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Serious Health Care Reform Proposal:

Let the Democrats put forward three different health care reform proposals. Let the Republicans put forward two different proposals. Find five states to volunteer. Each state adopts one of the proposals. Wait several years. See if any of these proposals worked out well, and if so, which one seems best, and why. Learn from this trial and error, and then pass a national health bill, instead of trying an untested, one-size fits all solution for 20% of the American economy.

glangston (mail):
If it were about fixing health care this would be acceptable to all sides.
7.20.2009 12:39am
Careless:
If only we were a collection of states allowed/encouraged to have different rules and practices, this might make sense.
7.20.2009 12:40am
Cornellian (mail):
Generally a good idea for most things, though for health care it might be hard to isolate the effect of each plan within each state, given overlapping federal jurisdiction in things like medicare.
7.20.2009 12:45am
DavidBernstein (mail):
Any "needed" reform to medicare should be allowed for residents of these states.
7.20.2009 12:58am
Mithras Invicti (mail) (www):

Wait several years.


Now the right is just stalling. Sorry, your time is up. There are over 40 million Americans with no health coverage at all right now, and untold millions who fear losing their coverage or that it will be inadequate. What we should be doing is adopting a single-payer system, which would cover everyone and produce the lowest society-wide cost. Because of conservative intransigence, instead we'll have a public option that people will be able to buy into that competes with the predatory, costly private plans. That's the experiment we're going to undertake, at the end of which we'll wonder why we allowed private companies to collect premiums and then cancel people's coverage when they got sick.
7.20.2009 12:58am
John Moore (www):

What we should be doing is adopting a single-payer system, which would cover everyone and produce the lowest society-wide cost.

If we did that, how would the Canadians get timely health care that they now come down here to buy? This would be a big problem!
7.20.2009 1:00am
BGates:
Sorry, your time is up.

Sounds like somebody's practicing to become a Government Health Care Allocator.
7.20.2009 1:01am
Kovarsky (mail):
that doesn't make any sense. you can't possibly control for all the variables necessary to make inferences like that. was a plan idiosyncratically successful in a state because it is disproporitionately young? healthy? subject to regional medical phenomena that create economies of treatment scale? is it less successful because it lacks economies of scale? is it going to be financed the same way nationally? if not, how does that affect program efficacy? do lemons problems manifest themselves differently depending on the nature of state/national mandates? are there features of the state labor economy that would make extrapolation on a national scale difficult?

i could go on and on. you might respond that you might still want to take the probabilistically stronger option over the probabilistically weaker one, and you would be right - if there were no costs to taking the time to assess the probabilities. but if you properly assign a cost to inaction, you might prefer the chance of a sub-optimal alternative now over a optimal alternative five years from now.

and the time value of inaction on this particular issue is very very very high, and the predictive value of state success is - for the reasons i explain above - very low. subject to those two conditions, the state laboratories approach to a complex phenomenon like health care is a particularly bad approach.
7.20.2009 1:04am
Oren:
Maybe we should have done this '94 -- then we'd be set by now!
7.20.2009 1:04am
glangston (mail):
If single payer is such a good idea for health care, why not for home insurance, fire insurance, auto, legal aid, college funding, indeed, there are no limits to what single payer systems can solve. Let's eliminate the middle man.
7.20.2009 1:05am
Cornellian (mail):

What we should be doing is adopting a single-payer system, which would cover everyone and produce the lowest society-wide cost.

If we did that, how would the Canadians get timely health care that they now come down here to buy? This would be a big problem!


It would be interesting to set up a single payer system in some place like Washington State, with a one year residency to qualify (leaving aside the P&I issue with that) and see what happens.
7.20.2009 1:07am
Danny (mail):
I've lived for 10 years with single-payer systems.. i.e. very slightly higher taxes and no health insurance, so I get to keep more of the money I earn than I did in the US. I've always been able to see a doctor immediately and free of charge. I would never go back to the US system.
7.20.2009 1:09am
spudbeach (mail):
Thank you.

In effect, you are proposing a Canadian style system, where there is more local control. Why should we all have to be alike? When did South Carolina and Southern California ever agree on anything?
7.20.2009 1:12am
CrazyTrain (mail):
Elections. Have. Consequences.*

*Obama ran very explicitly on health care reform, and very aggressive reform at that. The electorate gave him 8 more Senators (9 if you count Specter where Pennsylvanians basically told him to switch) and 20 extra House seats. Too late for you Republicans.

P.S. Also your blind support of Bush's election also has consequences as well, and this is it. But you elected a dolt who mailed it in during a time of war in his last four years. He was such a failure that he let Harry Reid become minority leader of 44 to majority leader of 60, and there is a black President with the middle name Hussein. That's how much the country hates your party. You own Bush (you can save your "I'm a libertarian" schtick for someone who is not paying attention).
7.20.2009 1:12am
jvarisco (mail) (www):
"Obama ran very explicitly on health care reform, and very aggressive reform at that. The electorate gave him 8 more Senators (9 if you count Specter where Pennsylvanians basically told him to switch) and 20 extra House seats. Too late for you Republicans."

