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Healthcare Reform Thread II

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  • Good Krauthammer column in the WaPo today.

    Obamacare: The Coming Retreat

    Yesterday, Barack Obama was God. Today, he's fallen from grace, the magic gone, his health-care reform dead. If you believed the first idiocy -- and half the mainstream media did -- you'll believe the second. Don't believe either.

    Conventional wisdom always makes straight-line projections. They are always wrong. Yes, Obama's aura has diminished, in part because of overweening overexposure. But by year's end he will emerge with something he can call health-care reform. The Democrats in Congress will pass it because they must. Otherwise, they'll have slain their own savior in his first year in office.

    But that bill will look nothing like the massive reform Obama originally intended. The beginning of the retreat was signaled by Obama's curious reference -- made five times -- to "health-insurance reform" during his July 22 news conference.

    Reforming the health-care system is dead. Cause of death? Blunt trauma administered not by Republicans, not even by Blue Dog Democrats, but by the green eyeshades at the Congressional Budget Office.

    Three blows:

    -- On June 16, the CBO determined that the Senate Finance Committee bill would cost $1.6 trillion over 10 years, delivering a sticker shock that was near fatal.

    -- Five weeks later, the CBO gave its verdict on the Independent Medicare Advisory Council, Dr. Obama's latest miracle cure, conjured up at the last minute to save Obamacare from fiscal ruin, and consisting of a committee of medical experts highly empowered to make Medicare cuts.

    The CBO said that IMAC would do nothing, trimming costs by perhaps 0.2 percent. A 0.2 percent cut is not a solution; it's a punch line.

    -- The final blow came last Sunday when the CBO euthanized the Obama "out years" myth. The administration's argument had been: Sure, Obamacare will initially increase costs and deficits. But it pays for itself in the long run because it bends the curve downward in coming decades.

    The CBO put in writing the obvious: In its second decade, Obamacare significantly bends the curve upward -- increasing deficits even more than in the first decade.

    This is obvious because Obama's own first-decade numbers were built on arithmetic trickery. New taxes to support the health-care plan begin in 2011, but the benefits part of the program doesn't fully kick in until 2015. That excess revenue is, of course, one time only. It makes the first decade numbers look artificially low, but once you pass 2015, the yearly deficits become larger and eternal.

    Three CBO strikes and you're out cold. Though it must be admitted that the White House itself added to the farcical nature of its frantic and futile cost-cutting when budget director Peter Orszag held a three-hour brainstorming session with Senate Finance Committee aides trying to find ways to save. "At one point," reports the Wall Street Journal, "they flipped through the tax code, looking for ideas." Looking for ideas? Months into the president's health-care drive and just days before his deadline for Congress to pass real legislation? You gonna give this gang the power to remake one-sixth of the U.S. economy?

    Hardly. Whatever structural reforms dribble out of Congress before the August recess will likely not survive the year. In the end, Obama will have to settle for something very modest. And indeed it will be health-insurance reform.

    To win back the vast constituency that has insurance, is happy with it, and is mightily resisting the fatal lures of Obamacare, the president will in the end simply impose heavy regulations on the insurance companies that will make what you already have secure, portable and imperishable: no policy cancellations, no preexisting condition requirements, perhaps even a cap on out-of-pocket expenses.

    Nirvana. But wouldn't this bankrupt the insurance companies? Of course it would. There will be only one way to make this work: Impose an individual mandate. Force the 18 million Americans between 18 and 34 who (often quite rationally) forgo health insurance to buy it. This will create a huge new pool of customers who rarely get sick but will be paying premiums every month. And those premiums will subsidize nirvana health insurance for older folks.

    Net result? Another huge transfer of wealth from the young to the old, the now-routine specialty of the baby boomers; an end to the dream of imposing European-style health care on the United States; and a president who before Christmas will wave his pen, proclaim victory and watch as the newest conventional wisdom reaffirms his divinity.




    This fight isn't over yet, not by a longshot. Still, the chances of coming out of this with a sensible reform plan are looking much better.
    KH FOR OWNER!
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    GUYNEMER FOR OT MOD!!!

    Comment


    • To reiterate what I’ve been saying in this thread, I disagree with CBO accounting, both because of the omission of likely components in reform, and conservative estimates (which is appropriate) of certain components in the scored bills.

