you always have the power to change them.
And yes, that choice doesn't give you very many decent options right now. But instead of fixing a system where an individual choice is preseved, "public option" is a backdoor attempt (as admitted by Barney Frank just 2 days ago) to prepare the ground for single payer.
July 31, 2009 8:39 PM | Reply | Permalink
Care is rationed in the U.S. by ability to pay. You are deprived of important care, sometimes lifesaving care, if you can't pay for it, or if you simply refrain from seeking care because the expenses will be devastating. It's worse here than in any of the the other major industrialized democracies, all of which provide care for more people at lower cost and with better health outcomes. If you don't wish to define that as rationing, it still has the same devastating effect.
No current reform proposal will limit what care can be given, only what care might be paid for by someone other than the individual consumer - paid for by insurance, for example, with or without subsidies.
Of the other nations, all of which do better than we, one of the most successful is France, often touted has having the best healthcare system in the world. Like most of these other countries, France does not employ a pure single payer system, but rather a hybrid. The government, through revenues collected mainly by payroll deduction provides insurance coverage for everyone, but the coverage is only partial. Most families must supplement it with private insurance for fully adequate coverage. Other nations employ other forms of public/private combination, none of which has gravitated into a single payer system as far as I know, so the government takeover prediction is simply a propaganda ploy in reality (although some single payer advocates would welcome it).
What none of these successful healthcare systems do is attempt to achieve adequate healthcare without a very strong public component. Our experience here suggests that the burden of proof is on anyone who claims that to be possible.
July 31, 2009 9:19 PM | Reply | Permalink
"Care is rationed in the U.S. by ability to pay"
- Fred, please don't take this as offense, but this is nonsense.
Tell me, what in this life is NOT rationed by abilitiy to pay?
Food, drink, clothes, toys, transportation, books, education? Anything?
Even "Brides By Mail" are rationed, according to your theory.
Your explanation is wrong because under that theory everything is rationed.
The only way a concept of rationing makes sense is when you replace "the form" with "the authority". Bread is rationed by government during war. Bank withdrawals are rationed by government during bank runs in economic crisis. Etc. For rationing to apply as a concept, someone else must be making a decision that you ordinarily make.
July 31, 2009 9:31 PM | Reply | Permalink
"Care is rationed in the U.S. by ability to pay"
- Fred, please don't take this as offense, but this is nonsense. Tell me, what in this life is NOT rationed by abilitiy to pay?
Lalo - I thought you'd never ask. What is not rationed by ability to pay is adequate healthcare in every major industrialized democracy other than the U.S.
All of these other nations impose some restrictions on what they will pay for, requiring the consumer to pay the rest. What they do pay for are the essentials that many Americans find unavailable because trying to pay for them would be finanically devastating.
Of course it's true that there are limits everywhere, but we are more limited than in all these other countries. The reforms proposed here would lighten some of those limits. It would not eliminate them entirely, but would bring us closer to what everyone else is doing. As is true everywhere else as far as I know, no law would prohibit a health care provider from offering services not covered by public components of the system, and so no-one will be told what they can't have. With reform, however, fewer will be told what they have to pay for themselves, and those items will be much less likely to be essential for good health.
July 31, 2009 10:01 PM | Reply | Permalink
So you basically ignored everything I said and repeated your previous comment?
:-)
July 31, 2009 10:06 PM | Reply | Permalink
Sorry lalo, but price IS the main rationing device we use in our society. Anything limited in supply has to be allocated, and not all those who want or need the good can get it. Interesting that you don't regard the price system as involving OTHER people in determining what you get. But since they bid on these products, and have their own incomes, their actions and decisions can completely bar you from the good, or leave you with the dregs. Rationing, just not the way it's come to be used in the US - which is quite ideological, I would note.