Except that all those extra Senators/Reps he has don't support his bill. Which is why it's not going anywhere. He also promised that people wouldn't lose their private care that they like. But I'm sure you supported Bush's efforts in Iraq, etc. when the same electorate gave him clear majorities.
7.20.2009 1:18am
Careless:


*Obama ran very explicitly on health care reform, and very aggressive reform at that. The electorate gave him 8 more Senators (9 if you count Specter where Pennsylvanians basically told him to switch) and 20 extra House seats. Too late for you Republicans.

Well, yes and no. I'm confident everyone but the Senator would be happy if he had been forced out by the realignment
7.20.2009 1:21am
Kovarsky (mail):
jvarisco -

the white house is apparently quite willing to pass the bill with 50 votes, and the dems will hold 60 on nonmerits cloture. so, actually, he has the votes.
7.20.2009 1:24am
Danny (mail):

If single payer is such a good idea for health care, why not for home insurance, fire insurance, auto, legal aid, college funding, indeed, there are no limits to what single payer systems can solve. Let's eliminate the middle man.


In most of the Western world that is true of college funding (colleges are publicly financed and tuition is pocket change). But for the others many people in the society don't need or will not need these things. Everyone needs education and hospitals, not not everyone will have a house, a car, need a lawyer, etc. So it would not be fair to have those things be taxpayer funded
7.20.2009 1:29am
JK:
I think this type of idea is serious, the problem is that people often seem to advocate for these types of ideas when it also serves as a delay for impending legislation. I think most Democrats would have agreed to this if it was proposed right after Hillary care was defeated, but it just doesn't work to make a long-term proposal only after being cornered following years of refusing to even consider the situation.

No doubt the system of "get in power and quickly enact your agenda before you lose it" is a non-ideal system, but I don't think requests for unilateral disarmament from the other side is the solution.
7.20.2009 1:30am
BGates:
9 if you count Specter where Pennsylvanians basically told him to switch

Sorry, I'm only familiar with the Pennsylvania on Earth. What are you talking about?

Everyone needs education and hospitals, not not everyone will have a house

They will if the government buys them each one. That would be fair.
Besides, there's somewhat of a correlation between ability to benefit from an education and ability to earn enough to pay for an education, isn't there?
7.20.2009 1:37am
BGates:
Obama ran very explicitly on health care reform

As explicit as he was on a middle class tax cut, controlling the debt, ensuring a strong US-Israel relationship....

One of the things he most explicitly ran against was McCain's plan to tax health benefits. One could say he was given a mandate to not do that.

Sure, you knew which stuff Obama was lying about, but did the average voter?
7.20.2009 1:47am
/:
Or participate only in gray and black markets, earn an otherwise-honest wage, and get medical attention in Mexico from professionals with the same training and facility as in the US with an insignificant fraction of the cost (and the caveat of no realistic possibility of legal retaliation if something goes wrong -- which is mostly meaningless to the doctor in the day of government insurance in all but the most egregious cases).

This situation would combine contemporary technology with individual liberty, and seems more economical than any alternatives in all times, excluding exceptional patronage set-ups where you have a professional and his assets at your own disposal.
7.20.2009 1:53am
Sandman (mail):
Why wouldn't a state just go ahead and create its own single-payer system? Is there something preventing that? That's actually how the Canadian system was developed.

This would allow other states the opportunity to see problems and opportunities with the system and develop their own systems accordingly.
7.20.2009 2:07am
/:
Why wouldn't a state just go ahead and create its own single-payer system? Is there something preventing that?


Is there some way a state can opt out of nationalized insurance and medicine as it is?
7.20.2009 2:11am
Ohio Scrivener:


"Obama ran very explicitly on health care reform . . ."


He also ran very explicitly on not raising taxes below 250K and keeping your own doctor and health plan. The fact that Obama continues to make mutually exclusive promises seems to bother his supporters none at all.


"No matter how we reform health care, we will keep this promise to the American people," President Obama told the American Medical Association on June 15. "If you like your doctor, you will be able to keep your doctor, period. If you like your health care plan, you'll be able to keep your health care plan, period. No one will take it away, no matter what."



“I want to be very clear,” Mr. Obama said in his weekly address to the nation. “I will not sign on to any health plan that adds to our deficits over the next decade."

