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Against Universal Coverage:

An interesting op-ed by Ramesh Ponnuru.

sobi:
As I see it, the only good change in policy is the one that will keep me alive. This one won't. I'm not so interested.
4.9.2009 10:27pm
Hal9000:
The problem with healthcare charity (i.e. giving it to people who don't pay for it) is that there is no ham-sandwich healthcare -- everyone gets Fillet Mignon.

When someone is starving, I don't mind offering them a sandwich... but I don't expect them to expect, demand, or be entitled to Fillet Mignon. But someone on the dole who is "starving" for healthcare, gets the top-shelf stuff. That is the disconnect.

There is no left over unused healthcare to be donated.

There are no fields of picked healthcare that can be subjected to gleaning.

There are no boxes of healthcare approaching their expiration date that can be sold at a discount.

We can't (and the countries that provide universal healthcare don't) provide top-shelf healthcare to everyone. They do it with rationing. I propose something different:

Let the government run clinics. Staff there can not be sued. Government can not be sued for what happens to you there. Then they won't have to practice defensive medicine. No heroics. No million-dollar treatments. Any negligence or malpractice -- use a workers comp model with set amounts for each item. Lise a finger? $500. Lose a thumb? $2000. No chemo. No transplants. Spend the bucks where it counts the most.

You want more? Then *buy insurance*
4.9.2009 10:43pm
corneille1640 (mail):

The third complaint against free-market health insurance is that it wouldn't cover absolutely everyone, because it would neither force people to buy insurance nor require the government to provide it....

For most people, though, especially those in the middle class, it would mean paying less for health insurance.

Well, as long as the middle class gets health care, why worry about the others? I would, by the way, like to see a precise definition of he means by "middle class."
4.9.2009 10:47pm
Perseus (mail):
Gary Becker has some good posts on the topic here and here. My hunch is that the lack of portability has more significant negative economic costs (by increasing rigidity into the labor market) than Becker believes it does (who argues that "most job changes are by younger workers who have few serious medical conditions").
4.9.2009 10:57pm
Doc W (mail):
From the piece:

The moral case for universal coverage is that we have an obligation to see to it that the poor and the near-poor have access to good health care.

There has to be a difference between the moral obligation that some people accept and the sort of obligation that can be enforced at gunpoint. It is a measure of how far political discourse has degenerated that the coerced extraction of resources from some individuals purely for the benefit of other individuals is simply taken as an accepted fact. What about the moral obligation not to rob and coerce?

Those who feel a desire, or accept for themselves an obligation to come to the aid of their less-well-off brethren are welcome to do so. Even today, with government robbing us blind, there is an outpouring of philanthropy.

In a free society, there is a very effective mechanism by which new and better goods and services become generally available, and it applies as well to drugs and medical treatments as anything else. At first, it may be barely possible to make a product with limited functionality available for purchase by a few wealthy interested individuals. The prospect of a much larger market and higher profit beckons for innovators who can improve the performance and lower the cost. Eventually, the process of improvement leads to widespread availability of products that work quite well. This whole process cannot get off the ground, however, if government requires that everyone must have access to something--such as a medical treatment--if anyone does.
4.9.2009 11:29pm
Simon (391563) (mail) (www):
Why do people keep insisting that if health care purchases shift from employer groups to individuals the cost of health care will go down? When do you get a better price, when you buy something by yourself or when you're part of a group purchasing organization? (When you sell something, when do you get a higher price -- when you're one of 1,000 people selling it, or when you're the only one?)

There's a lot to be said for severing the link between employment and insurance. But the notion that shifting the point of purchase from a few larger purchasers (employers) to many smaller purchasers (employees) will somehow cause prices to go down is just absurd.
4.10.2009 12:07am
fishbane (mail):
Interesting? Really?

To mandate that everyone purchase health insurance, as many have suggested, would require that the government specify what constitutes adequate coverage — in other words, what health conditions an insurance policy would need to cover. Every provider group with a lobbyist, from massage therapists to fertility specialists, would want in. The result would be expensive insurance policies and costly government subsidies to help people buy them. Young and healthy people, especially, would be forced to overpay. So we would end up with more cost-shifting, and no savings.

Hint: The government already regulates insurance and specifies a great deal of what is in it.

Hint: Insurance shifting the cost from some in the pool to others? Unheard of!

There are reasonable cases to be made against UC. Most of them fail to actually address specific faults of specific proposals. Others, like this one, not only fail there but also are simply clueless.
4.10.2009 12:07am
John Moore (www):
Hint - the ever increasing ability of the insurance companies to accurately evaluate risk via medical underwriting of individuals will inevitably lead to a situation where only the very healthy can by meaningful insurance.

Oh wait... we're already there.

Try to buy health insurance at any price if you have pre-existing conditions. Good luck!

Or, you can use the "free market" price of medical goods, where a non-insured person pays 10 times or more what the insurance company pays. Two examples from my family's experience:

Facility charge (cost to non-insured): $50,000
Accepted as complete payment form insurance company: $14000

Cost to non-insured: $5000
Payemtn accepted from insurance: $500

The system is utterly broken.


The reasons for this are complex and historical, but not hard to understand.

The nostrums offered by conservatives (my ideological allies on almost everything) just don't cut it.

Libertarians, who never win elections when they champion an every-man-for-himself world, are nowhere with this also.
4.10.2009 12:23am
norm (mail):
Hall9000 please run for congress. I'll vote for you, several times if I can figure out how. Seriously, the lack of discussion about what level of health care is "basic" or "everyone is entitled to" is the most distressing part of the main stream political debate.
I suggest a new elected body in state governments, a board of say 5 members, that decide what standard of care shall be provided given the amount of money appropriated by state and federal legislatures, however much that is. Since they could be controlling something like one sixth of GDP a new elected body specializing in this complex issue would be justified.
4.10.2009 12:31am
sobi:
Insurance is the pooling of risk. The problem is, insurance companies get rich, and sick people get shafted. It is that very system, that pooling of money in a basket that made reaching into that basket via legal proceedings such a profitable move.

There is no policy that includes a mid-level predator that isn't going to cost many more times what it should.

And once the money is gone, and the health is also gone, you're supposed to lay down and die or buy insurance? As if it were a major character flaw on the patient's part to fail to be cured. It isn't like they give you a refund when they fail to cure you.

In fact, they will hound you till you die.

People lose that uppityness about "buying insurance* when they can't, and are staring death in the face. And until that time, the problems with the system are not fully grasped.
4.10.2009 12:32am
gattsuru (mail) (www):
Hal9000
There is no left over unused healthcare to be donated.There are no fields of picked healthcare that can be subjected to gleaning. There are no boxes of healthcare approaching their expiration date that can be sold at a discount.


Actually, there are : the difference between going to the Mayo Clinic and getting brand-name newest and most effective drugs, and going to a training hospital and getting generics even at the cost of not having the most effective treatment is non-trivial in terms of costs. Just treatment methods alone for chronic diseases can have a price difference of tens of thousands of dollars a year.

There is are 'ham sandwich' options. The problem is that even they are pretty damned expensive, and that the people calling for universal health care are unwilling to eat anything but fillet minion, often requiring their own chauffeur and specialty cook, when they don't think they have to pay for it.
4.10.2009 12:43am
einhverfr (mail) (www):
I agree with the basic thrust of the article, but disagree with the specifics. I have generally argued that IF we want to offer universal coverage, we should offer it for routine and preventative care only. All emergency, hospitalization, catastrophe conditions etc. should be covered through private insurance.

