Healthcare Reform Thread

[Drake Tungsten]

Looks like the Dem push for healthcare reform is in trouble. :b:

Dems reel on healthcare

Congressional Democrats and the White House are scrambling to regain their footing after a series of setbacks has stalled political momentum to reform the nation’s healthcare system.

Despite having a popular president in the White House and comfortable majorities in Congress, the Democratic rollout on healthcare reform has encountered significant bumps in the road.

A cost estimate hanging a $1 trillion price tag on an incomplete bill, salvos from powerful interest groups and great uncertainty among key Democrats on what will actually be in the legislation that moves through Congress have emboldened Republican critics.

http://thehill.com/leading-the-news/dems-reel-on-healthcare-2009-06-16.html

I imagine the Dems will regroup and make an effective push for their healthcare reform legislation, but this gives me hope that they can be stopped.

[Ramo]

Probably is going to pass, but real cost control (i.e. the public plan) will probably be neutered by the conservative Dems.

Meanwhile, on the other side of the aisle:

House Republicans presented a four-page outline of their health care reform plan Wednesday but said they didn’t know yet how much it would cost, how they would pay for it and how many of the nearly 50 million Americans without insurance would be covered by it.
http://www.rollcall.com/news/35940-1.html?type=printer_friendly

:lol:

[Ben Kenobi]

Single payer is total crap. You don't want it.

[Ramo]

Republicans don't really believe that. Otherwise, they woudln't be afraid of insurance companies competing with a public option on an equal footing.

[Drake Tungsten]

A public option in no way competes with private insurers on an even footing.

[Ramo]

Only in the sense that empirical evidence suggests that it'd be cheaper, and by the magic of capitalism, consumers would flow to it. The only public option that's half-way plausible (i.e. not John Conyers' Medicare for All) would be funded by premiums, just like private insurance.

[Drake Tungsten]

It's no surprise that a public option would be initially cheaper when it can be subsidized by taxpayers who have private insurance. This won't be true once the private insurers are pushed out of the market, however.

[DinoDoc]

Wouldn't a public option enjoy unlimited access to the Treasury being an entitlement and all? How on earth would it compete with private insurers (who have to deal with things like risk and hedging against losses) on an even footing?

[Ramo]

It's no surprise that a public option would be initially cheaper when it can be subsidized by taxpayers who have private insurance. This won't be true once the private insurers are pushed out of the market, however.

Again. No public option that anyone is seriously contemplating would rely on tax revenues to fund itself. That might change after private insurance fails to compete in primary care.

[Drake Tungsten]

Again. No public option that anyone is seriously contemplating would rely on tax revenues to fund itself.


True; the public option as contemplated now will rely on borrowed money to fund itself. The use of tax revenues will come after the 2012 election.

[Ramo]

Only to the same extent that private insurance would be subsidized by the public deficits (albeit offset by spending cuts/tax increases over a ten year period).

[Ramo]

Drake, you can argue about proposals that have the slightest chance of passing, or proposals that only exist in the WSJ Op-Ed page and the Congressional Progressive Caucus. But it's the latter, have fun - I'm out.

[Drake Tungsten]

Don't be ridiculous. You and I both know that Ted Kennedy and other influential Dems want a strong public option.

[Ramo]

Sure. But that phrase doesn't mean what you think it does. :)

[Ramo]

Show me proof that Kennedy is pushing a public option funded by tax receipts. :)

[Drake Tungsten]

Even your boy Ezra Klein won't claim that a strong public plan would compete on an equal footing with private insurers...

The Weak Public Plan: This is what people are talking about when they refer to a "level-playing field." This incarnation of the public plan -- first proposed by Len Nichols at the New America Foundation and later echoed by Peter Harbage and Karen Davenport at the Center for American Progress -- would have no special advantages over private insurers. It couldn't use the low rates that Medicare sets or access taxpayer subsidies. It couldn't force its way into networks. It would simply be another insurer, albeit with different incentives than traditional insurers.

The Strong Public Plan: This would be like Medicare for the rest of us. It could throw the federal government's weight around. It could negotiate deep discounts with providers. It could muscle its way into networks. Outside groups like the Commonwealth Fund estimate that it would save the average consumer 20 percent to 30 percent. That would give it a massive competitive advantage over private insurers, and would probably result in tens of millions of Americans dropping their current coverage and entering the public plan to save money. A variant of this was in the draft of Ted Kennedy's bill that was leaked last week.

http://voices.washingtonpost.com/ezra-klein/2009/06/health_care_reform_for_beginne_3.html

[Ramo]

As I said:
Only in the sense that empirical evidence suggests that it'd be cheaper, and by the magic of capitalism, consumers would flow to it.

[Ramo]

Thanks for emphasizing my original point, though. Your objection is that the public plan would outcompete the private industry. :)

[Drake Tungsten]

You are a moron.

[Ramo]

You are an ignoramus. Who can't back up his bald assertions. :)

[Drake Tungsten]

Let me help you understand what your boy Ezra Klein was saying...

The Weak Public Plan: This is what people are talking about when they refer to a "level-playing field." [Implication: A strong public plan won't create a "level-playing field"!] This incarnation of the public plan -- first proposed by Len Nichols at the New America Foundation and later echoed by Peter Harbage and Karen Davenport at the Center for American Progress -- would have no special advantages over private insurers. It couldn't use the low rates that Medicare sets or access taxpayer subsidies. [Implication: A strong public plan can use both!] It couldn't force its way into networks. It would simply be another insurer, albeit with different incentives than traditional insurers.

The Strong Public Plan: This would be like Medicare for the rest of us. It could throw the federal government's weight around. It could negotiate deep discounts with providers. It could muscle its way into networks. Outside groups like the Commonwealth Fund estimate that it would save the average consumer 20 percent to 30 percent. That would give it a massive competitive advantage over private insurers, and would probably result in tens of millions of Americans dropping their current coverage and entering the public plan to save money. A variant of this was in the draft of Ted Kennedy's bill that was leaked last week. [Implication: Ted Kennedy supports an unfair playing field that favors a public plan, which includes taxpayer subsidies!]

[Ramo]

Seriously, can someone who isn't a douchenozzle parse what Drake posted, and find one iota about funding from the tax payer?

The Strong Public Plan: This would be like Medicare for the rest of us. It could throw the federal government's weight around. It could negotiate deep discounts with providers. It could muscle its way into networks. Outside groups like the Commonwealth Fund estimate that it would save the average consumer 20 percent to 30 percent. That would give it a massive competitive advantage over private insurers, and would probably result in tens of millions of Americans dropping their current coverage and entering the public plan to save money. A variant of this was in the draft of Ted Kennedy's bill that was leaked last week.

[Ramo]

[But a strong public plan can do both!

You fail reading. :)

The strong public plan, obviously, won't create a "level-playing field"!

A level playing field is a subjective phrase. Obviously, a public plan could use its size to negotiate lower costs (like other large institutions). That's partially why I support a public plan!

[Drake Tungsten]

[But a strong public plan can do both!

You fail reading. :)

.

You are a moron.

[KrazyHorse]

My suggestions for health care "reform":

1) Break the back of the American Board of Medical Specialties when it comes to setting residency standards for physicians. Any guild which is allowed to legally disqualify others from practicing will move towards more and more stringent requirements in order to secure their own privileged position. Currently residents are unbelievably underpaid and overworked; this disincentive to enter medicine, along with the accrued debts incurred in medical school and in interest payments through residency restricts the supply of doctors. The same type of self-imposed requirement to have a certain number of attendings present increases the demand for attendings. Both of these factors increase the wages of attendings beyond all reason. The longer the residency requirements, the higher the salary of attendings in that specialty. What a ****ing load of nonsense.

2) Legally limit the number of hours hospitals may ask their residents to work. This will increase the number of slots available for residents, increase their wages and therefore increase the number of new attendings being pumped out. It will also increase safety, as there is ample evidence that overworked, overtired residents are the source of many medical errors.

3) Accept that not every working individual is going to be able to receive the latest, most technologically sophisticated treatments. This may sound harsh, but medical technology is increasing to the point where costs become prohibitive for cutting edge treatments. Individuals are going to have to make choices about what different levels of coverage are worth to them. Many of these treatments can be sacrificed without sacrificing much in the way of outcomes, so the choices are not as stark as they initially appear. But there are still going to be hard choices to be made.

[Ramo]

Seriously, can someone who isn't a douchenozzle parse what Drake posted, and find one iota about funding from the tax payer?

The Strong Public Plan: This would be like Medicare for the rest of us. It could throw the federal government's weight around. It could negotiate deep discounts with providers. It could muscle its way into networks. Outside groups like the Commonwealth Fund estimate that it would save the average consumer 20 percent to 30 percent. That would give it a massive competitive advantage over private insurers, and would probably result in tens of millions of Americans dropping their current coverage and entering the public plan to save money. A variant of this was in the draft of Ted Kennedy's bill that was leaked last week.
.

[DinoDoc]

Seriously, can someone who isn't a douchenozzle parse what Drake posted, and find one iota about funding from the tax payer?Why is it going to cost 1.5 trillion+ over a decade and why is the House considering 600 billion in tax increases to help pay for it if the reforms being discussed don't require taxpayer funding?

[Drake Tungsten]

My suggestions for health care "reform".

Good ideas, especially #3. The incentive structure of healthcare in America is what needs to be reformed; throwing more government money at the problem isn't going to fix things.

[KrazyHorse]

In general, I believe that my scheme would flatten pay across specialties, flatten pay between residents-fellows-attendings and increase the number of physicians per capita.

[Ramo]

My suggestions for health care "reform":

1) Break the back of the American Board of Medical Specialties when it comes to setting residency standards for physicians. Any guild which is allowed to legally disqualify others from practicing will move towards more and more stringent requirements in order to secure their own privileged position. Currently residents are unbelievably underpaid and overworked; this disincentive to enter medicine, along with the accrued debts incurred in medical school and in interest payments through residency restricts the supply of doctors. The same type of self-imposed requirement to have a certain number of attendings present increases the demand for attendings. Both of these factors increase the wages of attendings beyond all reason. The longer the residency requirements, the higher the salary of attendings in that specialty. What a ****ing load of nonsense.

Yeah, the whole medical standards infrastructure blows. We need more GP's with less debt. Specialization is not in the best interest of public health.

2) Legally limit the number of hours hospitals may ask their residents to work. This will increase the number of slots available for residents, increase their wages and therefore increase the number of new attendings being pumped out. It will also increase safety, as there is ample evidence that overworked, overtired residents are the source of many medical errors.

3) Accept that not every working individual is going to be able to receive the latest, most technologically sophisticated treatments. This may sound harsh, but medical technology is increasing to the point where costs become prohibitive for cutting edge treatments. Individuals are going to have to make choices about what different levels of coverage are worth to them. Many of these treatments can be sacrificed without sacrificing much in the way of outcomes, so the choices are not as stark as they initially appear. But there are still going to be hard choices to be made.

Yep. A Dartmouth study that has been going around recently shows variations in Medicare disbursements on the order of ~3 (controlling for demographics, IIRC), with very little correlation to health outcomes. Two major changes I'd like to see are portable insurance (and my preference would be a public insurer) and salaried doctors (so that they don't have immediate incentives to order more treatments).

[Ramo]

Why is it going to cost 1.5 trillion+ over a decade and why is the House considering 600 billion in tax increases to help pay for it if the reforms being discussed don't require taxpayer funding?

Because "the reforms being discussed" is specifically the public option. That's the score for a plan that doesn't include any public option (and any realistic option would be deficit neutral wrt the rest of the legislation). :)

[Kuciwalker]

Seriously, can someone who isn't a douchenozzle parse what Drake posted, and find one iota about funding from the tax payer?

Yeah, RIGHT HERE:

The Weak Public Plan: This is what people are talking about when they refer to a "level-playing field." This incarnation of the public plan -- first proposed by Len Nichols at the New America Foundation and later echoed by Peter Harbage and Karen Davenport at the Center for American Progress -- would have no special advantages over private insurers. It couldn't use the low rates that Medicare sets or access taxpayer subsidies. [Implication: A strong public plan can use both!] It couldn't force its way into networks. It would simply be another insurer, albeit with different incentives than traditional insurers.

[Drake Tungsten]

Don't bother, Kuci.

[Ramo]

Yes. I repeat. Klein didn't say what you believe he did.

Christ, he described the "strong public plan." Right here:
The Strong Public Plan: This would be like Medicare for the rest of us. It could throw the federal government's weight around. It could negotiate deep discounts with providers. It could muscle its way into networks. Outside groups like the Commonwealth Fund estimate that it would save the average consumer 20 percent to 30 percent. That would give it a massive competitive advantage over private insurers, and would probably result in tens of millions of Americans dropping their current coverage and entering the public plan to save money. A variant of this was in the draft of Ted Kennedy's bill that was leaked last week.

Nowhere does it talk about taxpayer funding. If you want, you can look up what Kennedy has actually put out about the upcoming legislation. :)

[Kuciwalker]

Nowhere does it talk about taxpayer funding. If you want, you can look up what Kennedy has actually put out about the upcoming legislation.

Yes it does, in the previous paragraph.

HYPOTHETICAL: I am trying to explain to you how apples are different from oranges. I say "apples are often red" but neglect to mention that oranges usually aren't. QUESTION: From this, would you assume that I wasn't trying to imply that oranges are not often red?

[Ramo]

He was comparing apples, oranges, and pomegranates (the trigger option). He says that apples are red, but neglected to say the same about pomegranates. They're red too. :)

http://voices.washingtonpost.com/ezra-klein/2009/06/health_care_reform_for_beginne_3.html

[Kuciwalker]

Why would the "trigger option" be taxpayer funded if the "strong option" wasn't?

[Ramo]

This isn't hard, people. Can someone show me Kennedy saying that he wants the public option to be funded by taxes?

[Ramo]

Why would the "trigger option" be taxpayer funded if the "strong option" wasn't?

What? Klein neglects to say that any realistic trigger option (i.e. Snowe's, which he mentions) is not taxpayer funded. The same is true for the "strong option."

[KrazyHorse]

Could you please explain to me what you mean by "weak" "strong" and "trigger" options?

I'm assuming that "weak" is as follows: optional buyin to Medicare coverage (or equivalent). Individual pays what (i.e. how is premium decided)? Overall, premiums must match additional cost to Medicare of treating additional individuals to avoid taxpayer funding of plan.

How do "strong" and "trigger" differ?

[Drake Tungsten]

Interesting...

Understanding the Kennedy health care bill

7. People from 150% of poverty up to 500% (!!) would get their health insurance subsidized (on a sliding scale). If this were in effect in 2009, a family of four with income of $110,000 would get a small subsidy. The bill does not indicate the source of funds to finance these subsidies.

http://keithhennessey.com/2009/06/08/kennedy-health-bill/

Of course, it doesn't specifically state that this subsidy will be paid for with tax revenues.

[Kuciwalker]

Why would the "trigger option" be taxpayer funded if the "strong option" wasn't?

What? Klein neglects to say that any realistic trigger option (i.e. Snowe's, which he mentions) is not taxpayer funded. The same is true for the "strong option."

So one or both of them is implied to be. Why would that one be the trigger option and not the strong option?