If you are keeping score at home, Obama has promised to deliver health care for the uninsured, with no new taxes save for the "evil" rich, and without adding anything to the deficit over the next decade. Before this is over, Obama is going to break at least one of those promises, and likely all three.
7.20.2009 2:14am
JHU BME:
I am uninsured and happy to be so. Not because I intend or expect to (ab)use the emergency rooms, but rather because I have calculated that I will save money by choosing to not pay $1500 for insurance this year and instead pay for care as I go, out-of-pocket (based on expected likelihoods of suffering significant health problems). Not that it is dispositive, but insurance companies rely on paying less for care than they take in from premiums, so a healthy, relatively physical-risk-averse person as I likely has a rational economic incentive to be uninsured. (I understand that insurance companies have means of reducing costs unavailable to individuals and that deductibles and co-pays reduce the actual costs of doctors visits to insurance companies.) Thus I question the premise that covering all uninsured is a good thing (for those uninsured).

While this point is mostly unrelated to the last, I think the best politically feasible way to mitigate the problems that plague health care is to mandate catastrophic health cost insurance and also mandate health savings plans (HSAs) with leftover money from HSAs available tax-free at retirement as a supplement to retirement funds. Any health costs (which the patient chooses to not pay for out-of-pocket) are taken first from the HSA and then, if covered and necessary, from insurance disbursements. This plan would incent health consumers to act as traditional consumers (balancing cost and expected benefit) and would insure against the (generally) unexpected, high-cost, oh-so-sad injuries and illnesses. However, I doubt presently-vested interests (particularly, insurance companies) are generally in favor of such a solution, but, these days, who knows (consider, the AMA throwing radiologists under the bus by supporting the Democrats' plan(s)).
7.20.2009 2:17am
Cato The Elder (mail) (www):
MASSACHUSETTS
7.20.2009 2:21am
Gabriel McCall (mail):
Washington tried, and tanked. Hawaii tried, and tanked. Tennessee tried, and tanked. Oregon tried, and tanked. Massachusetts tried, and tanked.

But when the federal government does it, I'm sure it'll all work out just fine, because they're so much bigger. Just like the guy who loses money on every TV he sells, but makes it up on volume.
7.20.2009 2:34am
JK:

He also ran very explicitly on not raising taxes below 250K and keeping your own doctor and health plan. The fact that Obama continues to make mutually exclusive promises seems to bother his supporters none at all.

It's the assertion on the right that this is a unique problem to Obama, and not something common to the vast majority of national politicians, and certainly every major party candidate in my lifetime that people aren't buying.

Sure, I'd prefer a system where this wasn't the case, but in terms of criticizing individual national politicians for breaking vague campaign promises I think it's just a Rorschach Test. Bush said he would protect the environment, not engage in nation building, and hire the best people, and balance the budget. McCain made them all to, do you really think he could lower taxes, balance the budget, increase military spending, and not cut Social Security or Medicare? If so your just as bad as the "Obamabots."
7.20.2009 2:42am
JK:
Could one of the critics of the Mass heath care system post a link to a serious analysis of the current situation by someone who supported the reform, but now believes it to be a failure (or at least needing major overhaul).

Honest request, I'm not doubting there is such a thing, in fact I imagine there is.
7.20.2009 2:53am
David Chesler (mail) (www):
FWIW, Massachusetts, with a median age over the national (11th of 51 -- I was surprised, I thought the colleges would have bumped it lower) mandated health insurance a few years ago. (The cheapest plan for an 18-year-old is $136/month; for a 27-year-old it's just under $200 -- as a middle-aged diabetic and survivor of a sickly wife I'm used to good insurance [and I ran a spreadsheet based on last year's visits and prescription costs to find the best plan] but there doesn't seem to be a "catastrophic only", in fact that $136 Young Adult plan has a $25, no-deductible PCP visit [which does make actuarial sense - want to encourage preventive care] but a $100,000/year maximum coverage - what happens after that?).

The penalty for not having insurance seems to be $76/month, still less than the cost of insurance -- if I were young and single and healthy I might consider having catastrophic only (does IEEE still have a good deal?) or (if I also had no assets, as was the case when I was young and single and healthy) taking my chances. Nevertheless, we've got some 97% of the population insured.

What we call health insurance not insurance in the traditional sense - you don't expect to collect anything on your fire or life insurance most years.

I get my health coverage through the Commonwealth. I'm a well-enough-paid software contractor, but my reasonable plan costs a little less than the similar COBRA coverage I was offered by my last direct employer two years ago. (I had dental then, but it had a low annual maximum.) I don't think they intended that the state-brokered plans were for people like me when the Governor put the system in place.

The costs are going up. I don't know how well the system is working for everyone, but it does show one experiment. I'd like to see if it's sustainable for a few more years.
7.20.2009 2:57am
David Chesler (mail) (www):
(I started writing that before Cato said MASSACHUSETTS.)
7.20.2009 2:59am
Patent Lawyer (mail):
JK-

You can say that all politicians lie and break campaign promises, or make mutually exclusive campaign promises. But then you can't claim that the winning politician has a mandate for the particular contradictory promise you support. In other words:

Obama promises A to constituency 1
Obama promises B to constituency 2
A and B cannot be done simultaneously.