Also, interesting that you're so spooked by the government having the role of single payer. "Orwellian." Do you spook at the idea of a government-owned and run Military? Courts? Schools? See, THOSE things bother me more than government run health insurance. ;-)
August 1, 2009 2:08 AM | Reply | Permalink
Lalo, you ask:
"Tell me, what in this life is NOT rationed by abilitiy to pay?
Food, drink, clothes, toys, transportation, books, education? Anything?"
Your analogy/comparison is faulty. You cannot equate healthcare with food, drink, clothes toys.
What is not rationed by ability to pay? How about, for example, fire protection?
Would you like a competitive market in that?
Let's see -- next time you smell burning wiring in your house and suspect that a fire may be imminent, settle down for a few hours on the phone to get pre-approval for a "test" in which your private fire company may choose to either recognize the legitimacy of your concern and come to your house right away, or may choose to deny approval as you sit and watch the sparks and smoke beginning to come out of an outlet.
When your house burns down, maybe as a believer in competitive markets for essential services, you will shrug your shoulders and agree that it was not the fault of your fire insurer for being focused on cost-savings, but rather, that perhaps it was your own" fault" because you didn't do enough comparison shopping when you selected your fire company and paid your premium.
What's that? You're mumbling just a bit... Oh, I can hear you now. You're saying that the policy you bought was from the only one that would accept you, because of the age of the house and its "pre-existing conditions" that cannot be changed or are too costly to change, because the house was built when it was built, and codes were laxer at the time of its construction.
Just say'in, Lalo, don't talk to me about clothes and toys.
August 1, 2009 9:48 AM | Reply | Permalink
Helpful post, Kali. And, as usual, illuminating comments.
I'm faxing a follow-up letter to one of my senators on the Finance Committee Monday concerning the public option. It's considerably more pointed with respect to insurance companies and their influence on politicians. It's important to keep the pressure on.
I'm confident there will be a strong public option. Whether it serves its intended purpose remains to be seen.
The nifty "Benefits of American's Affordable Health Choices Act" for my district looks promising. Here is the top line summary:
The numbers were derived from 2008 statistics for this area. (The $78 million reflects the cost of treating the uninsured here in 2008 -- the reference in the summary seems a little vague.) Once in place, I think these measures will be beneficial to our local economy and quality of life.
The document specific to your congressional district can be found at the link below. You have to scroll past the amendments. (Sorry if this is redundant.) It has great selling points for town hall meetings, letters to the editor, and gabbing with the neighbors.
http://energycommerce.house.gov/
July 31, 2009 6:35 PM | Reply | Permalink
Thanks for information and link.
July 31, 2009 7:48 PM | Reply | Permalink
You wanna do something? My Congresswoman A healthcare reform opponent, (her daughter is a healthcare insurance co. lobbyist) put up a straw poll asking Do you support the health care proposal that's in the House right now?
Go and vote and spread the word.
http://judybiggert.house.gov/Default.aspx
July 31, 2009 6:51 PM | Reply | Permalink
Voted. She's quite a character.
July 31, 2009 7:50 PM | Reply | Permalink
She's awful. Her middle name is Borg a in Borg Warner. She's an heir to that fortune and the Walgreen's fortune. She was born with a silver spoon in her mouth in a diamond encrusted platinum crib.
July 31, 2009 8:01 PM | Reply | Permalink
Pretty miserable right wing stuff in her so-called op-ed--"Reform
not revolution."
July 31, 2009 8:31 PM | Reply | Permalink
She hits on tort reform. We've had tort reform limiting the little guy's access to the courts in dozens of states, including Illinois for years. That hasn't lowered doctor's medical malpractice insurance rates has it? That decades long fraudulent PR campaign by the insurance lobby and the GOP has worked. Pelosi's right, read this:
http://www.washingtonmonthly.com/features/2004/0410.mencimer.html
Want to fix it? Let's have a public option for med mal insurance too. Then watch those rates drop like a rock and doctors lose their excuse for practicing "defensive medicine" which pays them for all those extra pointless, ineffective, wasteful tests they order under the guise of "there's a lawyer looking over my shoulder".