[Ramo]

Klein's breakdown is actually pretty good. Weak doesn't piggyback onto Medicare in negotation with medical providers; strong does. Trigger kicks in after a certain number of years if the private market fails to meet a certain set of metrics (i.e. cost control and coverage). Trigger is being pushed primarily by Olympia Snowe, and isn't catching much fire. Strong is being pushed by Senate liberals (i.e. Kennedy). A new idea being pushed by certain conservative Dems (i.e. Kent Conrad) is health care co-ops as a substitute for the private plan, which would resemble the weak plan in certain ways (i.e. lowering bargaining ability, smaller risk pools). All would be paid for by premiums, rather than being automatically covered by taxes.

[KrazyHorse]

Could we please stop the self-referential discussion and simply get a clear definition of the plans, as understood by Ramo?

After that we can figure out if they actually conform to reality.

EDIT: this is an xpost

[Ramo]

So one or both of them is implied to be. Why would that one be the trigger option and not the strong option?

I'm saying that it's neither, and that by your logic it would be both.

[Kuciwalker]

If it's neither, why did he bother to mention it in the first place?

[Ramo]

I don't know. Maybe he was comparing it single payer (i.e. Conyer's bill), which he referred to earlier in the post. Maybe because he's not the best writer in the world. But you know, there are sources to find this information beside that single blog post. I'd like to see some actual evidence. :)

But by your logic, Olympia Snowe ends up somewhere between Ted Kennedy and Bernie Sanders in terms of legislation that they're pushing.

[KrazyHorse]

Ramo: according to you the only difference between weak and strong is whether or not negotiations are conducted in unison with existing Medicare coverage or not?

By the way, your claim about "smaller risk pools" is a red herring. Current medicare recipients receive the vast majority of their benefits premium-free (medicare part A) therefore they are not "choosing" to join any risk pool; by subsidizing to such an extent the government is removing all choice from the matter. The people who choose to join Medicare under the new plan would form their own risk pool no matter what.

EDIT: the only risk pool the government could throw the new people in with is:

a) The people who are ineligible for the subsidy to Part A
b) A risk pool for the other medicare sections

[Ramo]

That's right.

I was talking about the co-ops. They'd be much smaller risk pools than a national plan.

[KrazyHorse]

health care co-ops as a substitute for the private plan, which would resemble the weak plan in certain ways (i.e. lowering bargaining ability, smaller risk pools)

[KrazyHorse]

By the way, you do realize that the adverse selection problem is extreme for any optional plan, right? Most states have a "last ditch option" for the uninsured. Modulo negotiation power with providers these are pretty good estimators for what an optional plan would cost. And it's not pretty. Only the sickest will choose to join.

[Ramo]

The idea is that you still have a relatively balkanized health insurance market with co-ops. Less pooling. This is a distinct issue from not piggybacking on Medicare disbursment (10% higher, specifically).

[KrazyHorse]

Ramo, when you say that the coops share certain features with the "weak" plan and then list "smaller risk pools" as one of these features, you are saying that the "weak plan" has smaller risk pools than the strong plan.

Be careful.

[Ramo]

By the way, you do realize that the adverse selection problem is extreme for any optional plan, right? Most states have a "last ditch option" for the uninsured. Modulo negotiation power with providers these are pretty good estimators for what an optional plan would cost. And it's not pretty. Only the sickest will choose to join.

Yep. Part of the reform is putting in no discrimination in the private market, and limiting the price range of premiums. Policing that will be difficult.

I'd prefer to see a taxpayer funded single payer for primary care, but that obviously isn't the realistic.

[Ramo]

Ramo, when you say that the coops share certain features with the "weak" plan and then list "smaller risk pools" as one of these features, you are saying that the "weak plan" has smaller risk pools than the strong plan.

Be careful.

True, I wasn't too clear. Some of the weak plans were limited in size to specific jurisdictions, i.e. states. So you have a strong similarity to that subset.

The generic "weak plan" is outdated. The options are currently (in order by likelyhood) co-op, strong, and trigger.

[Kuciwalker]

I don't know. Maybe he was comparing it single payer (i.e. Conyer's bill), which he referred to earlier in the post. Maybe because he's not the best writer in the world. But you know, there are sources to find this information beside that single blog post. I'd like to see some actual evidence. :)

But by your logic, Olympia Snowe ends up somewhere between Ted Kennedy and Bernie Sanders in terms of legislation that they're pushing.

No, because it's possible he mentioned it to contrast with only one of them, and "strong plan" seems like the more plausible of the two. It's not plausible that he wasn't using it as contrast at all.

[KrazyHorse]

I think that my preferred plan would be for:

1) National, non-optional catastrophic coverage along with coverage for certain public health measures, preventative measures (e.g. biannual checkups) and child coverage. Catastrophic coverage would provide only low-cost/high effectiveness treatments.

2) Means-tested aid for a small percentage of the population (US medicaid?) which covers additional non-catastrophic services (twisted ankles, sniffles etc)

1&2 taxpayer funded, with user fees (possibly no user fees for 2, or reduced user fees)

3) Employer provided (I still can't figure out a better way to reduce the adverse selection problem) coverage for more advanced treatments and non-catastrophic injuries. Force insurance companies to accept pooled coverage of all companies with greater than (say) 5 full-time employees (or equivalent in part-time covered employees; this requirement is to prevent the gaming of the system by individuals who form one-person companies). Part (1) covers hypothetical costs of basic treatment, part (3) pays the costs on top of this. Employers pay premiums which, if continued through the lifetime of employees, would cover lifetime coverage. In other words, they pay more than it would cost to simply cover their workforce. This is because we want:

4) Retirees with qualifying amounts of time worked can continue their previous employer-based coverage at the same price their employer was paying. i.e. retirement COBRA. Payments should probably be indexed to CPI, but that's a bit of a detail.

[Ramo]

It's not plausible that he wasn't using it as contrast at all.

Yes. It is entirely plausible.

So, your theory is that Klein is so deliberate with his language that his description of the weak plan implicitly describes something else. And he went ahead to describe the two other options that were on the table at the time, and failed to thoroughly describe one of them - despite his masterful use of the English language. But we don't know which one, for sure. And we have to make an assumption here because the only person who follows Ted Kennedy's public announcements is a single journalist, in a single blog post. Ok, dude. :)

[Kuciwalker]

Why would you both to mention one plan isn't taxpayer funded if none of them are?

[Ramo]

I think that my preferred plan would be for:

1) National, non-optional catastrophic coverage along with coverage for certain public health measures, preventative measures (e.g. biannual checkups) and child coverage. Catastrophic coverage would provide only low-cost/high effectiveness treatments.

2) Means-tested aid for a small percentage of the population (US medicaid?) which covers additional non-catastrophic services (twisted ankles, sniffles etc)

1&2 taxpayer funded, with user fees (possibly no user fees for 2, or reduced user fees)

3) Employer provided (I still can't figure out a better way to reduce the adverse selection problem) coverage for more advanced treatments and non-catastrophic injuries. Force insurance companies to accept pooled coverage of all companies with greater than (say) 5 full-time employees (or equivalent in part-time covered employees; this requirement is to prevent the gaming of the system by individuals who form one-person companies). Part (1) covers hypothetical costs of basic treatment, part (3) pays the costs on top of this. Employers pay premiums which, if continued through the lifetime of employees, would cover lifetime coverage. In other words, they pay more than it would cost to simply cover their workforce. This is because we want:

4) Retirees with qualifying amounts of time worked can continue their previous employer-based coverage at the same price their employer was paying. i.e. retirement COBRA. Payments should probably be indexed to CPI, but that's a bit of a detail.

Why means-test GP visits (assuming you have user fees)?

[Ramo]

Why would you both to mention one plan isn't taxpayer funded if none of them are?

Maybe because he isn't the clearest writer, meaning to distinguish it from Conyers/Sanders, and failed to add a caveat for the set of options. I'm pretty sure that my theory is better than yours.

[KrazyHorse]

Errr...because even with user fees there would be a public subsidy to doctor's visits which are probably not really necessary (they are comfort issues which will resolve themselves given time). I'm trying to offload as many of the costs as possible to private parties while:

1) Retaining some care for every individual
2) Reducing adverse selection problems as much as I can

[KrazyHorse]

By the way, since the national insurance plan would reduce the costs of employer-provided insurance (by paying for some large fraction of treatments) it would probably increase coverage rates...

There's also the possibility it would reduce coverage rates, since people would no longer be as scared of going without employer coverage, but my feeling is that most people are fairly risk averse for even non-catastrophic medical costs, so will still want to be lumped in with everybody else in a nice big insurance pool

[KrazyHorse]

Note: employer provided coverage is either for all full-time employees or for nobody. Individual employees cannot choose to opt out.

[Ramo]

Errr...because even with user fees there would be a public subsidy to doctor's visits which are probably not really necessary (they are comfort issues which will resolve themselves given time). I'm trying to offload as many of the costs as possible to private parties while:

1) Retaining some care for every individual
2) Reducing adverse selection problems as much as I can

Right, there would be a public subsidy. By a user fee, I mean similar in scale to a copay.

Why do you think that's a bad idea? The current system oversubsidizes secondary care, but I'd say that preventative care that goes beyond an annual physical would be prudent. I don't think people generally go to the doctor for the sniffles (except kids, but they'd be covered under your scheme). Lots of hassle, and you have to deal with the copay.

You don't have selection issues if it's automatic.

[KrazyHorse]

By a user fee, I mean similar in scale to a copay.


Yes, and I'm trying to reduce PUBLIC subsidies to these types of doctor's visits. There's a utility issue for those who truly cannot afford optional visits, so I'm willing to give them a chance at the public purse. But if I send the costs to private insurers we might at least HOPE that over time employees will agitate for higher pay at the cost of higher copays/deductibles for such visits. If it's given as an entitlement, on the other hand, it will not be reduced without a huge hassle.

And if you don't think that people go to the doctor for sniffles then you are sadly mistaken.

[Ramo]

Or is your threshold for "catastrophic" really low? Say, I dislocate my kneecap and am unemployed. How much of that should I have to pay?

[KrazyHorse]

I don't understand why you think it's necessary to cover people with reasonable incomes for non-catastrophic care.

There's not too much of an efficiency issue because the cost of this type of care (sniffles visits) is relatively low, thus covering it for low-income individuals doesn't increase marginal tax rates in the phase-out region too much.

So why should we cover somebody who could afford to pay for it (even without insurance)?

[KrazyHorse]

Or is your threshold for "catastrophic" really low? Say, I dislocate my kneecap and am unemployed. How much of that should I have to pay?

???

If you're unemployed then you should be included in part (2), no?

[Ramo]

I suppose this is an empirical question, and I don't have the data to argue this point. But my intuition is that primary care is heavily underutilized.

???

If you're unemployed then you should be included in part (2), no?


The Medicaid comparison implies severe means testing. You generally need to be poor with kids or some kind of disability. The Kennedy plan, for example, would be a lot more generous.

[KrazyHorse]

I suppose this is an empirical question, and I don't have the data to argue this point. But my intuition is that primary care is heavily underutilized.

From what I've seen it's heavily overutilised by large minority of the population and mildly underutilised by the rest (who are more motivated by inconvenience than cost).


The Medicaid comparison implies severe means testing. You generally need to be poor with kids or some kind of disability. The Kennedy plan, for example, would be a lot more generous.

If you're short term unemployed then cobraish coverage should be fine. If you're long-term unemployed and have no assets (and yeah, I'm including a primary residence) then I'd be fine with providing some coverage. With this much of a means test you're not going to get much in the way of moral hazard. Plus, I don't know why you brought up the example of a dislocated knee. The treatment for that involves manipulation of the knee back into position and bracing of the joint. Not particularly expensive. 400$?

There are surgical options to prevent recurrences, but I don't see why the public should cover that...

[Ramo]

Not a meaningful example, just something I know the costs associated with (happened to me three times). Ambulance, emergency room, doctor's visit, physical therapy. Last time, I had insurance (crappy school insurance covering only 70%), and out of pocket was ~$4k. I never ended up tallying the exact figure, since those bills were depressing the hell out of me.

[KrazyHorse]

Ambulance, emergency room, doctor's visit, physical therapy.

the first two are the expensive part, no? And I don't see why the public should fund the last one

Why did you get an ambulance for a dislocated knee? You could have taken a trip to a clinic the next day.

[KrazyHorse]

By the way, the last injury I had was a complete rupture of the anterio-tibular ligament in my ankle.

And no, I didn't visit the doctor. I just bought a set of crutches and used them for the next 2 weeks.

[Jon Miller]

The issue with a lot of treatments is that it is in the publics interest to do them to save costs later.

For example, if the knee was fixed after the first time, it would save the public from repeatedly paying for the same ailment over and over again. Besides decreasing the cost to society in work lost.

I think that national public health shuold be focused on preventative measures and on doing what is needed to decrease the likelyhood of future visits.

JM

[Ramo]

I'm pretty sure I got a fractured ankle a few months ago, didn't go to the doctor either. Dislocated kneecap was, um, somewhat different in terms of mobility and pain. Also I had to be carefully removed from an inflatable suomo suit. Yeah, ambulance and emergency room were a large majority.

[Kuciwalker]

The issue with a lot of treatments is that it is in the publics interest to do them to save costs later.

For example, if the knee was fixed after the first time, it would save the public from repeatedly paying for the same ailment over and over again. Besides decreasing the cost to society in work lost.

I think that national public health shuold be focused on preventative measures and on doing what is needed to decrease the likelyhood of future visits.

JM

I hear this repeated a lot, but it's non-obvious to me why preventative care should necessarily be cheaper than acute care.

(More precisely, why preventative care should prevent more $$ of acute care than it costs, since in reality you'll still need both.)

[Jon Miller]

A lot of disease/etc is caused by obesity, lack of exercise, eating bad for you stuff/etc.

It would cost almost nothing to fix these causes of the problems.

And millions (billions?) are spent on diabetes alone, which is ignoring all the other results of unhealthy living.

Similarly, going into the doctor and getting a breast or prostate exam provides a relatively inexpensive procedure, and if the cancer is caught early it is much cheaper to cure than if it is caught later (+ the costs to society to deal with the person and lost of productivity if it is caught later).

Also, dental cleanings are cheap. Fixing dental problems are expensive, this is why dental insurance has cleanings free...

In every case I can think of, preventative health is much much much cheaper than curing the results. This is also the case when you compare health care in the US versus other countries. Some of the reason we pay so much more, for so much less, is because our health care and culture isn't focused on prevention. It isn't just the inefficiencies in private insurance.

As part of the prevention, I would raise taxes on a lot of things like soda pop. And obviously end the subsidies on corn (which makes it more worth while to put corn syrup in everything).

JM

[Kuciwalker]

It would cost almost nothing to fix these causes of the problems.

It would cost almost nothing to radically change many people's behaviors? ;)

In every case I can think of, preventative health is much much much cheaper than curing the results.

That's assuming preventative health has a 100% success rate.

[KrazyHorse]

For example, if the knee was fixed after the first time, it would save the public from repeatedly paying for the same ailment over and over again. Besides decreasing the cost to society in work lost.


a) Surgery is goddamned expensive compared to relatively minor costs of readjusting a knee and bracing.

b) "Society" only loses taxes paid during the individual's work, as to a first approximation individuals are paid their marginal product pretax. And most people who cannot afford to get surgery/do not have insurance produce damned little, and are thus taxed very lightly.

[KrazyHorse]

I hear this repeated a lot, but it's non-obvious to me why preventative care should necessarily be cheaper than acute care.