However, I think the reform proposals offered in the article are problematic. The first one is to reduce the impact of employer-provided health care when we should be expanding this role through mandates for larger businesses.

The objection to this from many on the right is that government mandates are unconditionally bad. However, here we have a choice between government mandates and government insurance (medicaid). The mandates have a net effect of reducing the influence and participation of government in the field of medical insurance.

The second issue is the removal of state mandates for coverage of expensive conditions. The problem here is that this saves money while, at the same time, removing benefits. IMO, this would make worthwhile insurance more expensive for everyone. What this would mean is that more people would be without coverage for conditions like cancer.

The simple fact though is that in a true market system we will never have universal coverage. There will always be uninsured. The goal ought to be to make comprehensive insurance affordable and reduce the cost of the uninsured on our system by optimizing how care is provided for the uninsured.

The article does not seek to make comprehensive insurance affordable, just some sort of insurance affordable. This overlooks basic problems with the function of the system. Insurance contracts are long and complex, and most Americans can't understand them. Comprehensive coverage for most Americans is an important goal. Reducing the number of uninsured is an important goal. Furthermore, reducing the economic impact of the uninsured is another important goal. I just don't think the specific proposals offered by the author are helpful in achieving those goals.
4.10.2009 1:10am
einhverfr (mail) (www):
Hal9000:

Lise a finger? $500. Lose a thumb? $2000. No chemo. No transplants. Spend the bucks where it counts the most.


I have actually argued that this sort of thing makes sense. Keep malpractice out of court by offering a doctor a policy which offers standard payouts for good-faith errors based on the impact to the patient.
4.10.2009 1:12am
David Welker (www):
This isn't an interesting op-ed. This is an embarrassingly bad op-ed. You would think that some basic knowledge of health insurance would be necessary before writing an op-ed in a national newspaper.

Mr. Ponnuru apparently doesn't even grasp, much less understand, the problem with individual insurance markets. The problem with employers receiving a tax break for insurance purchases but individuals not is only a tiny bit of the problem.

The REAL problem is known as adverse selection which arises due to asymmetrical information. It is very similar to the market for lemons problem. If you want to sell your car, often people are going to assume that this is because there might be something wrong with it that you are not telling them about. So, if you are trying to sell a perfectly good care, the price you are going to fetch on the market is going to be lower than that car is really worth, because people will tend to discount the price to take into consideration the possibility that they are getting a lemon (even if your car is not a lemon). Similarly, asymmetrical information causes problems in health insurance markets. The individuals who would most likely want to buy health insurance has some sort of health problem for which they would like coverage. The people least likely to want to buy insurance are those who are in really good health and don't think they would use it. For this reason, if you are in perfectly good health but would like to buy insurance, insurance companies are going to take into considerations that individuals seeking insurance are more likely to have health problems. This could render insurance unaffordable for you, even if you don't have any problems right now. So much for the concept of "insurance" in that case. There is no indication from the op-ed that Mr. Ponnuru even grasps, much less grapples with this problem.

Furthermore, Mr. Ponnuru is also something of an idiot in some ways. What is the problem with "rationing" anyway? The problem with rationing is that you don't get the care you need.

A big part of Mr. Ponnuru's "solution" to health care is to lessen the requirements regarding the conditions that insurance companies have to cover. In other words, Mr. Ponnuru's "solution" means that people will not get the care they need. That sounds a lot like the problems that arise with rationing to me.

Finally, what is the problem with accepting less than universal coverage. Once again, the problem is that many people do not get the care they need. Again, that is the same problem you have with rationing.

It would be nice if Mr. Ponnuru could actually, you know, actually understand and engage in the actual issues (from a conservative perspective) instead of proposing non-solutions that apparently arise from ignorance combined with a serious deficiency in critical thinking skills.

I should point out also that to the extent that Mr. Adler is linking to this thoroughly deficient op-ed and saying it is interesting because he thinks the simplistic solutions therein are insightful would be revealing of a similar sort of ignorance and/or lack of critical thinking skills.

I should point out another thing that has been driving increases in the cost of medical care (besides completely artificial restrictions on the supply of doctors and nurses and other health professionals) is innovation. New innovations are wonderful things that increase human health and happiness. They are also protected by intellectual property, which increases the price way above marginal cost and to some degree (and in some contexts) inhibits further innovation. The long and short of it is there are a lot of dead weight costs here. This is a really tricky problem.

Again, Mr. Ponnuru is apparently completely clueless regarding these issues. Seriously, I think it is very unfortunate that the New York Times bothered to publish this garbage and that Mr. Ponnuru didn't put more effort into educating himself before spewing forth simplistic solutions.

And conservatives wonder why they are not equally represented in academia. Well, let me tell you, it is because people like Mr. Ponnuru often represent the cream of the crop when it comes to conservative thinking. That is pretty pathetic, really. When you have true conservative geniuses (like Milton Friedman) they do just fine in academia. Anyway, in general, I will be much more interested in the problem of so-called "bias" against conservatives in academia when I see more conservatives making more respectable and thoughtful arguments.
4.10.2009 1:27am
Soronel Haetir (mail):
efinger,

What you ignore is that most businesses are small. Focusing on employer insurance would be yet one more barrier to people striking out on their own. It's already fairly significant when the self-employed are (or until recently) unable to deduct insurance costs the way that employer provided plans are.

I do however find the government definition of small business fairly maddening where some firms with several hundred employees qualify depending on industry. I would put the small business limit around 10. Anything larger than that really ought to be considered a medium sized business.
4.10.2009 1:36am
David Welker (www):

Lise a finger? $500. Lose a thumb? $2000.


Wow. Talk about a cheap SOB. Don't you think your thumb is worth a little more than $2000?

This sounds like a conspiracy to make poor people hate government by providing horrible health care via unaccountable bureaucrats like you stereotypically find at the DMV.

Making clinics unaccountable for results sounds like a really horrible idea. What a great place to send people. As long as you don't care about, you know, what happens to them.
4.10.2009 1:36am
David Welker (www):

I have actually argued that this sort of thing makes sense. Keep malpractice out of court by offering a doctor a policy which offers standard payouts for good-faith errors based on the impact to the patient.


One problem with this idea is that "good-faith errors" are not equally distributed amongst doctors practicing a particular specialty. There are some really good doctors out there. There are also some that really aren't good. Unfortunately, licensing boards can be inadequate in policing quality.

I am not saying the tort system is perfect, but I don't think standard payouts are a good idea. I also don't think that malpractice insurance is somewhat problematic, in that maybe doctors who make too many mistakes don't suffer enough pain for those mistakes. And doctors who make many fewer mistakes suffer too much pain for the mistakes made by other, less conscientious or skilled doctors.

Overall, I don't think this standard payout idea is a good one, as if every case were equally bad.
4.10.2009 1:44am
David Welker (www):

There's a lot to be said for severing the link between employment and insurance. But the notion that shifting the point of purchase from a few larger purchasers (employers) to many smaller purchasers (employees) will somehow cause prices to go down is just absurd.


It doesn't matter if it is absurd. That is what many conservatives will argue, because they have low intellectual standards.