You can't then claim that when Obama wins, his mandate is to do A but not B, or B but not A.

Besides we all know that Obama won on the "I'm not Bush, and my election will be historic" platform.
7.20.2009 3:06am
JK:
Patent lawyer,
Fair enough, I'm not convinced that was the limit to the poster's claim I was responding to, but you're right that the mandate line requires assumption that people where able to distinguish the "real" promise from the boilerplate, "yes I want to be elected promises."

Also, the "mandate" line is also certainly not unique to Obama, the exact term was used by Bush, and the substance at least by previous presidents.


Besides we all know that Obama won on the "I'm not Bush, and my election will be historic" platform.

Still, I think that's got something on McCain's "is it my turn yet?" platform.
7.20.2009 3:31am
Jim at FSU (mail):

Obama ran very explicitly on health care reform


Too bad that he managed to spend all the money already. Maybe in another 20 years we'll have a few trillion lying around to waste on this shit.

More seriously, I really don't think you can accuse Obama of having promised national health care. At least not in so many words. Don't be mislead by Obama's peculiar talent to say something that goes 90 percent towards committing to your point of view without actually going all the way.

For example, there were actually a lot of non-politically-informed gun owners out there before the election that believed Obama was more pro-gun than McCain because of his convincingly spoken (but completely empty) platitudes in support of the second amendment. Health care is no different because Obama wisely applies this technique to everything he says.

In semi-related news, Obama won because:
-he wasn't Bush. In fact, he ran as a sort of anti-Bush. Wise move IMO.
-the media ate out of his hand, to put it mildly. Even a good candidate would have had a tough time against this historic level of media favoritism.
-he spoke in vague platitudes that made it seem like he was agreeing with both sides on every issue. This is an extraordinary political talent he has and it really shone with help from the media. In NYC he sounded like the second coming of JFK. In Florida he was presented like the second coming of Reagan. And of course the media never really put any pressure on these incongruities.
-and the number one reason was that McCain dropped the ball repeatedly and generally ran a very weak campaign. I cringed many times during the debates. There was so much room for him to have done better.
7.20.2009 3:43am
Can't find a good name:
I would note that Obama's having run for president and winning on a platform of "health care reform" does not obligate anyone to endorse any particular kind of reform. The details of the specific plan make a big difference.
7.20.2009 3:53am
Litigator-London:
Declaring my interest as a UK and European Resident who therefore benefits from health care throughout the EU, I wonder how may of you have actually been involved in the defence of claims by insurers (for example for personal injuries.

There is an aphorism that insurers lend their insured an umbrella for so long as the sun is shining but when it rains seek to have their umbrella back. And how often do insurers instruct their lawyers to do everything to delay a claim coming to trial, slow correspondence, raising unmeritorious defences, all in the hope of eventually settling for less than the claim is worth?

In whatever form a state mandated system provides a safety net for all and there is still nothing to prevent the very high earners taking out supplemental insurance for luxuries such as having one's cosmetic surgery in a private clinic (with hotel and catering on a par with the Ritz Hotel).

The US per capita spend on health care is greater than for any EU country, but the results in terms of life expectancy, infant mortality etc are not reflected by that higher spend - which the profits of the insurance companies are so reflected.
7.20.2009 4:35am
/:
but the results in terms of life expectancy, infant mortality etc are not reflected by that higher spend


Infants are considered alive here if they are alive when they are born, not only if it's convenient that they remain living.

In whatever form a state mandated system provides a safety net for all and there is still nothing to prevent the very high earners taking out supplemental insurance


So you don't understand what purpose "insurance" serves, do you? Everything is lumped into the privileges from the State.

There is an aphorism that insurers lend their insured an umbrella for so long as the sun is shining but when it rains seek to have their umbrella back


Good thing government isn't getting into the insurance industry.
7.20.2009 4:39am
Leo Marvin (mail):
Let's also try DB's proposal with national defense. The next time Al Qaeda attacks NYC and Washington, we'll find out which has the more effective response. And when Texas and Oklahoma decide to invade Iraq, and California and New York stay home, we'll see which one of those works out better.
7.20.2009 4:41am
Jim at FSU (mail):
Leo Marvin:
Yeah, lets counter DB's very reasonable proposal to try federalism in an area not reserved to the federal government with an argument that federalism doesn't work for national defense.

Nevermind that the framers explicitly rejected a federalized national defense after their experience with the pre-constitutional United States under the old articles of confederation.

Is this your first time experimenting with argumentum ad absurdum? Try to be a little less obvious in the future. Ad absurdum is a worthy rhetorical tool, but it requires a delicate touch. Also, a basic understanding of the constitution might be helpful in your future attempts at legal argument.
7.20.2009 4:55am
fair and balanced (mail):

Also, a basic understanding of the constitution might be helpful in your future attempts at legal argument.