      In the former category, you have two main aspects: Medicare disbursement reform and capping the employer tax deduction. I’ll say this again: we have a first order estimate for what disbursement reform can save, by looking at the deals that Congress is currently trying to make with the various stakeholders. There is no final set of cost cutting measures (as much as half a trillion over ten years), but the proposals have been roughly equivalent in cost of the Medicaid expansion. This is the part of the safety net through which most of the currently uninsured would get coverage. And this is Congress cutting deals at a politically treacherous moment, not an independent regulatory agency, and without the benefit of comparative effectiveness research. So I’d consider it more of a lower bound, with the possibility of even more savings in the future. Elmendorf has not offered a quantitative estimate, but his qualitative assessment is similar to Congress’ savings. This is not a magical expectation without any basis; there’ll be a tangible pot of money in the final bill.

      I don’t know how to estimate long term savings from taxing expensive plans, but Elmendorf certainly believes such a step to be effective. No committee has put out a bill including it (Senate Finance is almost guaranteed to include some version of it), but we know that the first order effect on government revenues would by at least a couple hundred billion dollars.

      We would also save a large amount of money due to universality of health insurance. There currently is a great deal of uncompensated care. This slack is picked up by government and private health insurance premiums (which trickle down to the public tab in a few ways). The explicit government expenditures for the uninsured are ~$35 billion/year (about half of which is borne by the feds through Medicare and Medicaid payments to providers). Estimates for how the cost is borne in premiums are something like a few hundred dollars per person (I’ve seen a study that said $1100/plan i.e. family, so that would have to be normalized accordingly). None of this is in CBO accounting.

      And here is a point that I’ve made in a number of other threads, but failed to make in this one: the health care reform that is to be passed is primarily NOT about cost control. It is about filling in the safety for those that the current system dramatically fails: people with pre-existing conditions, the unemployed, the self-employed, small businesses, and the working poor. Our system is so ossified (see the US Senate) that only incremental reform is possible, and political actors are unwilling to take the major steps that could cut costs: single payer for primary care, more public delivery, and ending the employer tax deduction. The hope is that we get on the path to cost control, and I’m optimistic. And once we get on this path (and more of the health care costs appear on the public ledger), there’s an impetus for more reform. MA passed a law with a lot of similarities to the consensus proposal, and now they’re getting serious about delivery reform (moving away from fee for service).

      I brought up cost control specifically to correct the stupidity of Krauthammer’s article (revenues = deficits, an average over ten years = an average over an arbitrarily long period).
      "Beware of the man who works hard to learn something, learns it, and finds himself no wiser than before. He is full of murderous resentment of people who are ignorant without having come by their ignorance the hard way. "
      -Bokonon

      Comment


      • Originally posted by KrazyHorse View Post
        That's absurd. The number of doctors is much larger than the constituency for just about any marginal treatment.


        The pushback is NOT by those who would be denied a given treatment. It is against the entire idea of limiting treatments based on cost-effectiveness, by anybody who fears that any of the treatments they might need someday might be denied.

        Holy ****ing ****, you're going on ignore.

        I refuse to believe that you're actually this obtuse. The only other option is that you're being disingenuous.
        Sent this PM. Since I still don't see a response, I'll post it for the public record.

        Originally posted by Ramo
        I provided an actual example of Medicare denying coverage due to perceived lack of effectiveness. If you honestly believe that (or a similar kind of decision) rouses more political opposition (so vehement, I didn't realize that decision was made until googling around) than attempts at cutting doctors' payments, that really is NOT an intuitive conclusion.

        I really don't understand this "intellectual dishonesty" horse**** that you're pulling.
        "Beware of the man who works hard to learn something, learns it, and finds himself no wiser than before. He is full of murderous resentment of people who are ignorant without having come by their ignorance the hard way. "
        -Bokonon

        Comment


        • Another huge transfer of wealth from the young to the old, the now-routine specialty of the baby boomers
          Bastards!
          I make no bones about my moral support for [terrorist] organizations. - chegitz guevara
          For those who aspire to live in a high cost, high tax, big government place, our nation and the world offers plenty of options. Vermont, Canada and Venezuela all offer you the opportunity to live in the socialist, big government paradise you long for. –Senator Rubio

          Comment


          • Ramo, I think PMs from people you're ignoring don't show up, or don't always show up in the inbox. I've had trouble with that before.

            Comment


            • Is he talking to me? I don't see any messages in my inbox.