To be fair, there are plenty of liberals who are deficient in critical thinking skills and there are plenty of conservatives who are smarter and more insightful than many liberals.

But, on the whole, I think overall the quality of conservative thought is often simply very much lacking. Maybe I just spend too much time reading National Review and I am being utterly unfair. (Yes, I tend to prefer reading that I disagree with for some reason.) But that is my impression.
4.10.2009 1:55am
Brett A. (mail):
You've got to love Ponnuru's idiotic conclusion,

Some people, of course, would still choose to go without it. But that would be their call, as it should be in a free country.


Sure - but it would be our burden anyways, since unless you are willing to change the law that requires that hospitals not turn away any emergency patient on the basis of ability to pay (and I'm not hearing that from even the conservative/libertarian side of the bench, probably because "let 'em die in the streets" isn't a popular position), anyone of those people who end up with an expensive medical condition are going to end up on either the taxpayer dime or the hospital owners'. I'm betting on the taxpayer.

Then, of course, there is his complete ignorance of one of the reasons why having employer insurance is a good idea (aside from the fact that the employer plays for all or a good chunk of it) - employers representing large groups of potential users have significantly greater negotiating power with the insurers, and can negotiate lower premiums. It's precisely this negotiating power that terrorizes the health insurance industry about a new public plan - they're frightened that it would have immense bargaining power, and would ultimately be able to offer care at a lower per-unit cost than any private insurer.

But you lose all of that if we switch to a system that consists of everyone purchasing plans with a tax credit. Suddenly, it's just you versus Kaiser Permanente, and there's no economy of scale like with the employer-covered care. That drives rates up, meaning that either you simply won't be able to pay for the full cost of your health coverage (and that was the joke of the McCain plan, that this imitates; McCain offered, what, a $3,000 tax credit when an average family plan cost something like $12,000 in total, much of it paid by the company you work for?), or (since there are no regulations on coverage requirements), the company will simply sell you an extremely cheap, extremely limited plan that will run out in any real crisis and leave you dependent on the public dime again.

Perverse, isn't it?
4.10.2009 1:56am
Brett A. (mail):

It doesn't matter if it is absurd. That is what many conservatives will argue, because they have low intellectual standards.


It absolutely boggles the mind, when you consider that some of the greatest conservative intellectuals (such as Milton Friedman) were economists, and conservatives are more likely to be prominent among business and finance majors vis a vis liberals. You'd think the concepts of negotiating power and "economy of scale" would sink it, but no.
4.10.2009 1:58am
CaseyL (mail):
It absolutely boggles the mind, when you consider that some of the greatest conservative intellectuals (such as Milton Friedman) were economists, and conservatives are more likely to be prominent among business and finance majors vis a vis liberals. You'd think the concepts of negotiating power and "economy of scale" would sink it, but no.



Eh. My guess is that the conservatives holding forth on how awful universal coverage would be all have employer-paid insurance, and have never been in a position where it's their healthcare at risk.

Put that together with the unfortunate, but abundantly demonstrated fact that conservatives are basically incapable of putting themselves in anyone else's shoes, and it's no wonder they can't comprehend such niceties as disparities in negotiating power and economies of scale.
4.10.2009 3:03am
Avatar (mail):
One points out that it's entirely possible to be a conservative and unable to afford health coverage. I was there for several years.

Both models have ups and downs. Currently, our health insurance model funds very advanced treatments for those with insurance (usually) at the expense of not providing care for those without (excepting emergencies).

Assuming we're not going to expand health expenditures by 10% (roughly the number of uninsured, discounted by a little because a number of the uninsured are healthy), and have the government pay for it all, a move to universal coverage would HAVE to include rationing of health care to those who currently have insurance coverage. (You can get part of the way there on systemic savings, but not all the way there.)

There are, honestly, societal advantages. Other commenters have mentioned that health care cost and portability of coverage are a major reason why older workers have trouble changing jobs. My own family has experienced that - after Dad got cancer (which he survived, thanks to a then-cutting-edge bladder replacement operation), there was effectively no way that he could afford to lose his health care coverage, because if he did, he'd never be able to afford insurance again... so he was effectively stuck with his employer for many years, despite the low pay he was receiving. Hell, he's still there, even though he's old enough to draw social security now.

On the other hand, it's not certain that Dad would have been able to get that operation under a universal-care system. For that matter, it's not certain ANYONE would have been able to, at that point; I'm not saying all medical and drug research will come to a screeching halt, but it's not like all that money doesn't go somewhere, and the US can't technologically free-ride off itself the way a lot of other Western countries can free-ride off the US, innovatively speaking.

So he might have died from cancer, or he might have survived but stuck with a urine bag for the rest of his life, which I'm sure wouldn't make Mom very happy either. So yeah, there are real quality of life issues involved both ways, huh?

This is one of those issues where there's not an obviously right answer and there are really good reasons to go either way. Cost consolidation could provide a lot of benefits. Advanced care also can provide a lot of benefits. It's clear that, at least to a degree, we have a guns'n'butter choice between the two - the only way to get more coverage and better care at the same time is to devote more of our GDP to health care as a whole, and frankly, we're just a little tapped out as it is.
4.10.2009 4:39am
David Welker (www):

It's clear that, at least to a degree, we have a guns'n'butter choice between the two - the only way to get more coverage and better care at the same time is to devote more of our GDP to health care as a whole, and frankly, we're just a little tapped out as it is.


If we stick with the status quo, we are going to devote more of our GDP to health care.

It should further be pointed out that there are a lot of inefficiencies in our system. And, contrary to what economists say, there is a free lunch. That free lunch is removing unnecessary inefficiency. What are some inefficiencies? (1) Artificial restrictions on the supply of health professionals. (2) Failure to make full use information technology for medical care and instead end up performing unnecessary diagnostic procedures without the full benefit of knowledge concerning health history. (3) Insurance companies fighting with individuals over who is going to pay for a necessary procedure. (4) Intellectual property protections for medical innovations which raise prices above marginal costs. A reward system is an alternative. (5) People not getting preventative care, but instead more expensive care later when problems arise that could have been prevented. (And no, it is not more cost effective for people to die sooner because (i) surviving longer is usually very beneficial to the individual and his or her family (ii) people dying during younger than necessary and losing years they could be working is costly and (iii) the time value of money implies that delaying the large expenditures typically associated with medical care near death is valuable.) (6) Tying health insurance to employment, which reduces mobility and prevents workers from doing the work that is most economically valuable. (7) All the effort that insurance companies spend trying to separate people into different groups based on risk. (8) Uncertainties in revenue associated with treating uninsured patients in emergency room settings. (9) Many different insurance companies doing business in different ways and the requirement that health care providers spend time trying to comply with a plethora of different procedures rather than treating patients.

The idea that we must stay with the status quo because we cannot afford to insure everyone is actually very wrong. What we cannot afford is the status quo.
4.10.2009 5:19am
Sarcastro (www):
BTW: There's no such thing as the "market."

So-called "markets" are simply a name for what happens when people are free!

Better article would be whether people prefer freedom or slavery.
4.10.2009 6:58am
Curt Fischer:
Mr. Welker was laying it on a bit thick earlier in the thread, but his list strikes me a good one. Especially #9. When the biggest predictor of the payments for health care that a company makes on behalf of its employees, normalized for quality of care, is the profitability of that company, it certainly seems like more competition would be in order.