A basic understanding of controlled experiments might be helpful in current attempts at basic argument.
7.20.2009 5:09am
Grover Gardner (mail):

I am uninsured and happy to be so. Not because I intend or expect to (ab)use the emergency rooms, but rather because I have calculated that I will save money by choosing to not pay $1500 for insurance this year and instead pay for care as I go, out-of-pocket (based on expected likelihoods of suffering significant health problems).


I have some advice for you. Get insurance NOW before you develop a condition that can be excluded from your future coverage, and/or you get older and the initiation costs skyrocket. Trust me, you'll save a lot more than $1500 a year.
7.20.2009 6:26am
Grover Gardner (mail):

Infants are considered alive here if they are alive when they are born, not only if it's convenient that they remain living.


Like in Texas?
7.20.2009 6:35am
Leo Marvin (mail):
Jim at FSU,

Yeah, lets counter DB's very reasonable proposal to try federalism in an area not reserved to the federal government with an argument that federalism doesn't work for national defense.

Nevermind that the framers explicitly rejected a federalized national defense after their experience with the pre-constitutional United States under the old articles of confederation.

And never mind how well federalized health care has worked for us so far. My point, in case it was too subtle for you, was that we've had more than enough experience with federalized health care to know it works just about as well as federalized defense would. So please spare me the advice on ad absurdum while you're suggesting, I assume with a straight face, that we "try federalism" in health care, as if that's a new idea.
7.20.2009 6:40am
Nice:
What happens when none work out well?
7.20.2009 7:09am
Owen H. (mail):

9 if you count Specter where Pennsylvanians basically told him to switch

Sorry, I'm only familiar with the Pennsylvania on Earth. What are you talking about?



Those of us who are going to keep him in office, rather that let Toomey represent us.
7.20.2009 7:16am
mcbain:
Peter Singer quite aptly explains how healthcare costs will be controlled in government controlled healthcare system in his Why we must ration Healthcare article.

If we get universal healthcare this is exactly what will happen (except much less efficiently than Singer desribes).

For a universal healthcare system to work, the government will need the ability to make the decision if you get to live past a certain age or with a certain condition. I trust that everyone who supports single payer is comfortable with that.
7.20.2009 8:00am
Floridan:
"I have calculated that I will save money by choosing to not pay $1500 for insurance this year and instead pay for care as I go, out-of-pocket"

And you could calculate that you have an 83% chance of not getting your head blown off playing Russian Roulette.

I recently had surgery to remove a benign tumor; the hospital's charge was $47,000. This didn't include the surgeon's or the anesthesiologist's bills nor all the other charges for tests, medications, supplies, etc. etc. Nor did it include the pre-op doctor visits, CT scans and other diagnostic procedures.

The fact is, one unexpected medical problem can quickly bankrupt an uninsured family (even for the insured, the deductibles and co-pays can be challenging). There is no way that saving $1,500 a year can adequately protect your financial well being if you end up in the hospital.
7.20.2009 8:22am
rosetta's stones:
And never mind how well federalized health care has worked for us so far. My point, in case it was too subtle for you, was that we've had more than enough experience with federalized health care to know it works just about as well as federalized defense would. So please spare me the advice on ad absurdum while you're suggesting, I assume with a straight face, that we "try federalism" in health care, as if that's a new idea.

How can you claim that we've had "federalized" health care? The federal government provides about 60% of the health care in this country, by some calculations. If it's paid for by the fed gov, they're running it, that portion of it at least.
7.20.2009 8:28am
SuperSkeptic (mail):
What does it matter to me if my doctor, my legislator, or "god" decides when I die? Either way, I don't have to do anything but pay...except in the last scenario
7.20.2009 8:42am
Bluesteed:
@mcbain:

"For a universal healthcare system to work, the government will need the ability to make the decision if you get to live past a certain age or with a certain condition. I trust that everyone who supports single payer is comfortable with that."

I really think this is overblown. Profit-driven insurance companies are already the gatekeepers to what medical care you receive. If anything, a public option would push zealous congressmen to get involved and protest the unfair denial of care.

I was also wondering if you're comfortable with the opposite of the sentiment you dismiss, that all medical procedures should be available to everyone in all circumstances. Spending $50,000 on a procedure for an 80 year old who only has a few more months to live? It's your right and, depending on your moral canon, maybe even your duty to have the operation done. But you should foot the bill yourself. Here's a more intelligent discussion discussion about cost-effectiveness analysis: http://www.slate.com/id/2221402/
7.20.2009 8:56am
Grover Gardner (mail):

What does it matter to me if my doctor, my legislator, or "god" decides when I die? Either way, I don't have to do anything but pay...except in the last scenario