(More precisely, why preventative care should prevent more $$ of acute care than it costs, since in reality you'll still need both.)

Particularly in a case like this. Surgery of any kind is really expensive. Minor orthopedic adjustments are not.

[KrazyHorse]

Basically, Jon: you are claiming MAJOR inefficiencies in the behaviour of most people when it comes to preventative care (particularly that they don't get enough) and that a relatively minor amount of money will fix this. That seems pretty absurd to me. Unless you're going to provide some numbers to back yourself up then I'm going to have to call bullshit on this. For an experimentalist you seem damn fond of theorizing with no evidence when it comes to economics and related fields.

:)

[Zkribbler]

Single payer is total crap. You don't want it.

Single-payer that is grossly underfunded as in Canada is total crap.

--But Canada still does have universal, free health care which costs the Canadian taxpayers far, far less than Americans in total pay for their health care. Canadians also have a longer lifespan and a smaller infant mortality rate [as do the citizens of EVERY country which has single payer].

[DinoDoc]

Because "the reforms being discussed" is specifically the public option. That's the score for a plan that doesn't include any public option (and any realistic option would be deficit neutral wrt the rest of the legislation). :)Let's deal specifically with the Kennedy bill:
A leading health care bill under consideration in Congress would cost the government an estimated $1 trillion over the next decade and reduce the ranks of the uninsured by about one-third, or 16 million individuals, congressional budget officials said Monday in a preliminary estimate.

...http://www.reflector.com/news/nation/cbo-senate-bill-1-trillion-over-10-years-664629.html

That's a hell of a lot of money to only reduce the uninsured by 1/3. I'd also like to know where your think the government is going to get the money to fund this if not through taxpayer funding. Will they pay for it with rainbows and the dreams of little girls?

[DaShi]

DD, there's enough ignorance in this thread. No need for you to add more.

[Ramo]

Let's deal specifically with the Kennedy bill:
http://www.reflector.com/news/nation/cbo-senate-bill-1-trillion-over-10-years-664629.html

That's a hell of a lot of money to only reduce the uninsured by 1/3.

That estimate scores an incomplete bill. It doesn't include either the employer or individual mandates, both widely acknowledged to be pivotal parts of the HELP bill. It also doesn't include the public option, incidentally.

I'd also like to know where your think the government is going to get the money to fund this if not through taxpayer funding. Will they pay for it with rainbows and the dreams of little girls?

You have no frame of reference. You're like a child who wanders into the middle of a movie, and keeps asking inane questions. :)

[DinoDoc]

That estimate scores an incomplete bill. It doesn't include either the employer or individual mandates, both widely acknowledged to be pivotal parts of the HELP bill. It also doesn't include the public option, incidentally.I don't see how that is going to actually help your case but if you can link to a CBO review that you would consider to be more complete, I would be interested in reading it. Specifically these magical formulas that detail how they plan to fund it without in your words "one iota of funding from the tax payer."You're like a child who wanders into the middle of a movie, and keeps asking inane questions. :)I'm starting to agree with Drake's assessment of you.

[DaShi]

I'm starting to agree with Drake's assessment of you.

Well, that's only because you are incapable of forming your own opinions.

[Ramo]

I don't see how that is going to actually help your case but if you can link to a CBO review that you would consider to be more complete, I would be interested in reading it.

The chairman's markup isn't complete. A realistic score will come out after that happens (HELP has been procrastinating, so there's no telling when - but I'd expect in the next couple weeks).

Specifically these magical formulas that detail how they plan to fund it without in your words "one iota of funding from the tax payer."

It's pretty remarkable that you still have absolutely no clue what I was referring to when I used those words. Only you, Dino. :love:

On second thought, Ben could pull this off too. :b:

[Arrian]

What about the Dole/Daschle plan? I don't know anything about it, yet, other than its "bipartisan" billing as reported (ever so briefly) on NPR.

-Arrian

[Ramo]

I could live with it, but wouldn't be terribly enthusiastic. It's similar to what the conservative Dems are pushing. It requires extracting more savings from Medicare than the other plans (which would be fine in principle, but makes it less likely to be deficit neutral than if it were funded through other sources). The Medicaid expansion would be more limited than Kennedy (HELP), but I'm not sure where it is wrt Baucus (Finance) - probably to the right. The public option is somewhat to the left of co-ops: you have a weak state-specific plan (functionally equivalent to co-ops), that triggers a national plan. It should be noted that no one really knows how weak the public option will be in HELP and Finance (but it's guaranteed not to be any stronger than the "strong option" described earlier by Klein).

[Ramo]

And a note about bipartisanship. The Republicans in question are Bob Dole and Howard Baker. The current party is so blinkered, they're well to the left of the median Republican Senator. You've got some of the more "reasonable" guys like Gregg calling fundamentally similar legislation "Marxist."

[Jon Miller]

Basically, Jon: you are claiming MAJOR inefficiencies in the behaviour of most people when it comes to preventative care (particularly that they don't get enough) and that a relatively minor amount of money will fix this. That seems pretty absurd to me. Unless you're going to provide some numbers to back yourself up then I'm going to have to call bullshit on this. For an experimentalist you seem damn fond of theorizing with no evidence when it comes to economics and related fields.

:)

No one has studied anti-obesity care as far as I can determine.

So I have to go on the studies which show that huge health differences between the obese and non-obese.

The most underutilized prevention according to one particular study (and other studies seemed to be in general agreement): tobacco-use screening and brief intervention, screening adults aged 50 and older for colorectal cancer, immunizing adults aged 65 and older against pneumococcal disease, and screening young women for Chlamydia. The best that was studied were discussing aspirin use with high-risk adults, immunizing children, and tobacco-use screening and brief intervention according to the study.

JM

[Patroklos]

o I have to go on the studies which show that huge health differences between the obese and non-obese.

You seem to be under the impression that obesity is driven health care access, why is that?

[Wezil]

Single-payer that is grossly underfunded as in Canada is total crap.


Are you saying the "fix" for our system is more money?

[KrazyHorse]

No one has studied anti-obesity care as far as I can determine.

So I have to go on the studies which show that huge health differences between the obese and non-obese.

The most underutilized prevention according to one particular study (and other studies seemed to be in general agreement): tobacco-use screening and brief intervention, screening adults aged 50 and older for colorectal cancer, immunizing adults aged 65 and older against pneumococcal disease, and screening young women for Chlamydia. The best that was studied were discussing aspirin use with high-risk adults, immunizing children, and tobacco-use screening and brief intervention according to the study.

JM

I think you're completely failing to misunderstand me; I want evidence that IN GENERAL a relatively low cost program to finance public use of primary services would lead to some sort of LARGE net health benefit. Not whether or not a couple of primary care techniques are effective and underutilised. The difference between those two questions is STAGGERING.

You seem to want to fund primary care based solely on your assertion of what I stated with absolutely no available evidence of ANY of the steps that you'd have to demonstrate. That's irresponsible in the extreme, and smacks of post hoc ideological reasoning.

[Jon Miller]

Obviously some preventative measures will be worth it, and some won't?

The biggest gains would be in an anti-obesity program, is my hypothesis. This hasn't been studied, except that a large portion of health problems that people have are related to obesity.

JM

[Patroklos]

The biggest gains would be in an anti-obesity program, is my hypothesis.

Do you seem to think that people don't understand that a big mac is bad for them? These problems are driven by life style choices which are themselves driven by culture. While these may in fact have a great effect on health care, it is not within the scope of health care to fix them and confusing the two is probably one of the single quickest ways to have heath care reform go down in flames.

Mission creep :q:

[KrazyHorse]

Obviously some preventative measures will be worth it, and some won't?

The biggest gains would be in an anti-obesity program, is my hypothesis. This hasn't been studied, except that a large portion of health problems that people have are related to obesity.

JM

What does this have to do with Ramo's question about dislocated knees? Your initial comment regarding preventative care was in direct response to that line of inquiry.

[Jon Miller]

I wasn't directly responding to Ramo, I hadn't posted in the thread yet and was referring to things in general.

I did have the idea, which is perhaps wrong, that the total loss in productivity and cost in health for going in to get a dislocated knee treated over and over again were higher than cost of going in to get it repaired. I know of a number of people who have gone in to get it repaired, so that they could do their work properly.

That was a separate issue from my general thoughts on prevention (which is heavily invested in lifestyle changes and anti-obesity).

JM

[Arrian]

I could live with it, but wouldn't be terribly enthusiastic. It's similar to what the conservative Dems are pushing. It requires extracting more savings from Medicare than the other plans (which would be fine in principle, but makes it less likely to be deficit neutral than if it were funded through other sources). The Medicaid expansion would be more limited than Kennedy (HELP), but I'm not sure where it is wrt Baucus (Finance) - probably to the right. The public option is somewhat to the left of co-ops: you have a weak state-specific plan (functionally equivalent to co-ops), that triggers a national plan. It should be noted that no one really knows how weak the public option will be in HELP and Finance (but it's guaranteed not to be any stronger than the "strong option" described earlier by Klein).


1. Thanks for the response.

2. Wow, a lot of that was gibberish to me. I think I'm a bit behind in this. Next time I have a few hours I want to kill, I know how to kill them.

-Arrian

[KrazyHorse]

Wow, a lot of that was gibberish to me

Ramo is being very obtuse in expressing himself on this, Arrian. Press him to define his terms.

[Arrian]

Maybe once I've done a modicum of my own research on it first, I will. But for now, I really haven't examined the issue in depth, so calling out someone else for being obtuse seems... childish.

-Arrian

[Drake Tungsten]

Ramo is being very obtuse

QFT

[Drake Tungsten]

As health care reform legislation moves forward in Washington, the political environment is somewhat different than the last time a major overhaul of the health care system was attempted sixteen years ago. In early 1993 the sense of a health care crisis was far more widespread than it is today – a 55% majority in 1993 said they felt the health care system needed to be “completely rebuilt” compared with 41% today. Health care costs were also a broader problem in 1993 – 63% of Americans said paying for the cost of a major illness was a “major problem” for them, compared with 48% currently.

The issue of limiting overall health care spending is also more prominent in 2009 than it was in 1993. Somewhat fewer today say the country spends “too little” on health care, and a larger share believe that limiting the overall growth in health care costs is a higher priority than expanding coverage. But overall, public support for guaranteed access to medical care for all Americans remains widespread.

http://people-press.org/report/?pageid=1534

Good news. :b:

[Drake Tungsten]

Centrist Dems unite to fight left on health

The House's two most conservative caucuses, the Blue Dogs and New Democrats, are banding together to come up with shared principles on healthcare and counter a process many see skewing to the left.

The two groups, which combined have 131 members — more than half the House Democratic Caucus — have been holding meetings to see where they can agree on a healthcare plan.

"We're looking at things like what the structure of a public plan would look like," said Rep. Ron Kind (D-Wis.).

Democratic leaders have taken note. Kind said House Speaker Nancy Pelosi (D-Calif.) called a meeting with New Democrats and Blue Dogs in her office Wednesday to discuss healthcare. The results of that meeting were not known at press time.

There is concern among centrists in the caucus that the draft bill, to be released Friday, will reflect some of the more liberal ideas in the caucus, although leadership has already rejected the idea of a single-payer system. It is being put together by the House Education and Labor, Energy and Commerce and Ways and Means committees.

"You have a bunch of crazy liberal chairs and their crazy liberal staffers, and they want to lay down a marker," said a senior Democratic aide.

The two caucuses have already put out separate written principles on healthcare that are similar, expressing reservations about a public option and opposing a "Medicare-like" system.

Where they differ is on the Blue Dogs' demand that the public option should be a last resort, kicking in only if reforms fail to achieve cost savings and there isn't enough competition. New Democrats have made no such request.

"Their principles mirror ours, except for the trigger," said an aide to a Blue Dog member active in the health debate.

Both groups say they're concerned about a public plan, and specifically don't want it to look like Medicare, which is exactly what the Congressional Progressive Caucus and the Congressional Black Caucus are pushing for.

Both sets of principles are geared toward making sure any public plan won't gain a competitive advantage over private insurance plans.

The 69-member Progressive Caucus threatened that its members will vote against healthcare legislation if it doesn't have a "robust public plan."

http://thehill.com/leading-the-news/centrist-dems-make-voices-heard-on-healthcare-2009-06-17.html

:b:

[Ramo]

1. Thanks for the response.

2. Wow, a lot of that was gibberish to me. I think I'm a bit behind in this. Next time I have a few hours I want to kill, I know how to kill them.

-Arrian

Sorry, I'd meant to concisely differentiate Daschle/Dole/Baker from the [more] plausible alternatives. I covered some of this lingo before, but I forgot that it is spread over a large number of posts. Anyways, here's an attempt at a summary:

Due to a set of historical decisions in WWII and its aftermath (the employer tax deduction and the failure to pass single payer legislation), we have a system largely built on employer-based insurance. When Clinton decided to re-engineer health care, as we all know, he created a monstrously complicated piece of legislation that was disastrously sold. A key argument against his plan would be that it could disrupt the lives and doctor-patient relationships of large numbers of people. When designing new legislation, health wonks figured that the new system would have to allow people who are satisfied to keep their coverage. So building upon the current employer-based system became a political necessity, regardless of everything else reform would do.

There are some people who disagree with this attitude. McCain, infamously, proposed to replace employer tax deduction with a pittance (a flat $2k tax credit). Wyden-Bennett is an interesting (and genuinely bipartisan!) piece of legislation, but is going nowhere for reasons I don't fully realize; there's a good argument to say that it's better than the proposals on the table (because it seriously tackles cost control).

But we're not going that way. So, starting with the current employer based system, you have a set of gaping holes:
1. Small businesses can't create sufficiently large risk pools to qualify for affordable health insurance. And it's even worse for the self-employed, who lose out on the employer tax deduction.
2. The safety net for adults under 65 is basically non-existent, and the safety net for kids could be a hell of a lot better.
3. Health care inflation is astonishingly high (IIRC, with a 6% annualized growth rate). This threatens to undermine everything, including the federal government's ability to pay for Medicare/Medicaid.

Health care is currently under two committee jurisdictions in the Senate. HELP is chaired by Ted Kennedy, and its Dem members are mostly in the left wing of the caucus. Finance is chaired by Max Baucus, and its Dem members are in the right wing of the caucus (but further to the right than HELP is to the left). Because the legislation affects entitlements (Medicare and Medicaid), Finance has the stronger claim (it's not entirely clear to me why HELP has any claim). The House is taking a unified approach, and is lead by Henry Waxman - a very solid progressive. And of course, there's Obama's bully pulpit (which will be important during House-Senate reconciliation).