July 31, 2009 8:46 PM | Reply | Permalink
Gonna have to read this report later.
July 31, 2009 7:41 PM | Reply | Permalink
"What is not rationed by ability to pay is adequate healthcare in every major industrialized democracy other than the U.S."
- I shouldn't but what the hell...
The joys of humane government-run health scare system:
"Millions of adults in England and Wales haven’t been to an NHS dentist since April 2006 mainly because they couldn’t find one to treat them, says new research carried out for national charity Citizens Advice as it urges Primary Care Trusts to spend newly allocated resources to improve access."
http://www.citizensadvice.org.uk/index/pressoffice/press_index/press_20080106.htm
July 31, 2009 10:17 PM | Reply | Permalink
I have the same problem in Indiana, to few dentist willing to take medi-care patients. The answer is gov't subsidies for family practitioners and family dentists.
August 1, 2009 10:36 AM | Reply | Permalink
I too should probably not belabor points that have been thoroughly bandied about above, so I'll try to be brief, even if still a bit repetitive.
No proposed reform legislation would deprive anyone of any medical intervention, but would only limit what that individual could expect someone else to pay for. No imposed limits = no rationing in the literal sense of the word.
In the figurative sense used in the healthcare debate, Americans are more restricted in the availability of most of the truly essential services than elsewhere in industrialized democracies, because of limitations due to inability to afford the services. Other nations impose few limits on the most important interventions, and so rationing due to inability to pay is minimal in these other nations.
All nations limit payments for at least some interventions, but in a humane and equitable system, these are usually non-essential. Undoubtedly there are exceptions, but they are few.
The other nations, by rendering health care universally affordable for the most essential services, cover more citizens at far lower cost and with better health outcomes. I know the last point is repetitive, but it is of such enormous importance to our society that I hope readers will forgive me for repeating it.
July 31, 2009 11:24 PM | Reply | Permalink
Fred: You certainly know this topic. Thanks for posting all your points and ideas.
August 1, 2009 9:53 AM | Reply | Permalink
Thank you for this post. I needed to answer similar questions in a different forum.
August 1, 2009 1:53 AM | Reply | Permalink
If this (as Fred has stated above) is true:
"no law would prohibit a health care provider from offering services not covered by public components of the system, and so no-one will be told what they can't have."
and
If the public option is not (as lalo has alleged) a Trojan Horse for single payer,
then
let's give the public option a whirl, so that poor folks can stay healthy.
However,
now that we've enacted (if it happens) an insurance plan that eliminates denial of treatment based on ability to pay,
Let us
address the systemic impact of patients who havechosen to sustain unhealthy practices--smoking, and becoming addicted to drugs or alcohol. The poor health and unsustainable, burdensome medical interventions that result from these addictive behaviors should be rationed in a limited way, so that public resources can be reserved for citizens who have chosen moderation rather than addiction.
August 1, 2009 8:16 AM | Reply | Permalink
While we're at it commissar let's tackle obesity by what....hmmm...let's see, mandatory calisthenics at dawn? How about massive tobacco type taxes on anything containing corn sweeteners?
My point is if you think it's a winning move to try to legislate personal behavior in this bill you're just asking to have your ass handed to you.
Yes we have to change people's habits but it's not alcoholics and drug addicts that are driving healthcare costs, they hardly ever seek or get treatment. It's sedentary lifestyles and bad eating habits by the majority of the population that get them in trouble i.e. obesity, diabetes, heart disease, etc. And anything we do about that will have to be done separately.
August 1, 2009 10:42 AM | Reply | Permalink
All smokers and alcoholics and drug addicts combined doesn't even begin to approach the cost of two-thirds of America being obese or overweight, a trend that is increasing unlike those for smoking and other personal behavior choices you mentioned.
America is addicted to unhealthy food and rarely enjoy their toxic treats in moderation. The poor health and unsustainable medical interventions for such addictive behavior far outstrip the combined expenditures for other types of addictive behavior.