Besides solving the portability problem, I think eliminating the tax benefit for employer-linked health insurance would eliminate an agency problem which drives up the cost of employer-funded health "insurance". This step would probably be necessary, but probably not sufficient, to engender increased competition in the health care program market. If health care was not employer-linked, would it make it easier for heath care providers to provide tiered pricing based e.g. on the results of fitness tests?

I would also like it if the public did a better job of distinguishing between health "insurance" and health care "plans". And I would be curious to see how pricing and payment systems would change in the health care industry if (i) the artificial restrictions on the number of doctors and nurses were lowered, and (ii) doctors and nurses somehow gained ownership interests in the majority of health care companies.
4.10.2009 7:48am
Aultimer:

John Moore (www):

Or, you can use the "free market" price of medical goods, where a non-insured person pays 10 times or more what the insurance company pays. Two examples from my family's experience:


That's not the "free market" price, that's the "consumed care before asking what it cost" price. Doctors are happy to negotiate a cash price for a check-up, planned procedure or whatever. If you're willing to pay in advance, you can even get a better discount than the HMO "write off".
4.10.2009 9:12am
Ben P:

That's not the "free market" price, that's the "consumed care before asking what it cost" price. Doctors are happy to negotiate a cash price for a check-up, planned procedure or whatever. If you're willing to pay in advance, you can even get a better discount than the HMO "write off".


I'm not sure that' entirely fair. Doctors are often willing to negotiate, but by the time most people need the kind of medical care that costs serious money, they are beyond the point of shopping around for that care.

People go in, get emergency care when they need it, then find out what it cost afterward.

You can still negotiate, but your only leverage in that case is being a turnip. The vast majority of hospitals consider it a good year if they collect 50% of their uninsured billings.
4.10.2009 9:34am
Connie:
Aultimer: I know that asking-for-a-cash-discount is a favorite conservative talking point. Have you ever actually done this? My family has. Here's our experience.

1. Doctor #1 said we they could do 10% off for paying cash in advance, but their insurance contracts forbid them from more than that for the uninsured.

2. Doctor #2 (the administrator, actually) said I DON'T KNOW what the cash price is. That's not in the system.


David's comment far above about the list price ($50,000) vs the insurer negotiated price ($14,000) is mostly ignored in these health care funding "reform" discussions (I refuse to call it insurance). Seems to me that a huge part of the answer is to make health care providers have one set of prices for all comers. None of this "list" price nonsense that only the uninsured are charged.
4.10.2009 9:45am
Connie:
Another problem with providers' "list price" nonsense. When you read that ABC hospital provided X gazillion dollars of uncompensated or unrecovered or charity care last year, just remember that's the undiscounted value of stuff that they never would have actually sold at that price to any insurance company.
4.10.2009 9:49am
Oren:

Seems to me that a huge part of the answer is to make health care providers have one set of prices for all comers. None of this "list" price nonsense that only the uninsured are charged.

That would only push doctors to perform more "procedures" so they could bill the same amount but for more items. I can't see this improving medicine.
4.10.2009 10:22am
Bruce Hayden (mail):
It should further be pointed out that there are a lot of inefficiencies in our system. And, contrary to what economists say, there is a free lunch. That free lunch is removing unnecessary inefficiency. What are some inefficiencies? (1) Artificial restrictions on the supply of health professionals. (2) Failure to make full use information technology for medical care and instead end up performing unnecessary diagnostic procedures without the full benefit of knowledge concerning health history. (3) Insurance companies fighting with individuals over who is going to pay for a necessary procedure. (4) Intellectual property protections for medical innovations which raise prices above marginal costs. A reward system is an alternative. (5) People not getting preventative care, but instead more expensive care later when problems arise that could have been prevented. (And no, it is not more cost effective for people to die sooner because (i) surviving longer is usually very beneficial to the individual and his or her family (ii) people dying during younger than necessary and losing years they could be working is costly and (iii) the time value of money implies that delaying the large expenditures typically associated with medical care near death is valuable.) (6) Tying health insurance to employment, which reduces mobility and prevents workers from doing the work that is most economically valuable. (7) All the effort that insurance companies spend trying to separate people into different groups based on risk. (8) Uncertainties in revenue associated with treating uninsured patients in emergency room settings. (9) Many different insurance companies doing business in different ways and the requirement that health care providers spend time trying to comply with a plethora of different procedures rather than treating patients.
1) So, the DoJ sues the AMA for antitrust violations, and maybe Congress tweaks those laws to eliminate the loopholes the docs slip through.

2) Ah, giving up my health care privacy so that you and anyone else who can get access (legal or not) can view my health care records. I am reminded of someone named Livingston in the early Clinton White House who managed to pull a lot of Republican FBI files. And, no doubt, there are miscreants on the other side too.

3) And you think that socialized medicine will help there? At least now, you can change companies, and if it is through your company, get them involved. But even that option disappears under government run insurance. Every try to get something that Medicare doesn't approve of? I am $75k poorer as a result of their arbitrary decisions. Of course, you could petition your Congresscritters, but that has other problems...

4) Oh, and then what is the incentive to innovate? To spend a billion or so on a new drug? (for those that actually make it to market) Far better to eliminate the FDA and then make sure that we can sue the drug companies if they didn't do their due diligence.

5) I like this. You will get preventive medicine. You will take those vitamins. You will exercise appropriately. And if you don't, then you can expect to spend your time in jail.

I remain unconvinced though that having mandated preventive medicine coverage is going to reduce overall expenditures. I have seen some studies that show just the opposite. If you can point me to research supporting your point, I would be appreciative.

6) This is currently more a tax policy issue than anything, dating, I believe to WWII.

7) It must be profitable, since they continue to do it. Actually, much of it is now done by computers, and I will suggest that as a percentage of healthcare dollars, is de minimis.

8) Sure, costs go up in bad times, since more primary medicine is done in ERs, but overall, when averaged out over thousands of patients and 12 months, according to some who do this, it isn't much worse than predicting police or fire costs.

9) In other words, choice costs money, and you are willing to give up choice in order to squeeze this out. Note also that many health care providers already address this by limiting the forms of insurance they take.
4.10.2009 10:31am
common sense (www):
The list price makes sense when you realize they are pricing in the probability that they won't get paid. With an HMO, it's easy to price in a discount because you know you will get the money.
4.10.2009 10:32am
Bruce Hayden (mail):
Another problem with providers' "list price" nonsense. When you read that ABC hospital provided X gazillion dollars of uncompensated or unrecovered or charity care last year, just remember that's the undiscounted value of stuff that they never would have actually sold at that price to any insurance company.
I will be the first to admit that there is massive cost shifting going on right now. The two groups who most benefit from it are the poor who don't pay for their health care, and those on government plans, such as Medicare and Medicaid.

But with socialized medicine, you lose that. All those great price caps, etc. that these programs have implemented will now summarily fail. Currently, a procedure, etc. may cost $100 to provide. Medicare pays $75. Insurance pays $110. Uninsured cost is $200. But with universal single payer system, the payment will now be the Medicare $75, and only the incompetent will provide it, since the competent providers are facing a $100 cost to provide that treatment.