During the primaries, Edwards released a plan that the Democratic Party largely adopted. The central points are:
a. You can opt into what's called a health insurance exchange. The idea is that you enter into a very large risk pool, and have your choice of health care insurers. To deal with any selection biases that segregate this pool, you have to mandate a certain class of employers to insure their employees or pay into the system, mandate individuals to enter the system, and heavily regulate the private insurers. The key parts to this regulation would be prohibit discrimination based on pre-existing conditions, and impose a limited range in which insurers can vary premium costs. You can also use this exchange to impose other reforms, such as a standardized adminstrative procedure. This is the centerpiece of health care reform, even if no one ever talks about it.
b. You drastically expand coverage. Full coverage through Medicaid would apply to some multiple of the federal poverty level, and subsidies (for your choice of insurer) would gradually decline up to some cutoff. If Dino or anyone else who ought to be is paying attention, this is the cost sink.
c. Because this costs money (upwards of $100 billion/year), you have a set of revenue sources and spending cuts. The key cuts would be in Medicare/Medicaid (i.e. fixing the Bush prescription drug boondoggle, among other things). An interesting idea that folks have been throwing around is to deal with Medicare like the military base closing institution, BRAC. The problem with eliminating wasteful procedures is that some Congressional power broker will complain, and reverse it. So instead you present a set of recommendations which Congress can approve on an up or down vote as a whole. The main sources of funding would be the employer mandate (if an employer doesn't provide insurance, it funds some portion of this person's premium in the exchange) and capping the employer tax deduction (which has a very regressive effect).
d. To impose long-term cost discipline, ideally you'd like a public option. And any option with a modicum of political support would be funded by premiums, not tax dollars. Just to be clear. ;) Peer reviewed studies suggest that you can cut 20-30% by using a quasi-monopoly scale to bargain with medical providers. This is the "strong" public option that we've been referring to in this thread.

All of the players agree with the exchange, which is good news.

Medicaid expansion is obviously contentious, given its pricetag. For the House and HELP full coverage is 150% of the federal poverty level (IIRC). For Finance, it's 100%. The cutoff for the House is 400%, for HELP is 500%, and Finance is 300% (this is a mild surprise, since everyone expected the House to be to the left of HELP). For kids and certain other classes of individuals, these multipliers are higher. I don't know where Daschle stands, but reporting I've read puts it somewhere to the right of HELP. I don't think Obama has put out any specifics here. I'd like to see us end up with a more generous, HELP-like, safety net.

Financing the bill is going to be complicated. Most of this is still up in the air. As I said, the cuts in Medicare that Daschle et al. were talking about is twice as high as the figure that Obama has mentioned, so I'm dubious about its practicality. It's reasonable to assume that the House and HELP will be tougher with the employer mandate than Finance. And because there aren't a lot of extra pots of money (a set of other options have been shot down), we're probably going to see a cap on the employer deduction, even though Obama is rather lukewarm about it. I'm pretty unattached about funding, as long as it is funded. As I said earlier, the less we have to rely on Medicare cuts, the better our fiscal outlook will be.

And of course, the most open issue of contention is the public option. Finance has come out in favor of providing the starting capital for health insurance cooperatives, while having fewer costs than the private market, wouldn't have the bargaining ability of a single payer. Daschle proposes state-based public options (again, small risk pools, low bargaining ability). If a set of metrics regarding cost control and coverage aren't met, a national public option kicks in after some time period. I'd prefer that to co-ops, but obviously not ideal. HELP is still negotiating its position, but hopefully it will come down on the side of a strong option. I don't remember if the House put out anything definitively, but they're pretty much guaranteed to have a strong option. And Obama is for the strong option.

I hope that was helpful. We'll have a much better idea what the specifics will be in a few weeks.

[Ramo]

An update from the House:

There appears to be a strong public option.

They also open up the possibility of other funding sources, namely a 1.5% VAT. The reason why they're considering that route is that a relatively limited funding (on the order of a $ trillion over ten years) can actually be found in the health care system. The dilemma is that route would make it a lot harder to sell the plan to the public. In general, though, a VAT is probably not a bad idea. I don't mind a slightly flatter tax distribution if the welfare state becomes a lot more robust. That's the tradeoff that much of the rest of world has made, and those models appear to be superior.

[Ben Kenobi]

But Canada still does have universal, free health care which costs the Canadian taxpayers far, far less than Americans in total pay for their health care. Canadians also have a longer lifespan and a smaller infant mortality rate [as do the citizens of EVERY country which has single payer.

The problem is that they shut down private clinics. The only other options are to go to the US and pay for timely care.

The only reason the system survives up here is because of the US private option. Take that away with Obamacare, and the overseas clinics will boom.

[Ramo]

Ben. Can you explain how "Obamacare" would lead to the shut down of "private clinics?" :)

[Drake Tungsten]

http://www.washingtonpost.com/wp-dyn/content/article/2009/06/19/AR2009061902334.html

http://beltwayblips.dailyradar.com/video/sen_russ_feingold_d_wi_ultimate_goal_of_health_reform/

Feingold :b:

[Ramo]

Do you believe that every clinic in Canada is publicly run? :)

[Ramo]

Hint: there's a world of difference between single payer health care models (i.e., Medicare, Canada) and where the government directly adminsters health care/"socialized medicine" (Veterans Administration, UK). This debate would be less ****ed if right wingers were willing to concern themselves with things like "details."

[Drake Tungsten]

Are you talking to me or Ben? It seems like me, but that would be stupid as I didn't say anything about Canada...

[Ramo]

Depends on whether your post was totally random, or a response to mine. It sure looks like you were responding to me (and introduced a common right wing fallacy). :)

The relevance here is that Canada has a single payer system, administered largely by the private sector.

[Drake Tungsten]

How could you interpret Russ Feingold and George Will talking honestly about the real purpose of including a strong public option in an American healthcare reform bill as a response to you and Ben arguing about the Canadian healthcare system?

[Ramo]

I obviously wasn't arguing about the Canadian system. See the post directly above yours. :)

But I suppose you have your plausible deniability. :b:

[Drake Tungsten]

I haven't really been paying attention to your posts in this thread since you decided to abandon any pretense of ingenuousness. You could learn a thing or two from Feingold. :b:

[Ramo]

I think I've repeated that I want to see a single payer for primary care a few times, in this thread alone. It's a nice way to introduce long term cost control. :)

I see that you're still unable to back up your bald assertion about Kennedy backing a tax payer funded public option. :b:

[notyoueither]

The relevance here is that Canada has a single payer system, administered largely by the private sector.


Nope.

At any rate, I strongly suggest that Americans not compare to Canada, and that Canadians do not compare to the US. We are each others' bogeymen, to be trotted out to scare the hell out of people whenever the subject of change is brought up.

[Ramo]

Yes.

Dr. Albert Schumacher, former president of the Canadian Medical Association estimates that 75 per cent of health-care services are delivered privately, but funded publicly.
http://www.cbc.ca/news/background/healthcare/public_vs_private.html

At any rate, I strongly suggest that Americans not compare to Canada, and that Canadians do not compare to the US.

I agree that it's far from the best model (but still much better than ours). I like the French model (with all that socialized medicine!), though a good number of other models are also appealing. I was using the Canadian example to explain what "single payer" actually means.

[notyoueither]

I agree that it's far from the best model (but still much better than ours). I like the French model (with all that socialized medicine!), though a good number of other models are also appealing. I was using the Canadian example to explain what "single payer" actually means.

I don't know if you understand ours though, and I'm not really up for reading all of this thread to find out.

Single payer here is one of the ways that private health care for covered procedures is strangled. It is/was (unclear of status at the moment) illegal for Canadians to get private insurance for a condition covered by the public system.

That, along with doctors and providers having to be totally in the public system or totally outside it has meant that we have had no wide-spread, meaningful private system (for covered conditions) for a very long time.

Even the subject of private, for-profit corporations running hospitals for the general public is controversial. Our problems go beyond single payer, although the way that is implemented is part of it.

There are two extremes in health care, with Canada being on one end and the US being on the other. I agree you'd gain more by looking at the French, or just about any other significant industrialised country.

[Ramo]

There are two issues wrt the private/public distinction: funding and delivery. The US and Canada are at opposite poles in funding (and I do think ruling out supplementary private insurance is extreme), but are much closer in delivery (see the quote above). The British NHS, for example, would be the opposite extreme in delivery.

[Ben Kenobi]

Do you believe that every clinic in Canada is publicly run?


Very few 'clinics' per se are publicly run. Hospitals are publicly run. Some private clinics get government funding and operate for profit. Some operate for profit. Some are privately owned and goverment funded not for profits.

As NYE stated it is illegal to 'jump the queue' by seeking private insurance here in Canada for conditions that are publicly funded.

As for the bogeyman, I've seen both systems, and I believe the US to be superior. For one, if I am healthy I don't have to pay for coverage if I don't want to, and two, the coverage and delivery of care is timely and effective.

The difference is between paying for full freight or for part of it. Sure, it's more costly in the US, but you pay for quality.

[Ramo]

Very few 'clinics' per se are publicly run.

Yes, that appears to be the correct answer. :)
Dr. Albert Schumacher, former president of the Canadian Medical Association estimates that 75 per cent of health-care services are delivered privately, but funded publicly.

[notyoueither]

There are two issues wrt the private/public distinction: funding and delivery. The US and Canada are at opposite poles in funding (and I do think ruling out supplementary private insurance is extreme), but are much closer in delivery (see the quote above). The British NHS, for example, would be the opposite extreme in delivery.


I'm not sure why you say that.

Private delivery here is very limited, aside from the prof corporations of some doctors themselves. Even there, they have to choose. Either they treat the public and collect from the government 100%, no exceptions, or they go 100% outside the public system. There are some very few, exclusive practices that treat high-paid executives and athletes. That's it.

There is the option, supposedly, for private providers in hospitals and other larger institutional care. That is largely lip service when it comes to hospitals as 'private hospital' is a dirty word, and whenever they try to sprout up they are driven out under one guise or another at some point.

There are private outlets for some niches, like testing and smaller clinics, but the main stream is public provision, by and large.

AFAIK, the Brits have dropped the private/public divide.

[notyoueither]

Very few 'clinics' per se are publicly run.

Yes, that appears to be the correct answer. :)
Dr. Albert Schumacher, former president of the Canadian Medical Association estimates that 75 per cent of health-care services are delivered privately, but funded publicly.


I think he is referring to doctors who have their own prof corporations.

75% in private facilities (like ORs and general hospital wards) is completely not the case. Try 98% of ORs are public. There are some private that do niche procedures.

[notyoueither]

Like I said, it would be best for Yanks to ignore Canada, and Ben.

It is not conceivable that Washington would be able to get away with transplanting our screwed up system to the US. There's just too much you'd have to screw up, and the doctors would never go along with it, as they did here in a different time. There's no way they could enact it here from scratch now either. Our continuing problem is there are too many special interests who benefit from the status quo and wink at each other to keep it going.

[Drake Tungsten]

Good Brooks column on healthcare reform in the NYT today.

If you did think that, you are mistaking the Senate for a rational organism. For while there are brewing efforts to incorporate a few Wyden-Bennett ideas, there is stiff resistance to the aspects that fundamentally change incentives.

The committee staffs don’t like the approach because it’s not what they’ve been thinking about all these years. The left is uncomfortable with the language of choice and competition. Unions want to protect the benefits packages in their contracts. Campaign consultants are horrified at the thought of fiddling with a popular special privilege.

So the process is moving along as it has been. There is a great deal of talk about the need to restrain costs. There’s discussion about interesting though speculative ideas to bend the cost curve. There are a series of frantic efforts designed to reduce the immediate federal price tag. Some senators and advisers suggest cutting back on universal coverage. Others have come up with a bunch of little cuts in hopes of getting closer to the trillion-dollar tab. The administration has ambitious plans to slash Medicare spending.

But there is almost nothing that gets to the core of the problem. Under the leading approaches, health care providers would still have powerful incentives to provide more and more services and use more expensive technology.

We’ve built an entire health care system (maybe an entire government) on the illusion of something for nothing. Instead of tackling that basic logic, we’ve got a reform process that is trying to evade it.

This would be bad enough in normal times. But the country is already careening toward fiscal ruin. We’ve already passed a nearly $800 billion stimulus package. The public debt is already projected to double over the next 10 years.

Health care reform is important, but it is not worth bankrupting the country over. If this process goes as it has been going — with grand rhetoric and superficial cost containment — then we will be far better off killing this effort and starting over in a few years. Maybe then there will be leaders willing to look at the options staring them in the face.

http://www.nytimes.com/2009/06/23/opinion/23brooks.html

[Ramo]

I think he is referring to doctors who have their own prof corporations.

75% in private facilities (like ORs and general hospital wards) is completely not the case. Try 98% of ORs are public. There are some private that do niche procedures.

Like Schumacher, I was characterizing administration of health care in general, not specifically large-scale facilities (FWIW, the Wiki entry on Canada's Medicare characterized the hospitals as mostly "semi-private"), as largely private. Dunno what your point here is, but I still don't see any source contradicting Schumacher.

Like I said, it would be best for Yanks to ignore Canada, and Ben.

Again, I'm not arguing that we should adopt the Canadian system (Ben quoted Zkrib). I was using the Canadian example specifically to characterize what "single payer" actually refers to.

[Ben Kenobi]

Ramo, listen to NYE, when he says 98 percent of ORs are public.

Private care up here is only for stuff that's not covered by medicare.

The US does not want our system at all. Please don't screw up your medicare the way we did ours.

[Ramo]

I'm still waiting for a source contradicting this. :)

Dr. Albert Schumacher, former president of the Canadian Medical Association estimates that 75 per cent of health-care services are delivered privately, but funded publicly.
http://www.cbc.ca/news/background/healthcare/public_vs_private.html

[Ben Kenobi]

Of that, just over $98.8 billion was spent by governments delivering public health care. About $43.2 billion was spent on private health care.


That shows that 70 percent of dollars spent are spent on delivering public health care.

Now, let's see what 'private' means.


What is private health care?
Anything beyond what the public system will pay for. For instance, should you have to spend some time in the hospital, the public system will cover the cost of your bed in a ward, which usually has three other patients. If you want a private room, the extra charge will come out of your pocket,


So lets be clear here, having a private room in a public hospital is 'private health care'.

I don't see where your source says what you claim it does Ramo.

It says 70 percent of the dollars spent go to Public health care.

[Ramo]

I am not referring to the funding mechanism. I am referring to the delivery services. Which are largely private. :)

[Ben Kenobi]

Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics …The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization.


Clearly this man has little understanding of 'private health care'. What he means is that they aren't paid by the government, and they aren't part of a union. What happens in reality is that the clinic bills the province per procedure, and the clinic pays their staff.

[Ramo]

What you wrote sounds like a non-sequitur to me. But I don't care enough about whatever argument you're trying to make to follow up.

Again. If you don't believe him (and former Pres of the Canadian Medical Association seems credible to me), give me another source. :)

[Ben Kenobi]

Again. If you don't believe him (and former Pres of the Canadian Medical Association seems credible to me), give me another source.


Your source says 70 percent of the dollars go to public health care. This fellow is 'estimating' which is a key word for 'talking out of his ass'.

It's to his benefit to play up privatisation to scare Canadians into putting more health care people into unions and become salaried employees.

What I am telling you is that the way it works is that the clinic bills the government. The only thing that makes these workers 'private' is the fact that the clinic pays them rather then them under a union contract with the government. That's it. The government still fully funds them.

[Ramo]

I am not talking about funding. Neither is he. Please stop polluting this thread. :)

[Ben Kenobi]

Fine. Define for me what counts as 'private health care'.

I have sources. I just don't have a clue what you consider to be private health care or not.

[Arrian]

I found this article interesting, and well worth the read:

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=1

-Arrian

[Ramo]

Any institution that's not administered by the government. Private practices, labs, clinics, hospitals, whatever.

[Ramo]

I found this article interesting, and well worth the read:

http://www.newyorker.com/reporting/2...?currentPage=1

-Arrian

Yeah, that's a good'un. :b:

[Arrian]

The major point it makes is the whole discusison of who should pay for care (private health insurance, government health insurance, patient) is secondary.