I trust you plan on remaining single and childless, will outlive all your relatives, and manage to die quietly in a ditch. Even then, somebody's got to pay to drag your body to the dump. But that's fairly cheap, compared to the alternative.
7.20.2009 9:34am
Tom952 (mail):
Your proposal is rational and reasonable. However, Congress is the body that must pass the legislation, and Congress is a political institution. Successful legislation must satisfy political concerns, but there is no requirement that it be rational and/or reasonable.
7.20.2009 9:42am
Abdul Abulbul Amir (mail):

The US per capita spend on health care is greater than for any EU country, but the results in terms of life expectancy ...are not reflected by that higher spend


Whenever you see life expectancy used to compare health care systems you know that you are being played for a sucker. The fact is that life expectancy is influenced by many factors and the health care system is only one. What is being done is to compare two countries with very different murder rates, illegitimacy rates, drug abuse rates, highway fatality rates, obesity rates, diet, smoking rates, gene pool, and literacy rates among others and then decide that the difference in life expectancy is due to the health care system. Rubbish. You should be ashamed.

Here is perhaps a more useful but incomplete set of criteria for judging health care systems:

1. Is the country a source or a destination for medical tourists? For example, do single payer citizens (Canadians) come to the US for breast cancer surgery (Stronach) or difficult pregnancies (Jepp), or is the flow the other way?
2. Is the breast cancer survival rate higher or lower?
3. Is the overall cancer survival rate higher or lower?
4. Is the wait for a hip replacement longer or shorter?
5. Are long waits for CAT and MRI equipment the norm?
6. Does the government hide or delay the availability of new and more effective but more costly treatments?
7.20.2009 9:53am
pmorem (mail):
And you could calculate that you have an 83% chance of not getting your head blown off playing Russian Roulette.


If the right payoff were there, I might take that gamble. My risk calculations are different than yours. My calculation ends up being a lot like Russian Roulette.

I'm uninsured. I have no dependents, and very little prospect for ever having any. Running without insurance allows me to save a significant amount of money. As best I can tell, that's my best chance for finding a way out of my misery.

I realize that there aren't many people who would present this in such stark terms. I also realize that my perspective on bonding is something most people (including myself) find distasteful. "Sometimes life can just suck."

I'm doing the best I can with what I have. I'd really appreciate people not making things even more difficult, even if they're "trying to help" me.

Please keep your laws off my body.
7.20.2009 9:57am
Anderson (mail):
Wait several years.

And the more people who die in that time for want of affordable health care, the lower the costs on the ultimate system.

Win-win! Just like Matt Yglesias called it:

"In the conservative free market utopia, as I understand it, what would happen to you is that you would just die."
7.20.2009 10:02am
glangston (mail):
Danny (mail):




In most of the Western world that is true of college funding (colleges are publicly financed and tuition is pocket change). But for the others many people in the society don't need or will not need these things. Everyone needs education and hospitals, not not everyone will have a house, a car, need a lawyer, etc. So it would not be fair to have those things be taxpayer funded,


We have a large state college system in CA and it is not pocket change for tuition. $2000 in fees for full time in-state and $7000 for full time out of state students. Car insurance is mandatory for drivers and has many of the same issues with the uninsured and underinsured as health insurance. When you NEED a lawyer and have any assets at all, you find out just how expensive legal care is. Someone carries Fire Insurance on that place where you live especially if there's a mortgage of any kind and you are paying for it as a renter. Possibly there's flood insurance mandated also and it IS a form of single payer insurance
My wife and I could easily have gotten by without health insurance and still could. My retirement had health insurance benefits. Education? Her father put 4 children through college in a 10 year span, two to USC, one to Stanford and another to Long Beach State, all personally funded. He was a farmer alongside his own father, an immigrant from France in the early 1900's. Typical, maybe not, but the opportunities were typical.

We can do better was a phrase that Obama used in his campaign. We certainly can do a better job of preventive health care. We can improve the overall health of the nation with better nutritional information and promotion of exercise. We can also do better teaching people to plan for a future and help them understand some basic economic principles. I'm not sure pocket change and a sense of entitlement will help them value their education or health care properly, nor the individuals who service those industries.
7.20.2009 10:31am
Losantiville:
Thanks to the commies I'll be making the big bucks as a legal consultant for American physicians who want to "go bare" and set up cash-only practices to profit off of Natty Health.

No reason you have to pay malpractice insurance or waste all that time with approvals and billing. Nice surgical suite instead of a "hospital" (with flesh-eating bacteria outbreaks like the UK) and cash on the barrel head paid by those turned down by Obamacare. Cheaper too. Tax benefits for practitioners.