Why do I expect that reimbursement will be $75, instead of the $105 or so needed to provide the product in a more free market? Because that is how single payer systems naturally try to control costs, by cramming down reimbursements to their suppliers. Of course, right now Medicare, etc. have draconian rules for making sure that they can do this, and docs have to completely opt out to avoid cross subsidizing their Medicare, etc. patients. But with a single payer system, that out goes away too. So, you have the prospect of putting the docs, hospitals, etc. out of business, or at least eliminating the best and brightest going into those fields.
4.10.2009 10:56am
Bruce Hayden (mail):
Malthus

Except that most of the cross-subsidization is by the insurance companies, and not the uninsured. Many of them are judgment proof, and many use the ERs as their primary health care.
4.10.2009 10:58am
corneille1640 (mail):

The argument that "The moral case for universal coverage is that we have an obligation to see to it that the poor and the near-poor have access to good health care" is a non-starter, since the same could be said for good food and good sex, both of which the market provides pretty well.

Malthus: that analogy doesn't seem apt to me. Or at the very least, I don't understand it.
4.10.2009 11:02am
Bruce Hayden (mail):
Both models have ups and downs. Currently, our health insurance model funds very advanced treatments for those with insurance (usually) at the expense of not providing care for those without (excepting emergencies).

Assuming we're not going to expand health expenditures by 10% (roughly the number of uninsured, discounted by a little because a number of the uninsured are healthy), and have the government pay for it all, a move to universal coverage would HAVE to include rationing of health care to those who currently have insurance coverage. (You can get part of the way there on systemic savings, but not all the way there.)
I am unsure why I should be excited about health care rationing and losing coverage at the expense of those who are too lazy or cheap to pay for insurance coverage.

That was a bit strong, but there is a real moral hazard issue here, esp. since the white elephant that no one talks about in the room is that a large chunk of the uninsured are voluntarily so. Many are young adults who still believe that they are invulnerable, are years away from having anything major go wrong (and if it does, just file bankruptcy when it is all over), and have more important uses for the money than paying for very cheap insurance policies, such as for partying.

I didn't believe it, until I saw it. For 5 years, I worked part time at a ski area, and it offered an accident policy to its employees for $5 a month. Then, one of the guys tried to flip on his day off, and ended on his head. He was hauled off the mountain on a backboard in a sled, to the clinic. He looked fine afterwards, but they wouldn't release him for work until he had a CAT scan, which he couldn't afford (but would have been covered by the accident policy). He spent the rest of the season as our dispatcher, riding the lift up in the morning and down at night, sitting in a hut answering radio calls. It turns out that of the maybe 15 guys in the 18-29 age group, only 5 were paying the $5 for the accident policy. The $5 was the cost of one beer a month, and they preferred the beer to the coverage.
4.10.2009 11:12am
Bruce Hayden (mail):
The argument that "The moral case for universal coverage is that we have an obligation to see to it that the poor and the near-poor have access to good health care" is a non-starter, since the same could be said for good food and good sex, both of which the market provides pretty well.
Malthus: that analogy doesn't seem apt to me. Or at the very least, I don't understand it.
I have yet to see a persuasive argument made why it is different. I see health care, at least over some minimal amount, as a luxury, and not a necessity of life, and food and shelter really are necessities. Sex less so.

I am still waiting to hear a persuasive argument why I would be better off with my health care quality and choices significantly reduced so that some who don't work as hard or as long, haven't spent 10 years in college, etc., should have equivalent health care coverage to mine.
4.10.2009 11:19am
Connie:
Kaiser has published some statistics on profiles of the uninsured, and the young-healthy-invulnerable American who could afford coverage but is too busy buying beer to bother is another undocumented favorite (right up there with "just ask your doctor for a discount and you'll get a price as good as Kaiser does") of those who oppose reform of our health care financing system. [Also, accident insurance =/= health insurance.]

The uninsured in this country are mostly 1) children, usually in households of 2) low income workers. The fastest growing category is 3) workers over 45 who have lost their jobs who aren't in the greatest health and 4)older laid off workers without children in the home, therefore ineligible for most states' Medicare programs. A huge percentage of employees without coverage work for small businesses (under 20 employees).

The point is not significantly reducing anyone's health care choices. That you believe you actually have many realistic choices is imaginary.
4.10.2009 11:38am
Bruce Hayden (mail):
There's a lot to be said for severing the link between employment and insurance. But the notion that shifting the point of purchase from a few larger purchasers (employers) to many smaller purchasers (employees) will somehow cause prices to go down is just absurd.
It doesn't matter if it is absurd. That is what many conservatives will argue, because they have low intellectual standards.

To be fair, there are plenty of liberals who are deficient in critical thinking skills and there are plenty of conservatives who are smarter and more insightful than many liberals.

But, on the whole, I think overall the quality of conservative thought is often simply very much lacking. Maybe I just spend too much time reading National Review and I am being utterly unfair. (Yes, I tend to prefer reading that I disagree with for some reason.) But that is my impression.
I get it. Liberals are smart, and conservatives are dumb. Very persuasive.

The reason that this is complex is because of the issue of cross subsidization. Those with individual policies have less leverage, and those with no coverage have less (but many have a lot, since the alternative is them paying nothing), in comparison with those covered by policies provided by their employers, unions, etc.

What you have to keep in mind is that the insurance companies have leverage to minimize the amount of cross-subsidization that they provide for government paid programs and the uninsured. The uninsured are left with only their potential to not pay as leverage. But there really isn't that much of the market that falls outside these groups.

Insurance companies typically don't discriminate on the leverage they use with providers to minimize this based on the type of policy the are providing (individual v. group), but rather, discriminate on how much they charge for their policies. The result is mostly that they pay the same regardless, for any given policy.

The place where things do change though above and beyond the cost of the policies is what happens when you get older, or worse, become marginally, or totally, uninsurable. This is the place where a group policy becomes very helpful (usually - a decade ago, I was working for a company with an average employee age in their mid 50s, and insurance there was expensive). This is where the adverse selection mentioned (and apparently misunderstood) above comes in. Girlfriend is now uninsurable, through no fault of her own. They just cranked her front end yearly deductible up to $10k for a policy that runs maybe $600 a month. They do that because they can, but more importantly, because they have to because the claims/loss ratio for that actual policy has gotten so bad that they need to to break even. Healthy policyholders have been migrated out into newer policies, leaving those who can't move.
4.10.2009 11:42am
Oren:



I remain unconvinced though that having mandated preventive medicine coverage is going to reduce overall expenditures. I have seen some studies that show just the opposite. If you can point me to research supporting your point, I would be appreciative.


Many hospitals seem to be voluntarily tagging patients that repeatedly wind up in the ER (with large unpaid bills) and giving them free stabilizing care. Since each ER visit costs >$20k, it seems like free $2000 checkups/updates are a net positive if they even marginally reduce ER visits.
4.10.2009 12:25pm
Suzy (mail):
Thanks Connie, those facts are often forgotten in this discussion. The main arguments one hears against universal coverage are that it's going to cost more and that it's going to reduce people's choices. The reality is that unless you're healthy and well off, right now you don't have these choices anyway. There are also money holes in the current system that might be eliminated by reforms--David Welker's list gives an idea about this. For example, any system of coverage that doesn't maximize the financial rewards of preventative care, and of keeping people out of emergency rooms when they don't need to be there, is not going to be effective.