The Japanese smoke like chimneys and drink like Sailors, yet outlive us by four years on average, so I will reserve my disdain for addiction to unhealthy food as being a central player in the rising cost projections for health care in America.
August 1, 2009 10:44 AM | Reply | Permalink
Fred writes - "No proposed reform legislation would deprive anyone of any medical intervention, but would only limit what that individual could expect someone else to pay for."
And that's a good thing???
The House bill as currently drafted does more than just provide a public option for the uninsured. It is changing the rules around ERISA, forcing companies that currently self-insure their employees to be subject to decisions made by the "health choices commissioner".
So when Obama says that you can keep your current health insurance, is he lying? He's not that dumb. He must realize that people's private insurance plans are going to radically change based on the House's bill.
I guess I just wish Obama would be more honest with the American public and say "If you want to keep your current private plan, you can. BUT that plan is going to be significantly different than what you have today, and it will be regulated by the government."
August 1, 2009 10:21 AM | Reply | Permalink
Your health insurance plan is going to change whether we enact healthcare reform or do nothing.
August 1, 2009 12:16 PM | Reply | Permalink
Sure. But there's good change and there's bad change. Are you implying that I am in favor of doing nothing? I never said that. I just said that the ERISA changes in the House bill are extremely problematic.
August 1, 2009 10:38 PM | Reply | Permalink
Quinn and Fred defend health care rationing, upthread, by using a very common argument: our health care is de-facto rationed today by price (i.e. affordability, or ability to pay for services).
This is a very smart argument, because it frames the health care reform debate in those familiar "pitchfork" terms - the have's versus the havenot's.
But this argument is utterly disingenuous, misleading and untrue.
Quinn says (and Fred seems to agree) that price is the main rationing device in our society today. They are wrong.
In western societies, price is an equializer between supply and demand. When the market is not providing enough of something that we want, prices increase. When the quantities of that desired something increase, prices go down.
There two key components here: supply and choice.
In a free market society, scarcity is an opportunity to increase supply. This is the reason we have choices at various prices when it comes to any product or service.
In a market economy, scarcity leads to higher prices until the supply is increased.
In a non-market economy, scarcity leads to some kind of authority to control distribution - rationing.
Various criteria are used to develop the justification of rationing logic: cost/benefit analysis, evidence-based medicine, etc. (Those of us who had anything to do to with the Soviet Union would know immediately what it means. Rationing can be communicated to people in various ways, some ostensibly more humane than others).
At its core, rationing is an ALTERNATIVE system of resource distribution that REPLACES the supply-demand model, and where some kind of authority allocates a scarce resource based on some kind of reasoning.
Interestingly, both proponents and opponents of single-payer system agree that there is scarcity of resources when it comes to our health care system.
However, the opponents think this scarcity is artitificial, unnecessary and easy to resolve. This includes removing the artificial restrictions on supply of doctors in the US, which leads to exorbitant rates. Artificial restrictions on patent length, where generic drugs take decades to become available and leads to stratospheric prices for prescription drugs. Etc, etc.
The proponents of single-payer, instead, argue that health care, as a matter of principle, cannot be adequately delivered by a free economy.
And because of this belief, proponents of single-payer system RELY AND DEPEND on existence of scarcity to advance the argument for single-payer system.
If scarcity didn't exist, they wouldn't have a case. But it does - and instead of eradicating scarcity, they use it to advance government rationing.
In other words, scarcity is a problem for opponents and an opportunity for defenders of single-payer system.
This is also the reason that there isn't a single sentence in the proposed "reform" that does anything to eradicate scarcity of any kind in our health care system.
August 1, 2009 10:53 AM | Reply | Permalink
Your argument hinges on a fallacy:
We don't exercise 'choice' in the medical marketplace as we do when purchasing other big ticket items such as cars and washing machines. We don't check around for which hospital has the best rates when we've been in a car crash, had a coronary, or break our leg snowboarding. This all goes back to Kenneth Arrow's paper on information asymmetries in healthcare.