              EDIT: I think I'll take him off. I was mainly just trying to annoy him anyway...
              12-17-10 Mohamed Bouazizi NEVER FORGET
              Stadtluft Macht Frei
              Killing it is the new killing it
              Ultima Ratio Regum

              Comment


              • On the other hand, I really do think that he's refusing to think very hard about all this because he's led to the uncomfortable conclusion that there are no significant health savings to be realized under reasonable assumptions, but he wants there to be (so that he can get his real wish of having the poor be covered...which is not a bad goal, but which will end up costing money. Period).
                12-17-10 Mohamed Bouazizi NEVER FORGET
                Stadtluft Macht Frei
                Killing it is the new killing it
                Ultima Ratio Regum

                Comment


                • No Christmans cards for Elmendorf from the Obama's I guess.
                  Congressional Budget Expert Says Preventive Care Will Raise -- Not Cut -- Costs

                  In yet more disappointing news for Democrats pushing for health care reform, Douglas W. Elmendorf, director of the Congressional Budget Office, offered a skeptical view Friday of the cost savings that could result from preventive care -- an area that President Obama and congressional Democrats repeatedly had emphasized as a way health care reform would be less expensive in the long term.

                  Obviously successful preventive care can make Americans healthier and save lives. But, Elmendorf wrote, it may not save money as Democrats had been arguing.

                  "Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall," Elmendorf wrote. "That result may seem counterintuitive.

                  "For example, many observers point to cases in which a simple medical test, if given early enough, can reveal a condition that is treatable at a fraction of the cost of treating that same illness after it has progressed. In such cases, an ounce of prevention improves health and reduces spending — for that individual," Elmendorf wrote. "But when analyzing the effects of preventive care on total spending for health care, it is important to recognize that doctors do not know beforehand which patients are going to develop costly illnesses. To avert one case of acute illness, it is usually necessary to provide preventive care to many patients, most of whom would not have suffered that illness anyway. ... Researchers who have examined the effects of preventive care generally find that the added costs of widespread use of preventive services tend to exceed the savings from averted illness."

                  Elmendorf offered this assessment in a letter (you can read it HERE) to Rep. Nathan Deal, R-Ga. Rep. Frank Pallone, Jr., D-N.J., Henry A. Waxman, D-Calif., and Joe Barton, R-Texas, were cc'ed.

                  Responding to the CBO letter, Linda Douglass, the communications director for the White House Office of Health Reform, said that, "to work, prevention has to be targeted. Proven services need to be directed to populations that need it, as the CBO letter suggests. We will continue to work with Congress on ensuring that dollars are spent on prevention that gets the biggest bang for the buck."

                  Douglass argued, however, that there would be long-term financial savings, saying "we can't forget that many of the benefits of prevention will accrue to the Federal government in thel long term as opposed to the near term. Prevention results in longer, healthier, more productive lives -- yielding savings that don't typically show up on a score sheet. We have to return to common sense: keeping people out of a doctor's office or hospitals saves money. Seventy-five per cent of our health care spending goes to treat chronic diseases, many of which could be prevented from developing in the first place . Proven preventive services are worth it."

                  In their continuing struggles with CBO, Democrats from President Obama on down have expressed frustration that Elmendorf doesn't give Democrats' health care reform proposals sufficient credit for cost cutting through preventive care.

                  "One of the things that's disappointing about CBO -- and frustrating -- is all the work ... done on prevention" that the CBO doesn’t factor in, Sen. Chris Dodd, D-Conn., co-author of the Senate Health Education Labor and Pensions Committee legislation, recently griped.

                  "You don't get the benefit in CBO of cost-savings with prevention programs,” Dodd said. They'll tell you how much an anti-smoking program may cost. They don't tell you the benefit occurs when a number of people stop smoking."

                  During the health care town hall meeting, President Obama said, "the Congressional Budget Office, the CBO, which sort of polices what all various programs cost, they're not willing to credit us with those savings. They say, ‘That may be nice, that may save a lot of money, but we can't be certain.’ So we expect that not only are we going to pay for health care reform in a deficit-neutral way, but that's it also going to achieve big savings across the system -- including in the private sector where the Congressional Budget Office never gives us any credit -- but if hospitals and doctors are starting to operate in a smarter way, that's going to help you even if you're not involved in a government system."

                  Before that, House Speaker Nancy Pelosi, D-Calif., said that "it's always been a source, yes I will say frustration, for many of us in Congress that the CBO will always give you the worst-case scenario on one initiative and never ... any credit for anything that happens if you have early intervention, health care. If you have prevention, if you have wellness ... you name any positive investment that we make, that we know reduces cost, brings money to the Treasury in the case of education but never scored positively by the CBO. Yes, it is frustrating."