We do need to think seriously about what an acceptable minimum level of coverage and treatment options would look like. What are the various points beyond which we are truly willing to leave people on their own, to pay themselves or go without? The conservative response on this issue has failed so far because it is unacceptably callous: it is okay for the have-nots literally to die without, as long as the haves can maintain the best levels of care. When half the society falls into the have-nots category, often because of bad luck rather than bad choices, it is no wonder that the conservative line on health care seems simply offensive. An average-income person who suffers a typical serious illness ought to be able to receive a basic standard of care without going bankrupt, and they ought to continue to be able to pay for insurance after an illness without going bankrupt. That is not happening in this country right now. Until conservatives recognize this, they are ceding the issue to the other side. And I think most of us here recognize that a liberal solution that does not allow the market to work on this problem as much as possible is going to be unpleasant!
4.10.2009 12:33pm
Hal9000:
No, I have too many skeletons to run for Congress... and I don't want the pay cut.

@gattsuru: I stand by my statement. There are lesser-cost alternatives like you mention, but that is a discount BRAND, not a premium brand being discounted because it is going to expire.


@David Welker:$200 for a thumb...

It was just an example... the price is negotiable, but take a look at what your state values a thumb at in its workers comp law.

If you don't like it as a patient - go somewhere else and PAY FOR IT YOURSELF. Just if you don't like the soup at the soup kitchen, you can go and buy a meal yourself. That's what happens when you rely on charity. Now you can negotiate with your charity-giver for more, and that's fine. The problem is paying for charity with taxes is forced charity. My former employer matched charitable contribs by employees... but ONLY if you gave to the United Way (which I will not do). If the government wants to mandate everyone give 10% to charity -- then I have MUCH less objection to that than the government taking 10% from everyone, and then using it to do "charity" the government wants to do, that is contrary to what I want the money to do.
4.10.2009 12:45pm
John Moore (www):
David Welker,

For somebody attacking Conservative intellectual standards, these are laughers:
David Welker


Intellectual property protections for medical innovations which raise prices above marginal costs. A reward system is an alternative.

Uh huh. So we will punish medical innovations relative to others through a destruction of the patent system rewards? Brilliant, I must say.


People not getting preventative care, but instead more expensive care later when problems arise that could have been prevented.

All the effort that insurance companies spend trying to separate people into different groups based on risk
4.10.2009 12:52pm
John Moore (www):
Continuing...


People not getting preventative care, but instead more expensive care later when problems arise that could have been prevented.


With the exception of certain diseases, with compliant patients (who usually have the insurance anyway), this doesn't work. It's a great idea, but like many such, fails in the face of reality. It's one reason HMO's went from clinics providing preventive care to medical rationing organizations hated by their members.

All the effort that insurance companies spend trying to separate people into different groups based on risk


That's gotta cost trillions. TRILLIONS, I SAY!
4.10.2009 12:54pm
John Moore (www):
Aultimer:


That's not the "free market" price, that's the "consumed care before asking what it cost" price. Doctors are happy to negotiate a cash price for a check-up, planned procedure or whatever. If you're willing to pay in advance, you can even get a better discount than the HMO "write off".


Ever tried actually doing that negotiation? Some doctors will do it. Hospitals will do their damnedest not to. For one thing, all of their profit comes from uninsureds!

My family, including my daughter who between college insurances (college switch between semesters) was effectively ordered by the state rabies control officer to go to a specific ER at 10PM on Dec 30th for rabies shots (sometimes foreign travel can be risky ;-). My daughter's bill for the INITIAL 2 shots (Human iGm and rabies vaccine) was about $8000. We, with insurance, paid the ER copay.

It took my daughter years to argue them down to $3500, which she only got as a poor college student whom they knew they couldn't squeeze any more out of.

Don't kid yourself. They set those retail prices very high for a reason.
4.10.2009 12:57pm
John Moore (www):

The REAL problem is known as adverse selection which arises due to asymmetrical information.


The REAL problem is a form of "perverse" selection that results from the steps taken to avoid adverse selection. For example, Arizona Blue Cross used to refuse ANY medical coverage to anyone who had ever taken a psychiatric medicine - say a little Prozac for a temporary depression. This perverse behavior is but one example of a huge number that make it essentially impossible for anyone with a medical history to buy insurance. It is also an example of insurance companies attempting to avoid socializing risk, and as the asymmetry of information is reduced with better and better data mining and diagnostic techniques, the trend is towards insurance that directly prices the risk of an individual.
This is fine if you're healthy, and are able to remain covered (without ONE day's lapse) until your terminal illness!
4.10.2009 1:02pm
John Moore (www):
Does anyone have a good reference to where the real costs go in our health care system? If we spend twice what Canada does per capita, what do we spend it on?

As a businessman, I am baffled by hospital bills, as the charges are extraordinarily large for the services rendered - even after the insurance company knocks them down. That means there are probably enormous overhead costs, and also a lot of cost shifting going on.
4.10.2009 1:03pm
einhverfr (mail) (www):
John Moore:

With the exception of certain diseases, with compliant patients (who usually have the insurance anyway), this doesn't work. It's a great idea, but like many such, fails in the face of reality. It's one reason HMO's went from clinics providing preventive care to medical rationing organizations hated by their members.


Perhaps it is just because I have seen systems in other (developing) countries, but actually the HMO model works quite well when properly directed. The issue in the US is cost-competition among HMO's. What I have seen is that HMO's in Latin America or South-East Asia tend to offer the best balance between cost of care and quality of care in their countries. Here in the US, there is only a focus on cost.

The other issue here is that HMO's in the US tend to be preventative care clinics with (very restrictive) hospitals attached. This s not what I am suggesting at all. I am saying that if you don't have other health insurance, the government should be able to pay to have you get a yearly checkup, standard vaccines, etc. If there is a concern you might be developing certain types of diseases, like diabedes, the government should be able to pay for those tests as well. However, this should be extremely restricted and provide everyone incentive to get proper insurance. The goal is simply to reduce the cost of care for uninsured people by ensuring that expensive diseases are caught earlier when they are less expensive (over a lifetime) to treat.

How many yearly checkups does it take to pay for one hospitalization for a heart attack?
4.10.2009 1:17pm
einhverfr (mail) (www):
David Welker:


One problem with this idea is that "good-faith errors" are not equally distributed amongst doctors practicing a particular specialty.


In that case, that element might be price-variable to the doctor. However, it would be helpful to reduce the matter to an insurance payment rather than go through discovery, etc.

What percentage of auto accidents go through discovery?
4.10.2009 1:22pm
Andy Freeman (mail):
> The problem is, insurance companies get rich, and sick people get shafted. It is that very system, that pooling of money in a basket that made reaching into that basket via legal proceedings such a profitable move.

The technical term for that situation is "huge business opportunity".

If you can actually run a health insurance company for significantly less, why aren't you doing it? If you're correct, at least four good things will happen.

(1) You'll provide better healthcare for less.
(2) You'll steal customers from bad insurance companies.
(3) Thanks to (2), bad insurance companies will go out of biz.
(4) You'll make some money which you can then use to do more good.

What? You're not willing to risk your money to do those good things? Why not?

Note that there's nothing about "insurance" that requires shafting sick people. You can either collect the money from them or collect it from other people.
4.10.2009 1:29pm
Kathryn In California (mail):
With the exception of certain diseases, with compliant patients (who usually have the insurance anyway), this doesn't work. It's a great idea, but like many such, fails in the face of reality. It's one reason HMO's went from clinics providing preventive

Catching skin cancer before it spreads: in-house procedure with a couple of hours off from work. Cost- $1000*.