August 1, 2009 11:58 AM | Reply | Permalink
"We don't exercise 'choice' in the medical marketplace as we do when purchasing other big ticket items such as cars and washing machines"
- why don't we and why shouldn't we?
"We don't check around for which hospital has the best rates when we've been in a car crash, had a coronary, or break our leg snowboarding."
- isn't it because these things you describe are called "ACCIDENTS"? And wouldn't it be a good idea of have a choice when it comes to policies that cover accidents?
" Kenneth Arrow's paper on information asymmetries "
- shouldn't we cut these assymetries instead of inserting the government as the middle-man?
Sorry, nice try but neither of the 3 is a serious arguments.
You're making exactly the point that I said in my comment you would make: the fact of a problem's existence as a rationale for policy, not for action plan to eradicate the root cause of the problem.
August 1, 2009 12:12 PM | Reply | Permalink
Time is of the essence in medicine. We don't have time to shop around. This is one of the areas the private insurers exploit when denying or delaying approval of services: They may get 'lucky' and have the claimant die before a claim can be processed.
First off,I don't think a coronary is considered an accident. Wouldn't it be good if we didn't have to worry about having the proper insurance to insulate us from a calamity that could disable us for life without proper medical treatment, so we could continue to work, generate income, and pay taxes that benefit us as well as the nation? Coverage so as to protect us from bankruptcies, that add additional uncounted cost to society by adding to uncollected monies, and in so doing increasing the strain on local businesses and local prices of affected creditors, while adding a more generalized cost to society through tax deductions claimed by those creditors as uncollected debts.
These asymmetries are a given due to the nature of the healthcare market. Seriously, you didn't really read the paper did you?
What is policy, but an action plan to correct or improve problems.
August 1, 2009 12:35 PM | Reply | Permalink
I disagree. Let's go back to your objection again:
"Your argument hinges on a fallacy: "There two key components here: supply and choice.""
I think we do excercise choice in medical marketplace. We choose a family doctor. We choose an insurance plan. We choose drugs we buy, based on co-pay, prescription, etc. We choose whether or not to use preventive care.
I assume you won't argue with supply, since Arrows talks about it quite extensively.
As I understand it, you're not arguing with what I said about rationing. You're defending rationing on the premise that market economy is not appropriate to health care systems.
August 1, 2009 12:47 PM | Reply | Permalink
We do exercise the choices you list. We don't exercise choice on the major big ticket items in our health care when calamity strikes. Most laymen are at an inherent disadvantage in knowledge or time constraints to determine whether a test or procedure ordered by their doctor is necessary or not. These are all results of those 'information asymmetries' in the healthcare market. We are at the whim of the supply side on those items. Those items comprise the bulk of our inflated healthcare costs, if you ignore administrative overhead costs.
As for rationing, I am arguing for a fair and even distribution of access to healthcare goods and services. Something that the insurance industry has not been able to live up to with the practice of recision, dropping/raising rates for those in need, failure to issue policies to those with pre-existing conditions. If someone wants and can afford to buy supplemental insurance to allow access to goods and services not covered by an outcome based protocol, more power to them.
Aside from that, our current 'System' has failed to keep the costs of medical goods and services under control. A public option allowed to pay medicare rates is one of the ways we can exert pressure on insurance companies to institute similar cost containment pressure on medical suppliers.
August 1, 2009 1:05 PM | Reply | Permalink
OK, so you agree that we have both supply and choice - except when it comes to accidents.
Then you say that we have an additional problem in that we don't have as much knowledge as doctors have when it comes to ordering procedures.
Presumably (based on Arrows and Krugman and you) these are the reasons why a free market is not an appropriate system for health care, since we've cleared the other ones.
The argument re: accidents is a non-argument in my opinion. Any insurance plan, public or private, can resolve this easily while preserving choice and supply.