The scary part, for me, was having read it and sitting there trying to come up with a way to do what the article argues must be done... and not having a clue as to how to do it.

-Arrian

[Ramo]

The main point in the article is this health outcomes are very poorly correlated with costs. Even if you look at just the US, you have huge variations in cost with very little to show for it. So you can save huge amounts of money without an appreciable loss in public health (and in the process, boost the safety net). The key is to create an incentive structure that allows this to unfold. That's going to be difficult. But examples of other countries (specifically, all the other countries) show that a stronger public role (at both the insurer level and the delivery level) can be useful in containing costs.

As for specific points he made, the suggestion to salary doctors was a good one.

[Arrian]

That's going to be difficult.

Which is what scared me.

I do like the idea of salaried docs, yeah.

-Arrian

[notyoueither]

I'm still waiting for a source contradicting this. :)

Dr. Albert Schumacher, former president of the Canadian Medical Association estimates that 75 per cent of health-care services are delivered privately, but funded publicly.
http://www.cbc.ca/news/background/healthcare/public_vs_private.html

Like Schumacher, I was characterizing administration of health care in general, not specifically large-scale facilities (FWIW, the Wiki entry on Canada's Medicare characterized the hospitals as mostly "semi-private"), as largely private. Dunno what your point here is, but I still don't see any source contradicting Schumacher.

Again, I'm not arguing that we should adopt the Canadian system (Ben quoted Zkrib). I was using the Canadian example specifically to characterize what "single payer" actually refers to.

That's because Schumacher's statement is bafflegab. Bullshit, in baser terms.

I've explained to you that doctors (private entities who deliver services) are either paid by the public system, serving the very rich, or out of business.

You may consider the 99% of doctors whose sole paymaster is the public system to be private if you wish. I consider them contractors who are paid on piece work, and they are as much part of the system as the nurse employed directly by the local health authority (government agency).

As for wiki, and how most hospitals are run by semi-private organizations. You seem to think this is an important distinction. It is not. Orders of nuns and various charities ran some hospitals many years ago. They have continued to manage hospitals that are 100% at the whim of government for funding. When the government decides a hospital is too expensive it is closed, no matter who runs it. In short, these are still public institutions despite the formalities of who serves on the boards.

There are some very few really private institutions. By that I mean privately owned, operated, and are not dependant on government for a cheque at the end of the month to keep the doors open.

In short, Canada is the nightmare of single payer. That single payer decides everything of consequence, and forbids people find alternatives, like insurance to be able to patronise a practice or institution that is truely private. If that is the example you wanted to press for, to compare with for plans in the US, congratulations. The only example Canada can give to Americans is why keeping the government at bay would be a good idea.

That is also why I said it is best to ignore Canada. I find it really difficult to believe that the US would **** up so badly you ended up from the extreme where you are to the extreme we have.

[notyoueither]

At any rate, here is a source that might explain a bit more, or confuse greatly.

As I've tried to indicate, there is a lot of BS flying around Canada about our health care system. Curiously, this government link counts private laundry services for public hospitals as being in the realm of private health care delivery. It's ****ed up. I tried to tell you.

http://www.parl.gc.ca/information/library/PRBpubs/prb0552-e.htm

[Ben Kenobi]

Any institution that's not administered by the government. Private practices, labs, clinics, hospitals, whatever.


:dizzy:

Ok, I'll see what I can find.

NYE. :b:

[Ben Kenobi]

That's going to be difficult. But examples of other countries (specifically, all the other countries) show that a stronger public role (at both the insurer level and the delivery level) can be useful in containing costs.


It's called RATIONING. You might have heard it from time to time. The true measure is efficiency, what you get out for what you put in. Americans pay more but get a hell of alot more out then we do.

[Ramo]

Like Schumacher, I was characterizing administration of health care in general, not specifically large-scale facilities (FWIW, the Wiki entry on Canada's Medicare characterized the hospitals as mostly "semi-private"), as largely private. Dunno what your point here is, but I still don't see any source contradicting Schumacher.

Again, I'm not arguing that we should adopt the Canadian system (Ben quoted Zkrib). I was using the Canadian example specifically to characterize what "single payer" actually refers to.

That's because Schumacher's statement is bafflegab. Bullshit, in baser terms.

I've explained to you that doctors (private entities who deliver services) are either paid by the public system, serving the very rich, or out of business.

You may consider the 99% of doctors whose sole paymaster is the public system to be private if you wish.

Yes. That's exactly what I'm going to do. From what I understand, Canadian health care is largely fee-for-service/visit. Beyond using its scale to bargain with providers, it does little to control costs. Compare this to, say, the NHS, which salaries GPs to a much larger extent (and fee-for-service playing a smaller role). It also has one of the leanest health sectors in the developed world (to turn it into a world class system, arguably, all it needs is funding comparable to, say, the OECD mean), as opposed to the comparatively bloated Canadian sector. For a primer on why this distinction is important, see the article that Arrian cited.

When the government decides a hospital is too expensive it is closed, no matter who runs it. In short, these are still public institutions despite the formalities of who serves on the boards.

How often does the state actually close a hospital? How does that compare to the size of the health sector? Without numbers, that isn't a particularly meaningful comment.

If that is the example you wanted to press for, to compare with for plans in the US, congratulations.

WTF, dude? How many times do I have to tell you that I do not like the Canadian system? Hell, I'm pretty sure I've told you this in previous threads. And yes, that's "threads" as in plural.

[Ramo]

It's called RATIONING.

Yes. I was just charged $655 for the first physical I've had in over three years because my private health insurer refuses to cover preventative physical exams. I know what rationing is. :)

but get a hell of alot more out then we do.

No. That is not true.

http://graphics8.nytimes.com/images/2009/06/17/business/17leonhardt-graf01-2.jpg
http://www.nytimes.com/2009/06/17/business/economy/17leonhardt.html?_r=1&hp

[Ben Kenobi]

Survival rates are a bad measurement. Much of that has to do with how quickly the cancer is caught, which requires self-investigation.

And the results are mixed. The US is much better with breast cancer, which is by far the most common cancer of those listed. If you were to do a case-by-case look, I'd wager Americans were more likely to survive cancer then Canadians.

[Ramo]

Breast cancer is the most common, but has only a 36.6% higher incidence in the US than colorectal.
http://seer.cancer.gov/csr/1975_2006/browse_csr.php?section=1&page=sect_01_table.23.html#b

Yes, thanks for the complete lack of data backing up your point. Deal in empirical evidence or go away. :)

[KrazyHorse]

A problem with those statistics is selection effects. If you catch cancer earlier, then you bias the survival rates upward, even if catching it earlier does not lead to better survivability.

[KrazyHorse]

BTW, I have no idea which direction that bias would go. Just mentioning it because it seems to me like it could easily overwhelm any actual differences due to quality of treatment.

[Ramo]

The point I wanted to emphasize was the relatively limited variation in outcomes. If there were large selection biases, I'd expect less tightly clustered data.

One can nitpick with a lot of health metrics, but the story is basically the same: we have mediocre health outcomes for a very expensive system. There appear to be rapidly diminishing returns past a certain amount of health expenditures.

[KrazyHorse]

I've seen a few good points made on this subject:

1) You have to be careful about what's being counted as a health care expense and what's not. Other countries subsidize the education of doctors, while the US does not (largely). How much would it add to the spending of other countries if you counted medical school costs?

2) Much of the savings lies in higher remuneration to doctors in the US. Any time the government exercises monopsony power it reduces the price paid for services. However, such savings are in reality largely just transfers from doctors to the general public.

3) If some relatively wealthy people spend much much more in the US than the relatively wealthy do in other countries then such spending can skew the per capita cost of health care. If stupid rich people in the US want to blow money on doctors they don't need then why should we care? Say that 70% of Americans spend the same amount (or slightly higher) per capita that other OECD countries do and receive comparable outcomes. 30% spend a whole hell of a lot more. Is this really something that needs "fixing"?

These are all questions which need to be answered before you can really make valid comparisons between countries.

[Ramo]

Well, (1) and (2) are pretty closely related. The AMA insists on expensive, graduate medical education for your standard issue GP. However, we do heavily subsidize undergrad education - so that's still accounted for. The problem is that this is a large cost sink that reform is not able to address right now. That's one big reason why I'd like to see the state have a large amount of leverage over the industry through a single payer.

As for stupid rich people getting treatment they have marginal use for, one problem is that they help to set the norms for medical treatment. I highly recommend the New Yorker article that Arrian cited for elaboration.

It's also cash floating around the system that could subsidize the poor.

[KrazyHorse]

Ramo: "floating around the system"? How is this any different than any other non-necessity that the rich spend their money on?

Basically, you aren't doing a good job of convincing me that there's an efficiency argument to be made here. Merely a distributional one. And if the issue is distributional then the obvious preference is for redistribution to be made in cash, not in kind.

[Ramo]

Seriously, check out the Gawande article (http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande).

He summarizes it in a follow-up (http://www.newyorker.com/online/blogs/newsdesk/2009/06/atul-gawande-the-cost-conundrum-redux.html):
In my June 1st article, “The Cost Conundrum,” I explored the question of why two border towns in Texas of similar size, location, and circumstances—McAllen and El Paso—should cost Medicare such enormously different amounts of money. In 2006, McAllen cost $14,946 per enrollee, which is the second-highest in the United States and essentially double El Paso’s cost of $7,504 per enrollee. Analysis of Medicare data by the Dartmouth Atlas project shows the difference is due to marked differences in the amount of care ordered for patients—patients in McAllen receive vastly more diagnostic tests, hospital admissions, operations, specialist visits, and home nursing care than in El Paso. But quality of care in McAllen is not appreciably better, and by some measures, it is worse. Indeed, studies have shown that the care for patients in the highest-cost regions of the country tends to go this way—with more high-cost care across the board, but less low-cost preventive services and primary care, and equal or worse survival, functional ability, and satisfaction with care. The causes that I found locally was a system of care that was highly fragmented for patients and often driven to maximize revenues over patient needs. And I pointed to positive outliers across the country, including Grand Junction, Colorado, and the Mayo Clinic that deliver markedly lower-cost, higher-quality care.

[KrazyHorse]

Ramo: that's Medicare, a gov't funded program. The real problem with your argument is why insurance companies don't find a cheaper way to deliver health outcomes. if they did so then they could charge cheaper premiums while still maintaining equivalent quality of care, take over the market and get rich(er).

The government using monopsony power delivers a large transfer from doctors to everybody else. Why will it also deliver efficiency gains?

[Ramo]

It's also a transfer from pharmaceutical companies to everyone else for the same reason. And it's a reduction in administrative costs. You can also do things like incentivize preventative care, something that the status quo does not do. There's a good McKinsey study on estimated savings.

The name of the game in health insurance is to create a large risk pool to bargain more effectively with health providers. The reason why you don't see a private monopoly is anti-trust legislation.

The article refers to Medicare disbursements, because they're referring to a systematic study that investigates health care costs. That article is pointing out problems with the cost structure (i.e. what you were asking about), not a specific remedy.

[Dr Strangelove]

It's called RATIONING.

Yes. I was just charged $655 for the first physical I've had in over three years because my private health insurer refuses to cover preventative physical exams. I know what rationing is. :)

but get a hell of alot more out then we do.

No. That is not true.

http://graphics8.nytimes.com/images/2009/06/17/business/17leonhardt-graf01-2.jpg
http://www.nytimes.com/2009/06/17/business/economy/17leonhardt.html?_r=1&hp
I wonder why they left out lung cancer, coronary heart disease and stroke?

I deal with dozens of insurance companies. Each one has its own rules for referral, its own coverage plan and its own drug formulary. It's a madhouse. Let me assure you, corporate bureaucracy is no better than government bureaucracy. Private insurance companies have taken to outsourcing their call centers, so when I want to find out why Mr. X isn't being permitted to fill a medication I prescribed for him even though the company's website says the drug is covered I call a number, where after pushing a bunch of buttons and some discussion with an operator my call is forwarded to another center, where the same process occurs until I'm finally connected with the insurance company's pharmaceutical management center. The list of annoying nickel and dime stuff with these insurance companies just goes on and on forever. Everyone is fed up with this system and it is time for it to go.

[Guynemer]

What my esteemed colleague just said.

The unbe-****ing-lievable amount of red tape we have to go through now for the simplest of visits and prescriptions, quite simply, can not be made any worse by the government. It is simply not possible.

[Ben Kenobi]

Yes, thanks for the complete lack of data backing up your point. Deal in empirical evidence or go away.


Incidence differentials are far higher then the differentials between the countries. If Breast cancer is 40 percent more likely, this means that a difference in maybe 10 percent on colorectal will correspond to a difference in 4 percent of breast cancer.

I could run the math on that but I'm being lazy today. Thanks for finding the source on Breast Cancer though. :b:

[DinoDoc]

The unbe-****ing-lievable amount of red tape we have to go through now for the simplest of visits and prescriptions, quite simply, can not be made any worse by the government. It is simply not possible.I know that everytime I think of the government, an image of an efficent well oiled machine w/o paperwork comes to mind.

[Ramo]

Incidence differentials are far higher then the differentials between the countries. If Breast cancer is 40 percent more likely, this means that a difference in maybe 10 percent on colorectal will correspond to a difference in 4 percent of breast cancer.

I could run the math on that but I'm being lazy today. Thanks for finding the source on Breast Cancer though. :b:

For the love of all you hold dear, please stop trying to do math. :(

[asleepathewheel]

Medicare/medicaid are a mess, I really don't want to think about more government involvement in healthcare.

The amount of waste and fraud in the m's is staggering.

[Guynemer]

I know that everytime I think of the government, an image of an efficent well oiled machine w/o paperwork comes to mind.

I'd rather have only one byzantine system to navigate than the 50+ I deal with now on a daily ****ing basis.

[notyoueither]

Yes. That's exactly what I'm going to do. From what I understand, Canadian health care is largely fee-for-service/visit. Beyond using its scale to bargain with providers, it does little to control costs. Compare this to, say, the NHS, which salaries GPs to a much larger extent (and fee-for-service playing a smaller role). It also has one of the leanest health sectors in the developed world (to turn it into a world class system, arguably, all it needs is funding comparable to, say, the OECD mean), as opposed to the comparatively bloated Canadian sector. For a primer on why this distinction is important, see the article that Arrian cited.

Quite to the contrary, the Canadian system controls costs by throttling the ability to deliver care, like testing, beds, OR hours, etc. It is quite effective, so long as you don't mind waiting for your chemo or other needed treatment.

I'm not sure that paying salaries would make a huge difference.

How often does the state actually close a hospital? How does that compare to the size of the health sector? Without numbers, that isn't a particularly meaningful comment.

When budget concerns say they need to. Those 'semi-private' hospitals you brought up that are mentioned on wiki, they are not private at all. They are paid for by government and run by boards that may or may not consist of government appointees. Who appoints doesn"t matter a whole lot. When budgets have to be slashed (80's, 90's) the government closes whatever hospitals they deem are surplus to requirements, no mattewr who sits on the board(s). Governments pay for them. They can do that.

The point is not how many were closed (quite a few). The point is they are not private in any meaningful sense of the word. They live and die at the whim of the government. They are public institutions. < period, and bullshit notwithstanding.


WTF, dude? How many times do I have to tell you that I do not like the Canadian system? Hell, I'm pretty sure I've told you this in previous threads. And yes, that's "threads" as in plural.