Today's Seasoned Citizens pay a higher percentage of their income out of pocket for health care than Seasoned Citizens did in 1964 before they became medical welfare queens. What a waste.
7.20.2009 10:32am
Danny (mail):
@ glangston

Auto insurance is mandatory for drivers, fire insurance may be mandatory for home owners, but they are not mandatory for people living in CA or the USA. And it's not single payer because the person getting insured pays. The "single payer" is the government, the government pays for everything in the case of health care. There is virtually no cost for the patient. The same is not true of the others (although reducing university tuition to $2000 per semester or 400-800 euros (600-1200 US dollars) at a European university is an equivalent principle
7.20.2009 10:59am
PLR:
I'm uninsured. I have no dependents, and very little prospect for ever having any. Running without insurance allows me to save a significant amount of money. As best I can tell, that's my best chance for finding a way out of my misery.

I realize that there aren't many people who would present this in such stark terms. I also realize that my perspective on bonding is something most people (including myself) find distasteful. "Sometimes life can just suck."

I'm doing the best I can with what I have. I'd really appreciate people not making things even more difficult, even if they're "trying to help" me.

Please keep your laws off my body.

I don't see how inserting the U.S. government as the financial intermediary puts any laws on your body. If you choose not to see a provider, so be it. And if you change your mind when your appendix ruptures, you shouldn't object to a system designed to produce lower pricing to the patient.
7.20.2009 11:26am
pmorem (mail):
I don't see how inserting the U.S. government as the financial intermediary puts any laws on your body. If you choose not to see a provider, so be it. And if you change your mind when your appendix ruptures, you shouldn't object to a system designed to produce lower pricing to the patient.

I do object. My body, my choices. You want to choose how my body is treated and cared for.

"Progressives" seem to be real big on "empathy". I don't think you can put yourself in my shoes and actually understand. If you could, when you stopped screaming you'd know just how meaningless that particular risk is to me.

I suspect that people like me can't possibly exist in your universe.
7.20.2009 11:52am
Grover Gardner (mail):

I suspect that people like me can't possibly exist in your universe.


On the contrary, we're all too aware that you do exist, and that someday you'll cost us money, whether you think you will or not.
7.20.2009 12:02pm
fishbane (mail):
Besides, there's somewhat of a correlation between ability to benefit from an education and ability to earn enough to pay for an education, isn't there?

So those who can earn enough to pay for an education are more likely to deserve to have an education, because they would benefit from it?

What?
7.20.2009 12:02pm
wfjag:

you shouldn't object to a system designed to produce lower pricing to the patient.

Were that true. The record of the federal government actually controlling the costs of any program is poor to completely awful. The Obama Administration is shaping up as no better in this area, and possibly worse than prior administrations. Check out Drudge Report on reports on the Recovery.gov website -- the one that is supposed to be telling us how well the "stimulus" dollars are being spent:

RECOVERY.GOV // AWARDED: $2,531,600 FOR 'HAM, WATER ADDED, COOKED, FROZEN, SLICED, 2-LB'...
RECOVERY.GOV // AWARDED: $1,191,200 FOR '2 POUND FROZEN HAM SLICED'...
RECOVERY.GOV // AWARDED: $351,807 FOR 'REPLACE AND UPGRADE THE DUMBWAITER'...
RECOVERY.GOV // AWARDED: $1,562,568 FOR 'MOZZARELLA CHEESE'...
RECOVERY.GOV // AWARDED: $5,708,260 FOR 'PROCESS CHEESE'...
RECOVERY.GOV // AWARDED: $16,784,272 FOR 'CANNED PORK'...
RECOVERY.GOV // AWARDED: $1,444,100 FOR 'REPAIR DOOR BLDG 5112'...
RECOVERY.GOV // AWARDED: $541,119 FOR 'INSTALL TRAFFIC SIGNAL'...

(Oh, and check out the "Home » About > The Act" on Recovery.gov:


The Act

Take a big step toward computerizing Americans’ health records, reducing medical errors, and saving billions in health care costs;


I guess we've already saved or created Billions in Health Care Costs savings. Can someone give me an example? I'd hate to think that this was a hollow claim by the Government of The One.

Also check out the report on Drudge Report how it is being proposed to to lower the costs of Obamacare -- simply pass additional unfunded mandates to the states via Medicaid. On NPR this morning another proposal was being discussed -- reduce reimbursements by 20% while requiring all physicians to accept Obamacare patients. All of the proposals involve some form of a price control to achieve "savings".

I thought that Nixon had thoroughly discredited wage and price controls. Apparently, not. Looks like The One learned economics from Tricky Dickie.
7.20.2009 12:10pm
Thorley Winston (mail) (www):




but the results in terms of life expectancy, infant mortality etc are not reflected by that higher spend




Infants are considered alive here if they are alive when they are born, not only if it's convenient that they remain living.




True, moreover people need to keep in mind that whenever someone talks about how supposedly bad the infant mortality rate is compared to other countries that we are talking about very small differences.

For example the infant mortality rate reported in the United States is 0.626 percent whereas Singapore (the country which reports the lowest infant mortality rate) reports an infant mortality rate of 0.231 percent.