Your argument on access to information is only valid if you believe (as Obama does) that doctors are consistently putting self-interest decisions (i.e. profit) above the interests of a patient.
I disagree with that argument. I think by and large politicians and government officials are far more likely to put their self-interest above the interests of those who elect or appoint them.
And even if it were true, no social system in the world, even communism, has ever solved it or come close, including all the wonderful countries we want to copy.
August 1, 2009 1:45 PM | Reply | Permalink
Heh. My point is that the choices we do have, have no impact to reduce healthcare costs as they do in other markets.
August 1, 2009 2:12 PM | Reply | Permalink
Duh!
See above, on supply. Arrows provides excellent background on how we are restricting supply (additional: education cost and availability, doctor licensing, drug approval, patent laws, etc)
August 1, 2009 3:16 PM | Reply | Permalink
I hate it when I appear to be so dense amigo, but you're going to have to be more specific, 'cause I'm just not following you.
August 1, 2009 3:23 PM | Reply | Permalink
Mi corazon, I made a giant comment above on price being the equivalizer in supply/demand and choice in a free market economy. Are you going to offend me forever by saying you didn't read or already forgot?
:-)
August 1, 2009 3:29 PM | Reply | Permalink
Pero mijo, I made many comments over the last couple of days which demonstrate, if you read Arrow's paper, and subscribe to its' tenets, as most economists do, that price is not subject to the same market controls one might expect in a market that wasn't governed by individual need in the face of medical catastrophe.
August 1, 2009 4:03 PM | Reply | Permalink
Mijito, you're subtly shifting the argument towards "catastrophic" scenarios.... I'm watching ya!
August 1, 2009 4:14 PM | Reply | Permalink
This is getting to be like a day at the office. We both assume our positions in our cubicles and chip and chop away at each others arguments as best we can. This one's getting stale, I'll meet you on the next thread, and don't be late. :)
August 1, 2009 8:36 PM | Reply | Permalink
Lalo above asserts a long argument based on the false premise that proposed reforms would ration health care. At the risk of belaboring the point I already made several times, that's untrue. In a reformed system, there would be no limit on the treatments that an individual could have, but only on what that individual could expect someone else to pay for. Such limitations based on ability to pay are part of what cripples our current system and penalizes millions of Americans who deserve essential medical services they don't receive. These harms imposed by our current system are "rationing" in a figurative sense, but neither today's system nor a reformed system would ration in the literal ssense of the word.
As the experience of every other free-market industrialized nation has demonstrated, reforms of the type under consideration actually remove limitations to a considerable extent by making healthcare more affordable. The result is more coverage at lower costs and with better health outcomes.
Readers can review the thread above for details.
August 1, 2009 11:22 AM | Reply | Permalink
"the false premise that proposed reforms would ration health care"
Obama vs Fred:
"..the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.
Q: So how do you — how do we deal with it?
THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place."
http://www.nytimes.com/2009/05/03/magazine/03Obama-t.html?_r=2&ref=magazine&pagewanted=all
So, Fred: any thoughts on what this "very difficult democratic" conversation would be about?
August 1, 2009 11:45 AM | Reply | Permalink
See my earlier links to evidence-based medicine.
Regarding your other comment on who accounts for most medical expenses, I must say I'm shocked, shocked, to learn that sick people account for more medical bills than healthy ones.
August 1, 2009 12:43 PM | Reply | Permalink
Fred - once again, you're ignoring my point.
You disagreed with the premise that proposed health reform would ration health care, but you didn't say anything when I provide a quote from Obama who implied that it would.
Instead you're providing links to evidence-based medicine. I assume you do this to show that EBM, and not rationing, will guide government decisions on what treatments will be covered. And that EBM will be used in those "end of life options" that Obama talks about.
But you don't explain - and I don't understand - where the difference is.
It doesn't matter what tool is used to justify government rationing. Greater public good, cost/benefit, evidence or efficacy.