I don't recall, and don't see why I should. I recall Che talking about Canadian helathcare before, but I do not recall you piping up. Plural or not.

Now that we're done with that, I think you have an inaccurate view of the benefits of a single payer system and would refer you back to Arrian'a article. The lesson there is that who pays does not matter one single drop of snot.

You seem to be hoping that a single payer will be able to mandate a change of attitudes on the part of prescribing doctors. I have no idea why you think that. OTOH, a single payer can exert control in other ways. Canada is an excellent example of that.

[Ramo]

Quite to the contrary, the Canadian system controls costs by throttling the ability to deliver care, like testing, beds, OR hours, etc. It is quite effective, so long as you don't mind waiting for your chemo or other needed treatment.

I'm not sure that paying salaries would make a huge difference.

Some care may be limited, but not everything is. The Brits are over 20% cheaper than you are. The key appears to be moving away from the fee-for-service/visit model.

They live and die at the whim of the government.

I understand they are being funded by the state. The relevant question here is how they are managed. Look, if you have an alternate source that estimates the degree to which delivery is private, I'd like to see it.

I don't recall, and don't see why I should.

I don't expect you to. I'm making this point because you're mischaracterizing my views over and over again. Like right here:

You seem to be hoping that a single payer will be able to mandate a change of attitudes on the part of prescribing doctors.

I mean, seriously. WTF? Let me make this crystal clear. I support a single payer (with the possibility of private supplementary insurance) primary because it can more effectively control costs by bargaining with medical providers, lowering administrative costs, and incentivizing preventative care. I do not think that single payer alone would be sufficient to contain health care inflation, so I think that a greater public role in delivery would be appropriate.

[asleepathewheel]

What a cluster

http://www.bloomberg.com/apps/news?pid=20601103&sid=aDvu77pZr7k4


Unions’ Health Benefits May Avoid Tax Under Proposal

une 26 (Bloomberg) -- The U.S. Senate proposal to impose taxes for the first time on “gold-plated” health plans may bypass generous employee benefits negotiated by unions.

Senate Finance Committee Chairman Max Baucus, the chief congressional advocate of taxing some employer-provided benefits to help pay for an overhaul of the U.S. health system, says any change should exempt perks secured in existing collective- bargaining agreements, which can be in place for as long as five years.

The exception, which could make the proposal more politically palatable to Democrats from heavily unionized states such as Michigan, is adding controversy to an already contentious debate. It would shield the 12.4 percent of American workers who belong to unions from being taxed while exposing some other middle-income workers to the levy.

“I can’t think of any other aspect of the individual income tax that treats benefits of different people differently because of who they work for,” said Chris Edwards, director of tax policy studies at the Cato Institute, a Washington research group that often criticizes Democrats’ economic proposals. Edwards said the carve-out “smacks of political favoritism.”

Baucus, a Montana Democrat, is proposing to tax Americans whose health insurance is valued at a higher rate than what is offered to federal employees. About 40 percent of insured Americans have costlier benefits, and Baucus has said he is trying to set the level at which taxes would be imposed high enough so fewer people are affected.

‘Gold-Plated’ Plans

The policy is aimed at so-called “gold-plated” plans such as the $40,543 in health benefits paid to Lloyd Blankfein, chief executive of New York-based Goldman Sachs Group Inc., the fifth largest U.S. bank by assets.

It can also affect companies such as Henderson, Nevada- based Zappos.com, where workers’ $11 per hour pay is supplemented by employer-paid health insurance plans worth about $7,500. Federal workers’ health benefits are worth about $4,200 for individuals and $13,000 for families.

Lawmakers are crafting legislation aimed at meeting Obama’s goal of bringing down the cost of health care and expanding coverage to the 46 million Americans who lack insurance. Obama wants Democratic congressional leaders to seek Republican support, and to send him legislation by mid-October.

Baucus said yesterday the cost of health-care options his panel is considering can be cut to $1 trillion over 10 years and won’t add to the deficit, citing the Congressional Budget Office.

Cost Estimates

The non-partisan budget office last week delivered an informal cost estimate of $1.6 trillion for the legislation to overhaul the health-care system, sparking protests from both Republicans and Democrats and prompting Baucus to say his panel may delay consideration of a bill until next month.

“CBO now tells us we have options that would enable us to write a $1 trillion bill, fully paid for,” Baucus, who set that amount as his goal, told reporters at the Capitol.

The panel’s legislation must be joined with competing proposals from other Senate and House committees and forged into a single bill subject to negotiation and approval by both chambers before it can be sent to Obama.

Senate Budget Committee Chairman Kent Conrad, a North Dakota Democrat, said earlier this week that senators are coalescing around the idea of taxing some employer-provided benefits. Baucus said the details are still being negotiated, including how high to set the tax-free exclusion and when any changes would take effect, and whether to exempt union employees until their current contracts expire.

Cutting ‘Subsidy’

“It is hard for me to see how you can have a package that is paid for that does not reduce the subsidy” on employer-paid benefits, Conrad said.

Kentucky Senator Mitch McConnell, the top-ranking Republican in the chamber, said today he has “serious reservations about capping the exclusion, particularly if they have a carve-out for union members,” according to his communications director, Don Stewart. Stewart taped McConnell’s comments and provided excerpts to a reporter.

Stewart said McConnell, discussing the prospect of a tax on some employer-provided benefits, said “table-pounding opposition” would result “if it were to exclude union members.”

Gerald Shea, an AFL-CIO official lobbying for health-care reform, said grandfathering benefits negotiated in a collective bargaining agreement is a “common thing when there is a big change in federal law.”

‘Expectations Are Set’

“Once a collective bargaining agreement is set, employer’s budgets are set, workers expectations are set. It doesn’t make sense to go back in the middle of the contract and change it,” he said.

Union groups and workers said Congress shouldn’t target contractually negotiated benefits.

Anna Burger, secretary-treasurer of the Service Employees International Union, said in an interview that workers have often traded salary increases for better benefits in agreements.

Taxes “shouldn’t be taken from the backs of workers who have bargained away wages and other things for their benefits over the years,” Burger said.

Sandra Carter, a retired Pacific Bell Telephone Co. technician from Stockton, California, said her health benefits, worth about $12,000 per year, were negotiated by the Communications Workers of America. She is unmarried with no children, meaning her individual coverage exceeds benefits paid to federal workers by about $7,800. If that amount were taxed at the 15 percent marginal rate, she would owe $1,170.

“I can’t afford the taxes I pay now,” said Carter, who said she suffers from diabetes. “Why should I get taxed on a benefit that keeps me a functioning person?”

Union Opposition

Other unions say they’re opposed to a tax on some employer- provided benefits, regardless of whether collective bargaining agreements are exempt.

“Either way, we are against a tax on health-care benefits in whatever form it takes,” said Jacob Hay, spokesman for the Laborers’ International Union of North America. The union represents 500,000 workers, largely in the construction industry.

[Drake Tungsten]

I'd rather have only one byzantine system to navigate than the 50+ I deal with now on a daily ****ing basis.

Even if you get paid less to do so?

[Ramo]

The complete Kennedy legislation (which includes a public option) was just scored by the CBO (http://voices.washingtonpost.com/ezra-klein/CBO_HELP_Title_I_07-01.pdf) (n.b. the previous score didn't include pivotal parts such as the employer mandate and assumed an excessively weak individual mandate). This legislation (and therefore the score) excludes the Medicaid expansion, Medicare cuts, and changes in the employer tax deduction since HELP has no jurisdiction over these issues. To the surprise of absolutely no one who gives a **** about health care policy in the US, when the provisions that change the deficit are enumerated (and tallied), the public option is not among them - because it would be funded by premiums.

Including the Medicaid expansion, the legislation would insure 97% of legal residents and cost between $1 trillion and $1.3 trillion over ten years. The cost would be offset by spending cuts (principally Medicare cuts) and tax increases (capping the employer tax deduction, possibly other sources) to make the legislation deficit neutral.

[Oerdin]

I wonder why they left out lung cancer, coronary heart disease and stroke?

I deal with dozens of insurance companies. Each one has its own rules for referral, its own coverage plan and its own drug formulary. It's a madhouse. Let me assure you, corporate bureaucracy is no better than government bureaucracy. Private insurance companies have taken to outsourcing their call centers, so when I want to find out why Mr. X isn't being permitted to fill a medication I prescribed for him even though the company's website says the drug is covered I call a number, where after pushing a bunch of buttons and some discussion with an operator my call is forwarded to another center, where the same process occurs until I'm finally connected with the insurance company's pharmaceutical management center. The list of annoying nickel and dime stuff with these insurance companies just goes on and on forever. Everyone is fed up with this system and it is time for it to go.

I find the French and Japanese systems to be interesting. They both have private health care providers and even private insurance companies but EVERYTHING is standardized so that coverage standards are identical no matter which provider you go with. It is extremely common for French doctors to do their own paperwork without a secretary to help because the standardized forms are so small and simple that he can do it in 2 minutes; compare that to the US where most hospitals or individual doctors have to hire staff to deal with the massively complicated paper work and problems you spoke about.

[Guynemer]

Even if you get paid less to do so?

Yes, I'd get paid less. But overhead would also be considerably lower. I haven't the faintest idea where the net would end up.

[Drake Tungsten]

The head of the CBO says that claims that the Democratic healthcare reform will control costs are bullshit.

CBO Sees No Net Federal Cost Savings in Dem Health Plans

ABC News' Z. Byron Wolf reports:

Here's a blow to President Obama and Democrats pressing health care reform.

One of the main arguments made by the President and others for investing in health reform now is that it will save the federal government money in the long run by containing costs.

Turns out that may not be the case, according to Doug Elmendorf, director of the nonpartisan Congressional Budget Office.

Answering questions from Democrat Kent Conrad of North Dakota at a hearing of the Senate Budget Committee today, Elmendorf said CBO does not see health care cost savings in either of the partisan Democratic bills currently in Congress.

Conrad: Dr. Elmendorf, I am going to really put you on the spot because we are in the middle of this health care debate, but it is critically important that we get this right. Everyone has said, virtually everyone, that bending the cost curve over time is critically important and one of the key goals of this entire effort. From what you have seen from the products of the committees that have reported, do you see a successful effort being mounted to bend the long-term cost curve?

Elmendorf: No, Mr. Chairman. In the legislation that has been reported we do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount. And on the contrary, the legislation significantly expands the federal responsibility for health care costs…

As we wrote in our letter to you and Senator Gregg, the creation of a new subsidy for health insurance, which is a critical part of expanding health insurance coverage in our judgement, would by itself increase the federal responsibility for health care that raises federal spending on health care. It raises the amount of activity that is growing at this unsustainable rate and to offset that there has to be very substantial reductions in other parts of the federal commitment to health care, either on the tax revenue side through changes in the tax exclusion or on the spending side through reforms in Medicare and Medicaid. Certainly reforms of that sort are included in some of the packages, and we are still analyzing the reforms in the House package. Legislation was only released as you know two days ago. But changes we have looked at so far do not represent the fundamental change on the order of magnitude that would be necessary to offset the direct increase in federal health costs from the insurance coverage proposals.

http://blogs.abcnews.com/thenote/2009/07/cbo-sees-no-federal-cost-savings-in-dem-health-plans.html

This has been obvious to anyone with a brain for quite a while now, but I imagine some people here need to have the point hammered home.

[Kuciwalker]

My dad sent me that this morning. Depressing and reassuring (that someone is pointing it out) at the same time.

[Ben Kenobi]

I haven't the faintest idea where the net would end up.


Net will be less. I know a few Canadian doctors, and compensation is usually higher in the US.

[Drake Tungsten]

ABC is also publicizing the effects of the Dems' healthcare reform on tax rates.

Study: House Democrats’ Health Care Bill Pushes Top Tax Rates to Over 50% in Most States

A study by the non-partisan Tax Foundation finds that the 5.4% surtax on top wage-earners proposed by House Democrats to help fund health care reform would push top tax rates over 50% in 39 states.

"That means government would be taking more than half of every additional dollar from high-income taxpayers,” said Tax Foundation President Scott Hodge. “The lowest top tax rate would be about 47% --and that's in the nine states that don't tax wages."

The proposal imposes a new surtax of 1 percent on married couples who earn between $350,000 and $500,000 (singles between $280,000 and $400,000). Couples with incomes between $500,000 and $1 million (singles earning between $400,000and $800,000) would have a 1.5 percent surtax imposes. Couples who make more than $1 million, and singles who make more than $800,000, would face a 5.4% surtax.

ABC News’ Dan Arnall reports that the latest data book from the IRS (Tax Year 2006) indicates that 0.3% of all individual income tax returns showed an income of $1 million or higher; 354,093 tax returns out of a universe of 138 million filed that year.

The hardest-hit states in terms of the highest tax bracket would be Oregon (57.5%), Hawaii (57.2%), New Jersey (57.1%), New York (56.9%), California (56.8%), Rhode Island (56.2%), Vermont (55.8%), Maryland (55.6%), Minnesota (54.4%) and Idaho (54.3%).

Washington, DC’s highest tax bracket would be 55.0%. New York City’s would be 58.7%.

http://blogs.abcnews.com/politicalpunch/2009/07/study-house-democrats-health-care-bill-pushes-top-tax-rates-to-over-50-in-most-states.html

Tapper :b:

[Guynemer]

I can understand (if not agree with) some of your other criticisms, Drake, but that one strikes me as hollow.

A top tax rate of ~55% is still far, far lower than it has been in the past.

[Drake Tungsten]

A top tax rate of ~55% is still far, far lower than it has been in the past.

What's your point? By this logic, a top tax rate of less than 94% is acceptable.

[Guynemer]

Yes, and...?

Seriously, the government had far less responsibilities back then, and you expect it to get by now with a top marginal rate that's just over half as high?

[Drake Tungsten]

Seriously, the government had far less responsibilities back then

The peak 94% top tax rate was instituted during WWII, so I think this statement is incorrect.

you expect it to get by now with a top marginal rate that's just over half as high?

Yes.

[Guynemer]

I dunno, I'd have to look up government spending per capita, and I'm too lazy. But between Iraq, Afghanistan, the Global War on Terror, and the myriad military bases we now have all over the world as a result of WWII, plus all the additional government spending in health care, education, law enforcement, welfare, housing, corporate subsides, etc. etc. etc., I'd be rather surprised if we're spending less now than we did then.

If you don't want a deficit, we're gonna have to raise taxes, health care reform or no.

[Drake Tungsten]

I'd be rather surprised if we're spending less now than we did then.

I'm not sure why you'd be surprised, but here's the evidence.

http://www.usgovernmentspending.com/usgs_line.php?title=US%20Government%20Spending%20As%20Percent%20Of%20GDP&year=1903_2010&sname=US&units=p&bar=0&stack=1&size=m&col=c&spending0=6.80_7.28_6.89_6.81_6.61_7.90_7.84_8.03_8.31_8.09_8.22_9.55_9.80_8.22_9.49_22.12_29.38_12.81_14.31_12.67_11.27_11.49_11.44_11.12_11.75_11.75_11.27_13.07_15.92_21.19_22.38_19.40_20.17_20.00_18.74_20.53_20.66_20.14_19.22_28.15_46.68_50.02_52.97_35.86_23.64_20.46_23.46_23.94_22.38_27.88_29.01_29.27_26.69_26.47_27.21_28.84_28.77_28.74_30.26_28.94_28.71_28.50_26.96_27.45_29.79_30.46_30.07_30.99_31.48_31.35_29.77_30.22_33.60_33.98_32.90_32.01_31.57_33.71_33.62_36.23_36.29_34.42_35.46_35.69_35.07_34.71_34.92_36.00_37.20_37.07_36.36_35.45_35.62_34.79_33.88_33.42_32.95_33.01_33.91_35.32_35.86_35.32_35.44_35.69_35.49_37.04_45.19_41.90&legend=

If you don't want a deficit, we're gonna have to raise taxes, health care reform or no.