Treating cancer that's spread a bit: several scans, weeks of chemotherapy, days off of work. Cost- $30,000+*.

Early treatment makes medical insurance less expensive for everyone Association of Insurance with Cancer Care Utilization and Outcomes. "Early detection through screening has been demonstrated to decrease mortality from breast and colorectal cancer, yet people without health insurance are half as likely as those with private insurance to receive such screening."


--------------
* estimated, because contrary to what some imply above, it can be ridiculously difficult to find the costs of treatments. If you've got health insurance and are bored, take your last few medical treatments and try to price them on the open market, as if you were buying them yourselves.
4.10.2009 1:35pm
sobi:
The health care that the comfortably insured enjoy has been paid for by sick people turning over every bloody dime they can earn to the medical community.

No health care is pay-as-you-go. None. You all owe to prior patients the advances you seem to think belong to you because you are currently able to pay for it.

There is no genuine character measurement that equates income and contribution. The assumption that hard work is what produces dollars is absurd in our economy.

All you people who are angry about the possibility that others are going to benefit from one of your nickles are deluding yourselves that you alone produced your ability to survive and receive health care.

Health care is a collective product.
4.10.2009 1:52pm
sobi:
Andy Freeman,

You're right, I couldn't run a health insurance company for less. Huge business opportunity is the spin.

Insurance itself is the predator *because* it is a business and seeks to profit.

That profit is not a small healthy increase to one family's income, it is billions of dollars. I think it is fair to say that it increases the cost of health care.

I think health care has to be socialized, and insurance profits eliminated.
4.10.2009 2:01pm
Connie:
Another problem with trying to negotiate with providers. Say I need knee surgery. I would have to negotiate with (at a minimum) 1) the surgeon; 2) the hospital; 3) the anesthesiologist (notoriously unwilling to bargain!); 4) the pharmacy; and 5) the followup physical therapist. That would be like buying a car, and instead of negotiating with the dealer, I have to make separate deals for the chassis, the engine, the tires, the carpeting, etc.

And for the person above whose girlfried is paying $17,000/year for premiums and deductible BEFORE HAVING ANTHING COVERED: yeah, that's quite a deal. Because of some condition (do we try to segregage these into fault-based [e.g., obesity] and no-fault [e.g., asthma]?), she can't even get reasonable coverage for unrelated conditions, say, a broken leg. She's paying $17,000 for the right to receive an insurance-company negotiated discount off list price.
4.10.2009 2:24pm
Aultimer:

sobi:

No health care is pay-as-you-go. None. You all owe to prior patients the advances you seem to think belong to you because you are currently able to pay for it.

The same is essentially true of all products and services. So what? Should I give away my legal services because I owe the judges, legislators and lawyers who created the legal system? Or should my clients pay double because of the debt they owe prior clients, citizens and litigants?
4.10.2009 3:36pm
Suzy (mail):

If you can actually run a health insurance company for significantly less, why aren't you doing it?


I think I could run a car company better than any of the Big 3 are doing it, and I think I could run a bank without trading junk and demanding billions of tax dollars in welfare payment. However, because I am not actually doing those things--what am I? lazy? incompetent?--I must be mistaken. Large companies are never to blame for their own lousy or unfair business practices, because their customers can always be blamed first for not creating our own companies to replace them.

Seriously, the free market system is not working in health care right now, just like it's not working in the financial industry. And the worst, last-ditch solution is to nationalize and federalize everything, so we need a plan for health care that avoids this without leaving the average person in the lurch. I'm not saying a conservative solution is the only possibility, but at least we need stronger conservative solutions to keep this debate balanced. The solutions can't involve half the population being at risk of going bankrupt because they have a serious but typical health problem. We can't expect everyone but the wealthy to "suck it up" if they can't find a way to "pay for it themselves".

What worries me is that the moral blindness of the right on this issue is going to open the door to real abuses on the left, when we end up with real socialized medicine.
4.10.2009 4:49pm
sobi:
To the extent that the legal system has evolved, for better and worse, it is also a collective product. Whether that evolving has been an advancement to enjoy is more subjective.

Are you saying that legal representation belongs only to those who can pay? Because even our current constitutional interpretation says that's not the case.

Legal representation is considered so fundamental to justice that it is provided for those who cannot pay in criminal proceedings where liberty is threatened.

Is health care equally fundamental to life? It is to the ill. It seems rather equivalent to me.

You already charge your clients to include the payment of taxes that provide indigent representation.

It is a matter of what are the basics that all should have in our society that we find so necessary to civilization that we use a collective system versus a free market.

Food? Babies don't earn anything, should we toss them out when they cost too much, cry too much, interfere too much?

The retired? How about them? Do they deserve continued existence if they were among those who's retirements were wiped out in the grand theft over the last few decades?

When is it proper to abandon people to their own resources when the only land they can navigate has a pre-determined design and a whole bunch or prerequisites built in, all of which are founded on money as the basic survival measurement?

The argument isn't health care, it is money. And the average citizen cannot go out hunting for money, shoot some, and bring it home.

The polarity is individuality versus collectivity. All the rest is relative. You can't shoot your neighbor to get their house and land, and you can't live in a society that has collective protections and not contribute. Society will not permit it.

And there's no place else to go. There is no wild frontier.

So stop screaming over your nickles, unbend those cramped little fingers, and start negotiating a fair pool.
4.10.2009 5:01pm
Brett A. (mail):
Would having a public plan, plus some government coverage of prescription medicines, actually damage the pharmaceutical industry?

What if, for example, you had your Health Medicine Decision Board basically do comparisons on possible prescription medicines for various treatments. They pick out the ones that are best in terms of cost and effectiveness, then say that they'll either subsidize or cover the whole cost for doctors and patients to purchase and use them.

Doctors and patients wouldn't be required to use those medicines, but other medicines wouldn't get the subsidy unless they can prove they are overall better than the selected alternative.
4.10.2009 5:58pm
Russ (mail) (www):
@sobi

You're problem though is your statement reflects a belief that somehow being kept alive is the business of government.
4.10.2009 6:07pm
einhverfr (mail) (www):
Kathryn In California:

Actually, it is worse than that.

Suppose you spend $100 on a medical checkup once a year. Over 50 years, that is $5000. Suppose you start to develop warning signs of diabetes. Suppose base tests, etc. cost $1000. Now we are up to $6000 costs total.

How much does this cost compared to 2-3 trips to the hospital ER for heart attacks? Each trip will probably cost $1000 if it is benign chest pain. If it is not benign chest pain, you could have stabilizing care, some hospitalization, etc. Figure at least $45000. One gets to the cost of the life-long treatment before any other costs begin to add up (such as lost productivity, etc) and before treatment for the diabetes even begins.

Also if we assume $5000 of routine medical care for working-age adults, you need to be able to have about one case like this per hundred begin to exceed this amount (the bill there was over $500000).