Any excuse the government will use to allocate scare resource is rationing, whether you care to say the dreaded word or not.
And at the same time as you insist that there will be no rationing apart from the EBM standard, you also say that there would be no limit on treatments you can have - only limit on treatments you could the money of others to pay for.
That means that EBM will be the exclusive guidance when it comes to the low-income Americans, since they won't be able to pay for any other option.
In other words, we're going to take Medicaid, add EBM-driven rationing on top of it and call it a great new system for the poor.
August 1, 2009 1:04 PM | Reply | Permalink
Please read this, Lalo:
http://www.newsweek.com/id/209817
August 1, 2009 1:22 PM | Reply | Permalink
I did. It has nothing to do with what we're discussing here, because I'm not arguing against the reform - but against the type of the reform currently on the table.
August 1, 2009 1:26 PM | Reply | Permalink
Readers can review what I've already stated to draw their own conclusions. No-one has, and no-one will propose rationing healthcare. Because resources are never unlimited, even a reformed system will have to choose not to pay for certain medical interventions, but the interventions will still be available - i.e., not rationed.
The importance of reform is that it will greatly reduce the quantity of essential medical services that do not get paid for. This improvement will bring us closer to all other industrialized democracies, which surpass us in that they cover almost all citizens, at much lower cost, and with better health outcomes.
Rather than trying to referee TPM arguments, interested readers might find it worthwhile to review the health care systems utilized elsewhere, single payer or public/private combinations, to understand why we find outselves at the bottom of the list in both health and affordability, despite our national affluence.
August 1, 2009 1:25 PM | Reply | Permalink
"review the health care systems utilized elsewhere"
- Only one fifth of women who are diagnozied with breast cancer die in the United States, compared to one third in France and Germany, and almost half in the United Kingdom and New Zealand
- among men who are diagnosed with prostate cancer, fewer than one fifth die in the United States, compared to one fourth in Canada, almost half in France, and more than half in the United Kingdom
- we measure infant mortality differently than other OECD countries, which results in different numbers
But it's fine, let the law of averages triumph.
We can adopt rationing, give it a fancy name like EBDM, and pat ourselves on the back for looking better in comparison with other countries.
August 1, 2009 1:51 PM | Reply | Permalink
CVille Dem - That's a powerful and entertaining article that you link to. I don't want to be overconfident but I think the reformers have probably won this battle, based on the latest House and Senate negotiations. We won't accomplish all we want, but we will see a dramatic and salutary transformation of American society toward one that emulates all the other nations that achieve better health at lower cost than we do.
I regret that Lalo persists in pushing the "rationing" bogeyman, despite its falsehood. I doubt that the cancer statistics he cites are accurate, but since I have access to the medical literature, I would be able to read the original references there or in other reputable epidemiological sources. We are at or near bottom of the list of industrialized democracies when it comes to health outcomes, and those statistics are available from multiple sources.
August 1, 2009 2:03 PM | Reply | Permalink
Recent cancer mortality statistics show the U.S. to have a poorer record than the UK, France, Sweden, and Australia, and about equal to New Zealand. France, with its hybrid public/private health care system, is frequently cited as a model for health care reform -
http://www.nationmaster.com/graph/hea_dea_fro_can-health-death-from-cancer
These data are hard to interpret because the role of factors unrelated to medical care differs among the nations. Regarding a point Lalo made above, statistics based on survival as a fraction of patients diagnosed are almost meaningless, as their lack of correlation with mortality data show. The reason is that such a fraction is very sensitive to rates of overdiagnosis of cancers, which if undiagnosed, would never cause problems. This distortion has been recognized for a long time in the case of prostate cancer overdiagnosis from PSA testing, but more recent Scandinavian data indicate that mammographically detected breast cancers not infrequently disappear later, and would never have been diagnosed if the mammography had been conducted at less frequent intervals.
August 1, 2009 3:08 PM | Reply | Permalink