You also need to cut spending, which the Democrats appear to have no interest in doing.

[Guynemer]

Ah, I stand corrected. Mea culpa.

We're getting close, though. To have the top marginal rate that much smaller when our spending in only marginally less still makes no sense whatsoever.

[Drake Tungsten]

We're getting close, though.

That's the problem. There's no reason to be spending that much money.

[Ben Kenobi]

Having a top tax rate of 94 percent is useless. No one will claim enough to get into that bracket, and find loopholes around the number.

You'd be better off lowering taxes and removing incentives to cheat.

[KrazyHorse]

Thinking that the top marginal rate is the prime determinant of tax revenue isn't very insightful.

Currently the proposals are to levy extra taxation on households in the top < 1% range of annual income, with most of the increases on households in the top 0.1% range or so. Unfortunately, the top 0.1% of households only have ~6% of the total income of US households. You can jack up their rates all you want and still not get to where you need to be, especially at marginal rates close to 60% are beginning to get close to the regime where there are definite disincentives to work, and strong incentives for tax avoidance. Most of the new revenue needs to come from the bottom 99%. The math just doesn't work any other way.

[Drake Tungsten]

Elmendorf sure is a buzzkill...

The Long-Term Budget Outlook

Under current law, the federal budget is on an unsustainable path, because federal debt will continue to grow much faster than the economy over the long run. Although great uncertainty surrounds long-term fiscal projections, rising costs for health care and the aging of the population will cause federal spending to increase rapidly under any plausible scenario for current law. Unless revenues increase just as rapidly, the rise in spending will produce growing budget deficits. Large budget deficits would reduce national saving, leading to more borrowing from abroad and less domestic investment, which in turn would depress economic growth in the United States. Over time, accumulating debt would cause substantial harm to the economy. The following chart shows our projection of federal debt relative to GDP under the two scenarios we modeled.

Keeping deficits and debt from reaching these levels would require increasing revenues significantly as a share of GDP, decreasing projected spending sharply, or some combination of the two.

Measured relative to GDP, almost all of the projected growth in federal spending other than interest payments on the debt stems from the three largest entitlement programs—Medicare, Medicaid, and Social Security. For decades, spending on Medicare and Medicaid has been growing faster than the economy. CBO projects that if current laws do not change, federal spending on Medicare and Medicaid combined will grow from roughly 5 percent of GDP today to almost 10 percent by 2035. By 2080, the government would be spending almost as much, as a share of the economy, on just its two major health care programs as it has spent on all of its programs and services in recent years.

In CBO’s estimates, the increase in spending for Medicare and Medicaid will account for 80 percent of spending increases for the three entitlement programs between now and 2035 and 90 percent of spending growth between now and 2080. Thus, reducing overall government spending relative to what would occur under current fiscal policy would require fundamental changes in the trajectory of federal health spending. Slowing the growth rate of outlays for Medicare and Medicaid is the central long-term challenge for fiscal policy. ...

Federal spending on Medicare, Medicaid, and Social Security will grow relative to the economy both because health care spending per beneficiary is projected to increase and because the population is aging. As shown in the figure below, between now and 2035, aging is projected to make the larger contribution to the growth of spending for those three programs as a share of GDP. After 2035, continued increases in health care spending per beneficiary are projected to dominate the growth in spending for the three programs.

The current recession and policy responses have little effect on long-term projections of noninterest spending and revenues. But CBO estimates that in fiscal years 2009 and 2010, the federal government will record its largest budget deficits as a share of GDP since shortly after World War II. As a result of those deficits, federal debt held by the public will soar from 41 percent of GDP at the end of fiscal year 2008 to 60 percent at the end of fiscal year 2010. This higher debt results in permanently higher spending to pay interest on that debt. Federal interest payments already amount to more than 1 percent of GDP; unless current law changes, that share would rise to 2.5 percent by 2020.

http://cboblog.cbo.gov/?p=328

[Guynemer]

Yup, we're pretty much ****ed.

[Drake Tungsten]

The Baby Boomers screwed the country well and good. Hopefully this is their last term in control of the Presidency...

[Oerdin]

It seems like there is going to be so much wasted potential in the attempts to reform. I mean big pharma is making out like bandits and proving that being one of the largest lobbyists in Washington does indeed mean you've bought special protections and privileges from lawmakers. Everyone's talking about how big pharma was so nice that they made $30 billion in price reductions for perscription drugs but that's, on average, less then a 3% cut in price, while in return big pharma got it written in that drug coverage will only buy name brand and not generic drugs. That's insane. They gave away 2%-3% and in return they lock in taxpayers paying 300% or more for name brand drugs when a cheap generic would do the exact same job much, much cheaper.

:shame:

[Adam Smith]

Elmendorf sure is a buzzkill...

The CBO Director's job is to be the skunk at the Congressional garden party.
Each new director receives a stuffed animal skunk courtesy of the staff.

Adam Smith
Proud member of the skunk works since 2007

[Guynemer]

Adam Smith sighting!

[KrazyHorse]

CBO: :b:
Adam Smith: :b:

[Kuciwalker]

Adam Smith: :b:
Skunks :q:

[Ramo]

The most significant cost control measures that would be part of health reform would be a broad public option, changing the way Medicare disbursement happens, and attacking in some way employer-based health care.

The public option (even the House version, which is the strongest possibility) is going to be very limited in the number of people covered (i.e. would likely exclude people currently covered by large employers) and its legislative mandate to bargain with providers. The CBO scored a relatively broad proposal as cutting $150 billion/ten years, but that version is probably not going to happen.

Medicare disbursement rates are set by an institution called "MedPac," but its recommendations are frequently overturned by Congress. So you have a ton of waste on lots of parochial bullshit. For example, Ted Stevens, just before he left, secured a 35% increase in disbursements for Alaskans, specifically. Orszag and Sen. Rockefeller are pushing to change this structure, setting the institutional bias towards reform. The idea is to impose a set of rules on how MedPac makes changes (i.e. aggregate spending doesn't increase, changes either improve quality or efficiency). Then the set of recommendations are presented to Congress for an up or down vote. The military base closing committee (BRAC) operates on similar principles. This was not in the House bill, and HELP does not have jurisdiction over these rules. The question is whether it makes it out of Finance, where Rockefeller has been pushing it. I think if it gets out of Finance, it happens.

The other reform Elmendorf is pushing is moving away from employer-based health care. Removing the employer tax deduction would eliminate a regressive subsidy for health care - gold plated plans without demonstrable utility in furthering public health. This is not on the table, but certain members of the Finance Cmte are pushing for using a capped deduction as a revenue source. The House went with a surtax on the rich (something a lot more politically popular), and Obama has been pushing for capping the charitable deduction (which is better than the House, but not as good as taking a stab at employer system). This is one issue where the conservative Dems (minus Conrad) are probably more helpful than Obama. Sen. Wyden is pushing legislation, the "Healthy Choices Act," to allow a much broader health insurance exchange, where anyone can buy in if they choose (coupled with the employer mandate and subsides up to some multiple of the federal poverty level). Without utilizing this hidden subsidy, the idea is, people are not going to spend more on health care than is needed (but a lower bound conducive to public health is imposed by the regulatory structure). This legislation, incidentally, also allows the public plan to be broader (since it lives within the exchange). I have no idea what its legislative prospects are.

So cost control, within the limits of political reality, comes down to these areas. Hopefully, Elmendorf makes substantive reform (as opposed to boosting the safety net) significantly more likely. :b:

[Ramo]

The CBO Director's job is to be the skunk at the Congressional garden party.
Each new director receives a stuffed animal skunk courtesy of the staff.

Adam Smith
Proud member of the skunk works since 2007

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[Kuciwalker]

Ramo, did you just not read Drake's post, or are you deliberately pretending you didn't?

[Ramo]

Do you have a point, or are you deliberately pretending you do?

Because Orszag/Rockefeller's "IMAC" and Wyden's legislation have not been scored. Indeed, it would be very difficult to score something like the IMAC - since we don't even have a set of consensus recommendations. A variant of Wyden's legislation (comprehensive reform, as opposed to an amendment to the consensus legislation) has been scored, and is deficit neutral almost immediately. :)

[Ramo]

And a clarification to my post: Wyden's legislation to amend the consensus is the "Free Choice Act." The "Healthy Americans Act" is his comprehensive reform legislation. The "Healthy Choices Act" doesn't exist. :)

[Drake Tungsten]

Good article on healthcare reform on Slate today. Sounds a little like the previous Brooks' column...

It is on the sociological level, though, that we're missing the boat most completely by sticking doggedly with a workplace-based system that no longer makes sense. America has always been a mobile society with a labor market that grows more fluid over time. Once, the norm was to work for a single employer for one's entire career. Today, people change jobs an average of 11 times before they reach 40. Fear of losing health coverage keeps people in jobs they would otherwise leave, creating a drag on economic efficiency. As the Senate's smartest health care wonk, Ron Wyden of Oregon, says: "A big part of the reform challenge is to look at how the culture of the American workforce has changed since the basic structure of American health care was put in place. Today's culture is all about flexibility."

The premise of Wyden's bipartisan bill is that we should move away from job-based insurance. It would do this by converting the tax deduction for employer-provided health insurance into a tax credit and requiring that individuals use it to buy insurance. Wyden's bill would achieve universal coverage, apply meaningful cost controls, and, according to the Congressional Budget Office, pay for itself within a few years. It's going nowhere. Instead, Democrats are poised to pass legislation that spends an additional $1 trillion, fails to restrain spending, and shores up an anachronistic employer-based system. I guess you could call it a uniquely American solution.

http://www.slate.com/id/2223037/

[Guynemer]

Urge to kill: rising.

[Oerdin]

The reform so far, according to the GAO, is revenue neutral so that's not good or bad. Really they need to take on the drug companies because that's where the big savings are to be found.

[Ramo]

When a Republican (with the possible exceptions of Snowe and Collins) actually votes for something like Wyden-Bennett, I'll believe it. Look at the some of the supposed "cosponsors" opinion on the employer mandate (a feature of both Wyden and the consensus).

The last time the Dems pushed reform with the potential of disrupting doctor-patient relationships, it was demagogued into oblivion. Not a huge surprise they're avoiding that route this time.

But if these Republicans are genuinely on board, there is the Wyden amendment (Free Choice Act) that will be coming to a Senate floor near you. :)

[Drake Tungsten]

The GOP needs to make sure that it kills the public option for good before it starts devoting serious effort toward passing a more responsible healthcare reform bill.

[Ramo]

Yes. Once we privatize Medicare, the Republicans will give us our fantastic, cost-effective universal health care system. :nod:

[DinoDoc]

The GOP needs to make sure that it kills the public option for good before it starts devoting serious effort toward passing a more responsible healthcare reform bill.The tide of public opinion seems to be swinging in that direction (http://www.rasmussenreports.com/public_content/business/healthcare/july_2009/50_oppose_government_health_insurance_company). The final deathknell will probably come when it fails to pass before the recess.

[Oerdin]

The GOP needs to make sure that it kills the public option for good before it starts devoting serious effort toward passing a more responsible healthcare reform bill.

The public option is the only way to keep insurance companies honest and seriously contain health care costs. Which, of course, is why Republicans as a party (along with those Dems who are also owned by insurance companies) oppose it so much.

[Oerdin]

The tide of public opinion seems to be swinging in that direction (http://www.rasmussenreports.com/public_content/business/healthcare/july_2009/50_oppose_government_health_insurance_company). The final deathknell will probably come when it fails to pass before the recess.

That is the goal of those people who want to stop reform. Just delay, delay, delay... "We need to slow down and review this"; yeah, because having 17 years or so of studying the health care issue has just not been enough. Everyone knows what needs to be done but some politicians have been bribed off and just don't want it to happen so the public option needs to be passed now before the obstructionists kill it.

[Drake Tungsten]

The public option is the only way to keep insurance companies honest

:lol:

and seriously contain health care costs.

:rolleyes:

[Oerdin]

Funny how the public option massively contains costs in every country where it is allowed. The reality is publicly sponsored/funded/run (however you would like to put it) is EXTREMELY cost effective virtually every where it is tried simply because it has economies of scale which can batter down prices on just about everything. Plus it doesn't have to worry about costs such as marketing/advertising or a whole host of things private companies do. Call it the Walmart effect or economies of scale but the big guys can force prices down.

The funny thing is how Republicans are trying to play this both ways. In Congress they're claiming a public option would be such a strong competitor it would put all the private insurance companies out of business while in public they claim it would be horrible and would ruin health care. Yeah, tell that to the people in every other 1st world country who gets better health care then us for around 1/4 what we pay. It really does drive down costs.

[DinoDoc]

It really does drive down costs.
Post #177 (http://apolyton.net/forums/showpost.php?p=5639366&postcount=177)

[Drake Tungsten]

Oerdin's last post

:lol:

[Oerdin]

Ignoring the typically stupid Drake post...

Post #177 (http://apolyton.net/forums/showpost.php?p=5639366&postcount=177)

Right now the proposal is revenue neutral from a government standpoint but would put a lot of pressure on private insurers to keep costs down in order to compete. Of course, if they really want to get costs down then they'd need to do what no law maker has been willing to do yet; namely, take on big pharma. The current proposal cow tows to big pharma and says that the government cannot buy any generic drugs only buying high priced name brand drugs. Just one change right there would amount to huge savings but then politicians would have to stand up to the biggest lobby in Washington, big pharma.

[DinoDoc]

Right now the proposal is revenue neutral from a government standpoint but would put a lot of pressure on private insurers to keep costs down in order to compete.Did you even read the post I referenced? I ask because the tone of this post doesn't seem to jive with the articles reporting of the CBO's assessment showing no cost savings for the Federal government under the Dem plans. Feel free to block out anything written by Drake in there if it would make it easier to process.

[Ramo]

EXCLUSIVE: Early CBO Score on Public Plan. It's Good!

A lot of conservative Democrats, not to mention Republicans, express two big concerns about health reform. They're worried that reform will cost too much. And they don't want a government-run insurance plan.

It's about to get a lot harder to make those two arguments simultaneously.

According to a pair of Capitol Hill sources, preliminary estimates from the Congressional Budget Office suggest that a strong public option--the kind that the House of Representatives is putting in its reform bill--should net somewhere in the neighborhood of $150 billion in savings over ten years.

The sources cautioned that these were only the preliminary estimates, based on previous discussions--that CBO had not yet issued final scoring on language in the actual bill. But the sources felt the final estimate would likely be close.

Exactly how the plan produces those savings is, obviously, a key question. The reason--well, a reason--centrists and conservatives don't like a public plan is that they fear it will use the government's bargaining leverage to force doctors, hospitals, and drugmakers to accept unfairly low reimbursements. Private insurance would go out of business, since they couldn't compete; meanwhile, providers and producers of medical care would struggle to stay afloat.