Now, one thing we are seeing is that there is a rise in preventable hospitalizations among uninsured vs insured individuals. This means more cost to the rest of us. Once they are in the hospital we are all going to have to pay anyway. The goal really ought to be keeping them out of the hospital in the first place which is why I think there should be some modest routine and preventative care provided by the state to the uninsured.
4.10.2009 6:21pm
einhverfr (mail) (www):
Brett A:

I think we should say you can't export to Canada, the UK, Germany, etc. unless you offer the same price to Americans. Simple rule. Make them choose whether the other markets are worth giving us the same price. If not, then maybe some negotiations will happen with other countries.
4.10.2009 6:24pm
einhverfr (mail) (www):
Sobi:

Food? Babies don't earn anything, should we toss them out when they cost too much, cry too much, interfere too much?


I am a Norse Pagan. I would only recommend tossing babies in the river if they don't cry or interfere enough, and only in the first 8 days after birth ;-) Good, strong, assertive children are good.
4.10.2009 6:27pm
sobi:
Russ--

That oversimplifies my position for the purpose of a rhetorical spin that says I want to depend upon government, generally-speaking, a character assassination in the good ol' usa. Argumentum ad hominem.

Not true. Given a frontier, I would have gone. There aint one.

Since I'm stuck here in this collective, required to take part by paying in tax dollars every time I turn around, I'm saying that what I want out of that is health care.

With all the money that is collected and applied to various things, frankly, I put health care higher.

True, it could be because I'm one of those sick people trying to stay alive long enough to afford it again, and I've put plenty of $ in that system already, so a certain amount of bias might be considered.

However, preserving corporations versus people is a non-contest in my moral perspective.
4.10.2009 6:39pm
Rebecca Shaw (mail):
Ramesh Ponnuru missed the whole point of the health care issue in the first paragraph of his op/ed: What we need is universal access, not universal insurance coverage.

Proposing various ways to make insurance more affordable is only rearranging the deck chairs on the Titanic if you don't address the risk pool problem, since insurance will still be unavailable to millions who have pre-existing conditions now -- a previous cancer diagnosis, diabetes, high blood pressure. Insurance is only one way of providing access -- and it may not be the best way, especially since Ramesh doesn't address the 1-800-whocares aspect of trying to actually gain access to the insurance benefits to which you're entitled under the terms of your policy, a frustratingly obfuscatory system that anyone who's ever had individual coverage has likely experienced if they've ever had anything worse than a cold.

However the insurance plans are structured, the key is to make the risk pools huge -- I think Switzerland does this. Everyone in the country pays the same rate for their coverage, and the basic coverage is mandated, so the plans don't really differ.

Grouping everyone in a state or even a region of the country or even nationwide would be one way to reduce cost.
The services to be covered is another thing Ramesh doesn't really address -- it would be relatively easy to provide affordable insurance to everyone if its coverage were very limited. Again, 'universal coverage' is not the goal -- it's universal access, for both preventive care and for acute care.

And any 'universal access' plan should avoid the problems inherent with insurance policies that dissect the human body in unholy ways -- as if the teeth, the eyes and the mind are not part of the whole, and thus don't require coverage unless you have the wherewithal to buy another insurance plan or pay out of pocket for eye, dental and mental health care.

Ramesh also doesn't address the problem inherent with our current system: People do have universal access, but only via the most expensive means of entering the system: the Emergency Room. Even an ER run by a for profit hospital can't (legally) turn an emergent patient away, although what they can do is not offer services directed at what is known in the industry as the "knife and gun club," who end up in a not-for-profit trauma center or public city hospital. If you don't include everyone in that system, you continue to present hospitals with the canundrum of patients who can't pay, but whom they are legally required to treat. For a long time, hospitals covered that unfunded liability by passing the costs along to all other patients in the form of higher costs. Then, Medicare, Medicaid and private insurance programs cracked down on that, so now there's a constant struggle. The bottom line: As long as we all adhere to the basic humanity of treating any individual who presents with a life-threatening emergency, we need to provide universal access in such a way that the healthcare institutions don't bear all of the cost.

Finally, and this is my own personal prejudice, Ramesh doesn't address the fact that universal access will require rationing. Here, I have a Modest Proposal based on the idea that people must assume some personal responsibility for actions they take that bear the potential to create health care costs. I'd advocate a public access plan that requires people who smoke, use 'illegal drugs,' and those who ride a motorcycle without a helmet to pay the portion of their hospital bills they can conceivably afford through mandatory payroll deduction.
4.10.2009 6:41pm
einhverfr (mail) (www):
Rebecca Shaw:

Grouping everyone in a state or even a region of the country or even nationwide would be one way to reduce cost.


Given our great success with medicaid and medicare, you will still end up with 1-800-who-cares if it is done via the government and will not address any of the issues with private insurance companies.

One of the key issues here is that we need universal access to routine and preventative care. We also need to preserve access to emergency room care, including to those who can't pay.

I also don't think it is necessary to appeal to our humanity to make the case for preserving access to emergency room services prior to payment. Trying to sort out whether the individual is insured, what may or may not be covered, etc. in advance of providing care will accomplish a cost reduction in the care, but will also lead to a reduction in care even for the insured. If you walk into the ER and collapse, do you really want the ER not to treat you until they determine that you are, in fact, insured and you pay your deductable? Well, you will get what you pay for (in this case, probably via your life insurance policy)....

I also think that one element here should be a basic co-pay of $10 per routine checkup, and insurance policies would be expected to only cover up to, say, 80% of hospitalization-related bills.
4.10.2009 7:55pm
ChrisTS (mail):
Bruce Haydn:
some who don't work as hard or as long, haven't spent 10 years in college, etc., should have equivalent health care coverage to mine.

I beg your pardon, but I spent 4 years in college (10??), 6 in graduate schools, work very hard, and happen to have ended up with both rheumatoid and psioratic arthritis.

I do have coverage, now, but I will probably never be able to retire until I am on death's door. My meds currently cost (list price) $4,000 a month; with insurance, I'm paying $400 a month. My doctor tells me I will probably end up paying most of the meds costs after retirement - and I certainly will not be able to live for long on retirement funds paying anything close to $4,000 a month for one medicine, even if nothing else befalls me as aging marches on. So, I can retire and suffer exruciating pain while becoming crippled, or I can work until I drop.

As Connie and others have pointed out, most people without adequate health care coverage - or living in fear of being without it - are not the lazy slugs you like to imagine sticking their dirty fingers into your pockets.
4.11.2009 6:47pm
ChrisTS (mail):
Malthus:

So, you compare health care with (a) good food and (b good sex. Let's think that through.

Food is necessary for survival, although good food is not. So, life-preserving health care is analogous to having enough food to live. Perhaps you would be a tad generous - charitable, one might say - and allow for something a bit more? Enough food for normal growth and general health (you know, no rickets or rotting gums or whatever)? That would be analogous to health care to prevent illnesses or deterioration. Too charitable?

Sex is not necessary for survival, and good sex is far from necessary. Of course, you were just being funny. You did not really mean to analogize between something utterly unnecessary for life and health care. Just a chuckle for people with cancer or diabetes or debilitating pain, right?
So we do not need to waste time on that funny part of your 'argument.'
4.11.2009 6:55pm
einhverfr (mail) (www):
ChrisTS


Sex is not necessary for survival, and good sex is far from necessary. Of course, you were just being funny. You did not really mean to analogize between something utterly unnecessary for life and health care. Just a chuckle for people with cancer or diabetes or debilitating pain, right?
So we do not need to waste time on that funny part of your 'argument.'


However, collectively.....
4.11.2009 8:27pm