                  Pelosi said, "I hope we will see them say, 'This is what we see the cost of something. We have not accounted for the benefits' because they don't and they haven't and it should not be inferred from what they do that they have."

                  Not quite.

                  Elmendorf cited an article published last year in the New England Journal of Medicine which he said provides a good summary of the available evidence on how preventive care affects costs..

                  The article by Joshua T. Cohen, Peter J. Neumann and Milton C. Weinstein, “Does Preventive Care Save Money? Health Economics and the Presidential Candidates,” was recently updated and can be read HERE.

                  The authors of that NEJM study wrote that "Sweeping statements about the cost-saving potential of prevention ... are overreaching. Studies have concluded that preventing illness can in some cases save money but in other cases can add to health care costs. For example, screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures. Preventive measures that do not save money may or may not represent cost-effective care (i.e., good value for the resources expended). Whether any preventive measure saves money or is a reasonable investment despite adding to costs depends entirely on the particular intervention and the specific population in question."

                  The authors based their conclusions on an analysis of the Tufts–New England Medical Center Cost-Effectiveness Analysis Registry. They concluded, "Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not."

                  Wrote Elemendorf, "After reviewing hundreds of previous studies of preventive care, the authors report that slightly fewer than 20 percent of the services that were examined save money, while the rest add to costs."

                  CBO also cited a study in Circulation magazine called "The Impact of Prevention on Reducing the Burden of Cardiovascular Disease" (read it HERE) that "estimated the effects of achieving widespread use of several highly recommended preventive measures aimed at cardiovascular disease — such as monitoring blood pressure levels for diabetics and cholesterol levels for individuals at high risk of heart disease and using medications to reduce those levels. The researchers found that those steps would substantially reduce the projected number of heart attacks and strokes that occurred but would also increase total spending on medical care because the ultimate savings would offset only about 10 percent of the costs of the preventive services, on average."

                  -jpt

                  I make no bones about my moral support for [terrorist] organizations. - chegitz guevara
                  For those who aspire to live in a high cost, high tax, big government place, our nation and the world offers plenty of options. Vermont, Canada and Venezuela all offer you the opportunity to live in the socialist, big government paradise you long for. –Senator Rubio

                  Comment


                  • CBO also cited a study in Circulation magazine called "The Impact of Prevention on Reducing the Burden of Cardiovascular Disease" (read it HERE) that "estimated the effects of achieving widespread use of several highly recommended preventive measures aimed at cardiovascular disease — such as monitoring blood pressure levels for diabetics and cholesterol levels for individuals at high risk of heart disease and using medications to reduce those levels. The researchers found that those steps would substantially reduce the projected number of heart attacks and strokes that occurred but would also increase total spending on medical care because the ultimate savings would offset only about 10 percent of the costs of the preventive services, on average."
                    Interesting that there's no discussion of eating right, exercising and regular check ups, which are usually tops on the list for preventative care. To me, it looks as if a certain result was desired, and then the data was gathered to get there.

                    Comment


                    • "Eating right and exercise" are not, AFAIK, part of the health care bill.

                      Comment


                      • It's fun watching the Democrats struggle to find some way to criticize the CBO without looking like blatant partisan tools.
                        Last edited by Kuciwalker; August 10, 2009, 23:23. Reason: tense

                        Comment


                        • "Eating right and exercise" are not, AFAIK, part of the health care bill.


                          I'm ready and willing to be paid to eat more vegetables under the "Cash 4 Cabbage" program. Bring it on, Dems.
                          KH FOR OWNER!
                          ASHER FOR CEO!!
                          GUYNEMER FOR OT MOD!!!

                          Comment


                          • Obama will force us to eat Brussels sprouts!
                            Apolyton's Grim Reaper 2008, 2010 & 2011
                            RIP lest we forget... SG (2) and LaFayette -- Civ2 Succession Games Brothers-in-Arms

                            Comment


                            • Originally posted by Kuciwalker View Post
                              It's fun watching the Democrats struggle to find some way to criticize the CBO without looking like blatant partisan tools.
                              It's fun watching Republicans kowtow to a thumb-on-the-scales bean counter when it comes to questions of health.

                              I wonder if they also forego maintenance on the cars on the assumption it's cheaper to have them fixed once they break down.

                              Comment


                              • you managed to prove my point while not making any sense.

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