Advocates of a public plan (myself included) think those fears are overblown--and that there are ways to make sure a public plan doesn't have that effect. But if the CBO is scoring significant savings, then chances are the House version gives the public plan the kinds of power conservatives and centrists fear.

But, for now, the bigger story is the number. At a time when finding the $1 trillion it will take to finance coverage expansions remains the major challenge of reform, the discovery of $150 billion in potential savings is an important--and encouraging--piece of news.

Update: Ezra Klein with a very important caveat:

It's important to remember, though, that this really is preliminary. As I understand it, this is an expected score of the public option on its own. The final score will go up or down depending on the interactions between the public option and other elements of the final bill. If the Health Insurance Exchange is open to only the uninsured and small businesses, for instance, then fewer people will have access to the public option, and so there will be less savings. Conversely, if the exchange is large, and dominated by the public option, then CBO might decide to put all dollars spent in the exchange on the federal budget. That could increase the "cost" of health-care reform by trillions of dollars, making it look like the public insurance option is expensive, even as it's actually saving $150 billion. Thus does budgetary accounting rule our world.

Also, it's worth remembering this is actually less savings than some other, outside projections had shown--most likely because the House bill wouldn't let the public plan reimburse at the same rates as Medicare. (Most likely, it will be Medicare rates plus some fixed increment.)
http://blogs.tnr.com/tnr/blogs/the_treatment/archive/2009/07/10/exclusive-early-cbo-score-on-public-plan-it-s-good.aspx?cid=xrs_rss-nd

[Drake Tungsten]

You do know that the head of the CBO said the House healthcare reform won't save the government any money less than a week after that was posted, right? I don't understand why you'd post something that's been superseded by events...

[Ramo]

What has been superseded by recent events? :)

Please show me where the CBO says that a public option available to everyone (which the House is NOT) saves less than $150 billion/ten years. That number, BTW, is despite the handicap of paying service providers higher than Medicare rates (+10%, IIRC), i.e. not using the full leverage of the government.

[Drake Tungsten]

which the House is NOT

:hmmm:

According to a pair of Capitol Hill sources, preliminary estimates from the Congressional Budget Office suggest that a strong public option--the kind that the House of Representatives is putting in its reform bill--should net somewhere in the neighborhood of $150 billion in savings over ten years.

It seems you're being deliberately obtuse again. :shame:

[Ramo]

Cohn mischaracterized the public plan (because the House plan wasn't fully released), as Klein's quote implies:

As I understand it, this is an expected score of the public option on its own. The final score will go up or down depending on the interactions between the public option and other elements of the final bill. If the Health Insurance Exchange is open to only the uninsured and small businesses, for instance, then fewer people will have access to the public option, and so there will be less savings.

Specifically:
BREAKING: House Bill Looks Good (So Far)

The three House committees writing health care legislation have just released the full text of their bill. And my immediate, admittedly tentative reaction is strongly positive. Once fully implemented, this reform plan will accomplish most of the goals on my mental checklist:

* Generous subisidies, available to people making up to 400 percent of the poverty line
* Expansion of Medicaid to cover people making less than 133 percent of the poverty line
* Guarantees of solid benefits for everybody, with limits on out-of-pocket spending
* Strong regulation of insurers, including requirements that insurers provide insurance to people with pre-existing conditions without higher rates
* An individual mandate, so that everybody (or what passes for everybody in these discussions) gets into the system and assumes some financial responsibility
* A public plan, one that appears to be strong, although I'll reserve judgment on that until I hear from the experts
* Choice of public and private plan, at first just for individuals and small businesses, but later for larger businesses and--possibly--eventually for everybody
* Efforts at payment reform, if not necessarily as strong as they could be
* Investment in primary care and prevention, which is not sexy but potentially important for general health .

The Congressional Budget Office score? Their initial estimates have it covering 94 percent of people living here and 97 percent of legal immigrants, for net outlays of just over $1 trillion over ten years. That figure includes the offsetting effect of the employer mandate, which--at a healthy 8 percent of payroll for larger companies that don't insure workers--would generate $30 billion a year by the end of the decade-long planning window. (Smaller businesses would be exempt.)

I've not yet seen assessments for the new revenue and offsetting savings; I believe everybody is still waiting on numbers from the Joint Committee on Taxation, which does official estimates for revenue. But my House sources say they expect that between savings and a new surtax on the wealthy, the bill pays for itself. In other words, it won't inflate the deficit.*
I do have one, not minor concern: It will be a while before people see the best stuff. Most of the major elements--the insurance exchange, the subsidies, the insurance regulations, the public plan--won't come online until 2013 or later. This is, I believe, also true of counterpart bills in the Senate.

There's a sound policy rationale for going slow; it takes a lot of work to set up exchanges, regulations, and the like. But four years is a long time. And I suspect money has a lot to do with the pace. Slower implementation makes it possible to keep the price tag to around $1 trillion.

On the bright side, some provisions--filling in the Medicare drug donut hole, bolsteirng the primary care workforce, among others--would start in the next two years.

And at least one key insurer regulation would kick in right away: Come 2010, insurers could no longer yank coverage from people retroactively because they've uncovered new evidence of pre-existing conditions. This practice, known as "rescission," is among the most patently unjust features of our health care system.

So, no, it's not perfect. I gave up on perfect quite a while ago. And I'm sure more flaws will emerge as we all have time to give this more scrutiny. (Expect more analysis, here and elsewhere, in the next day.) But within the existing political constraints, it's hard to do imagine a much better bill than this.

An implementation timeline, along with those initial CBO assessments, appear below.

*Update: A source just passed along the revenue estimates from the Joint Committee on Taxation. As expected, JCT projects that the reforms would raise $580 billion in new revenue over ten years, the vast majority from an income tax surcharge affecting wealthy Americans.
http://blogs.tnr.com/tnr/blogs/the_treatment/archive/2009/07/14/breaking-house-bill-good-wish-it-could-happen-quicker.aspx#comments

Just saw the most recent posting. I'm guessing your Hill staffer is on the Senate side, the House side takes care of this!

In the Tri-Committee draft proposal, after one year the exchange will be open to individuals with employer-sponsored insurance [ESI], but whose ESI is "unaffordable" (as determined by the regulations issued by the exchange). After four years the exchange will be open to all individuals who want to get their coverage there.

And even in the first years, once you're eligible for the exchange and buy coverage, you can maintain that coverage as long as you'd like even if you get another job that offers affordable ESI. So the scenario your other Hill staffer envisions wouldn't happen under the House plan!
http://voices.washingtonpost.com/ezra-klein/2009/06/more_thoughts_on_the_health_in.html

2020-2013-4 = 3
That's 30% of the period under which the plan is scored. Cost savings wouldn't necessarily scale linearly, but that's a large hole. :)

Like I keep reiterating, it helps to actually know what the hell you're talking about.

[Drake Tungsten]

The three House committees writing health care legislation have just released the full text of their bill. And my immediate, admittedly tentative reaction is strongly positive. Once fully implemented, this reform plan will accomplish most of the goals on my mental checklist:

A public plan, one that appears to be strong, although I'll reserve judgment on that until I hear from the experts

I fail to see the change you claim took place between the 10th and the 14th.

[Ramo]

The full text of the plan was released. Hence the "breaking" and the date 7/14. The big news that day was that implementation of major parts (including the public option) would be delayed longer than expected. I'll say it again to emphasize the point. The impact of the public option latest CBO score of the House bill doesn't include 30% of the next ten years - because the public option wouldn't exist. It is crippled in terms of access for another 40% of the period. And it's crippled in terms of cost to a tune of 5% (not 10%, as I said earlier) in perpetuity.

[Drake Tungsten]

I have no clue what your point is now. If you're trying to disprove Elmendorf's verdict on the cost savings of the House plan, you're doing a pretty bad job of it.

[Ramo]

More on cost savings:
By Jacob Goldstein

Health ReformSo House Democrats just released their big health-reform bill. As expected, it includes a new, government-backed health plan — a plan that’s been among the most contentious topics in the health reform debate.

As we were poring over the analysis out today from the CBO (the Congressional scorekeeper whose estimates are key in shaping the debate), we were struck by one estimate in particular:

…total enrollment in the public plan would equal about 11 million or 12 million, counting both individually purchased policies and employer-sponsored enrollees.

That’s about 4% of the current U.S. population, and seems rather small in comparison to how much attention the debate over the public plan has drawn.

Of course, the CBO itself notes that its “estimate is subject to an unusually high degree of uncertainty,” which means that the actual number of people who enroll in a public plan could be significantly higher.

The plan would pay doctors and other practitioners 5% more than Medicare pays. Rates for hospitals and others would be the same as Medicare. And the public plan would negotiate rates for drugs, according to the CBO. The public plan would have premiums on average around 10% lower than private plans, because of factors including the lower rates it would pay to doctors and hospitals, the CBO says.

For more on the bill, including new taxes that would be used to fund insurance subsidies, see this story from the WSJ.

The next big shoe to drop is likely to be the health bill coming out of the Senate Finance Committee, which is expected in the next week or so. It’s unclear whether that bill will include a public plan; it may instead create a system of health co-ops.
http://blogs.wsj.com/health/2009/07/14/cbo-public-health-plan-would-enroll-less-than-5-of-americans/

It should be noted that a significant drop in premiums due to the bargaining leverage of the public plan would force a smaller drop in premiums of private plans. I don't know how large that would be, but I'd be that it would be significant. You can come up with an estimated savings figure if you make a few assumptions (average premium over the relevant years, portion of public funding of the average premium, number of people enrolled in the public plan, effect on the premium on private insurers), but these aren't necessarily trivial amounts we're talking about. And as I was saying, there is the crippling of its ability to piggy-back on Medicare disbursement that should be accounted for if we're talking about an ideal public plan (which Oerdin was).

[Ramo]

I have no clue what your point is now. If you're trying to disprove Elmendorf's verdict on the cost savings of the House plan, you're doing a pretty bad job of it.

Who said I was responding to Elmendorf? He's a good guy, and he should be in public more. I was clearly talking about the public plan, and why anyone who cares about cost savings should get on board with making it stronger (and support other cost control measures). You still haven't explained what has been superseded by events. The only new event is that right wingers got new talking points. :)

[Drake Tungsten]

I was clearly talking abou the public plan, and why anyone who cares about cost savings should get on board with making it stronger.

The House bill includes a strong public option, yet doesn't reduce costs.

[Ramo]

Yes, we all know that talking point by now.

It's a "strong plan" that exists for 3 out of the 10 years that the CBO actually scored, and operates on a disbursement handicap. Even then, it's not anywhere near as strong as it could be. If Wyden's amendment passes, the public plan would be significantly more effective by allowing anyone into the exchange (and therefore with public plan access), subsidized by the employers.

And no, it reduces costs (almost a logical corollary of operating 10% cheaper than its competition), if not necessarily very much. The more interesting score would be ten years afterward. But that isn't what the CBO does.

[Drake Tungsten]

Elmendorf's statement was temporally open-ended; he doesn't see the House bill (which includes a strong public option) ever reducing healthcare costs for the government. You're grasping at straws...

[Ramo]

Jesus. I'm not referring to the House Bill. I'm referring to a public option. They are not interchangeable. The House Bill includes a variant of the public option (that isn't as strong as it could be), but it also includes other things. Like a broadened safety net that gets 97% of legal residents insured. If you haven't noticed, those things do not come cheap.

There are actual CBO numbers characterizing the efficacy of potential public options. And savings could be pretty sizeable. Like $150 billion/ten years. But yes, let's ignore that and focus on temporally open-ended vagueries.

[Drake Tungsten]

The Mayo Clinic comes out against the House healthcare reform bill...

Although there are some positive provisions in the current House Tri-Committee bill – including insurance for all and payment reform demonstration projects – the proposed legislation misses the opportunity to help create higher-quality, more affordable health care for patients. In fact, it will do the opposite.

In general, the proposals under discussion are not patient focused or results oriented. Lawmakers have failed to use a fundamental lever – a change in Medicare payment policy – to help drive necessary improvements in American health care. Unless legislators create payment systems that pay for good patient results at reasonable costs, the promise of transformation in American health care will wither. The real losers will be the citizens of the United States.

http://healthpolicyblog.mayoclinic.org/2009/07/16/mayo-clinic%E2%80%99s-reaction-to-house-tri-committee-bill/

Obama is a big fan (http://healthpolicyblog.mayoclinic.org/2009/06/24/obama-cites-mayo-clinic-in-advance-of-white-house-conversation-on-health-care/) of the Mayo Clinic. Maybe he'll listen to them and veto this POS if it comes to it... :lol:

[OzzyKP]

No matter how bad the bill may be, Obama won't veto it.

[Drake Tungsten]

That's why I laughed.

[OneFootInTheGrave]

The real losers are the citizens of the United States.[/q]

http://healthpolicyblog.mayoclinic.org/2009/07/16/mayo-clinic%E2%80%99s-reaction-to-house-tri-committee-bill/

Obama is a big fan (http://healthpolicyblog.mayoclinic.org/2009/06/24/obama-cites-mayo-clinic-in-advance-of-white-house-conversation-on-health-care/) of the Mayo Clinic. Maybe he'll listen to them and veto this POS if it comes to it... :lol:

QFT

[KrazyHorse]

Spam spam spammy spam

[Drake Tungsten]

That was more insightful than anything Ramo's posted in here in the past week. :b:

[KrazyHorse]

Hell no, can't stop me now

[Ramo]

The Mayo Clinic comes out against the House healthcare reform bill...

Although there are some positive provisions in the current House Tri-Committee bill – including insurance for all and payment reform demonstration projects – the proposed legislation misses the opportunity to help create higher-quality, more affordable health care for patients. In fact, it will do the opposite.

In general, the proposals under discussion are not patient focused or results oriented. Lawmakers have failed to use a fundamental lever – a change in Medicare payment policy – to help drive necessary improvements in American health care. Unless legislators create payment systems that pay for good patient results at reasonable costs, the promise of transformation in American health care will wither. The real losers will be the citizens of the United States.

http://healthpolicyblog.mayoclinic.org/2009/07/16/mayo-clinic%E2%80%99s-reaction-to-house-tri-committee-bill/

Obama is a big fan (http://healthpolicyblog.mayoclinic.org/2009/06/24/obama-cites-mayo-clinic-in-advance-of-white-house-conversation-on-health-care/) of the Mayo Clinic. Maybe he'll listen to them and veto this POS if it comes to it... :lol:

Waxman (i.e. the House) is on board (http://online.wsj.com/article/BT-CO-20090721-717218.html) with the kind of Medicare disbursement reforms (the Orszag/Rockefeller plan) that Mayo was referring to (http://healthpolicyblog.mayoclinic.org/2009/07/21/mayo-sees-potential-in-new-imac-proposal/). Sorry to mess up your narrative. :(

[Drake Tungsten]

This message is hidden because Ramo is on your ignore list.

[Ramo]

I'm crushed. Incidentally, if you want ignoring me to look somewhat plausible, a couple steps you might want to take would be to not respond to my posts and to not refer to me. :)

[Drake Tungsten]

I can't read that one, either.

[Lorizael]

Stop discussing ignore lists. Start discussing healthcare.

[DaShi]

I wish we could put healthcare on our ignore lists.

[Drake Tungsten]

This message is hidden because Lorizael is on your ignore list.

This message is hidden because DaShi is on your ignore list.

[Lorizael]

The ignore list meme is done. Thread closed.