Even if we ignored differences in ethnicity (Asians in the United States tend to have a lower infant mortality rate than Whites, Hispanics or Blacks) and reporting, we’re still talking about a difference of less than four-tenths of a percent.
7.20.2009 12:12pm
JK:

I do object. My body, my choices. You want to choose how my body is treated and cared for.


Are you under the impression that any proposed plan includes "forced treatment"? The Government might be putting its hands in your wallet, and that can certainly be a reasonable thing to get annoyed about, but I don't think there's any real risk of being forced to get treatment.
7.20.2009 12:15pm
Bruce Hayden (mail):
Now the right is just stalling. Sorry, your time is up. There are over 40 million Americans with no health coverage at all right now, and untold millions who fear losing their coverage or that it will be inadequate
This is getting a bit tiring. The 40 million (or more often 47 million) figure was created by combining a lot of different groups, many of which are not all that sympathetic. After dropping off 10 million or so illegal aliens, all the 20 somethings who can afford health insurance, but spend their money on beer instead, those already eligible for some federal or state program, and the frictional uninsured, you have maybe 10 or so million hard core uninsured, and if you start there, you quickly discover that it would be far cheaper and easier to just loosen up the requirements a little bit for state and/or federal programs like Medicaid, Medicare, etc.
7.20.2009 12:16pm
Bruce Hayden (mail):
For any proposing a single payer system, or something close, I am interested in your reasons why you think that there would not be both rationing and politically mandated coverages that bear little relationship to actual need or economics.
7.20.2009 12:19pm
SeaDrive:

The record of the federal government actually controlling the costs of any program is poor to completely awful. The Obama Administration is shaping up as no better in this area, and possibly worse than prior administrations.


I agree the record is bad, but I put the blame on the legislative branch, not the executive branch.
7.20.2009 12:22pm
PLR:
For any proposing a single payer system, or something close, I am interested in your reasons why you think that there would not be both rationing and politically mandated coverages that bear little relationship to actual need or economics.

Rationing would be a feature, not a bug.

Not sure what you mean by "politically mandated coverages." Abortion services? Gender reassignment?
7.20.2009 12:24pm
Oren:

I'm uninsured. I have no dependents, and very little prospect for ever having any. Running without insurance allows me to save a significant amount of money. As best I can tell, that's my best chance for finding a way out of my misery.
[...]
Please keep your laws off my body.

Only if you sign a waiver stating that if you are in an traumatic emergency without any/sufficient coverage (i.e. hit by an uninsured driver, stabbed by a mugger, ...) that the ER can let you die unless you can post a bond for the cost of treatment.

Otherwise, you are essentially freeloading off the rest of us that do pay for the E.R.
7.20.2009 12:28pm
pmorem (mail):
On the contrary, we're all too aware that you do exist, and that someday you'll cost us money, whether you think you will or not.

You obviously know me better than I could possibly know myself. I clearly must yield to your superior knowledge and wisdom, and grovel before your mighty power.

That's what this is really about, isn't it? Your ability to compel everyone to act in the manner you deem appropriate?
7.20.2009 12:28pm
George Smith:
JHU BME - You have analyzed your situation and made an individual decision about your health care and have assumed responsibility for your decision. We just can't have that, and we will soon put a stop to such heresy.
7.20.2009 12:29pm
rosetta's stones:
True, moreover people need to keep in mind that whenever someone talks about how supposedly bad the infant mortality rate is compared to other countries that we are talking about very small differences.

For example the infant mortality rate reported in the United States is 0.626 percent whereas Singapore (the country which reports the lowest infant mortality rate) reports an infant mortality rate of 0.231 percent.

Even if we ignored differences in ethnicity (Asians in the United States tend to have a lower infant mortality rate than Whites, Hispanics or Blacks) and reporting, we’re still talking about a difference of less than four-tenths of a percent.


The 1st rate is about 3-times greater than the 2nd rate. This is statistically significant. Sorry.
7.20.2009 12:38pm
zuch (mail) (www):
Why should states be forced to take any of these plans (particularly when other states are not)?

Why should the Republicans be afforded two plans? Elections have consequences.

Cheers,
7.20.2009 12:46pm
dan:
Find five states to volunteer. Each state adopts one of the proposals. Wait several years. See if any of these proposals worked out well, and if so, which one seems best, and why. Learn from this trial and error, and then pass a national health bill, instead of trying an untested, one-size fits all solution for 20% of the American economy.

Or instead, how about we look at 50 or so nations that have different systems and see which one works best? Oh, wait -- we can already do that! So we already have the data.
Q: Why not just adopt the system that works best in the
world?
A: Because stubborn conservative Americans simply don't believe that anything Not Invented Here could possibly be any good.

For any proposing a single payer system, or something close, I am interested in your reasons why you think that there would not be both rationing and politically mandated coverages that bear little relationship to actual need or economics.

For all those complaining about "rationing" in single-payer systems: we have tons of rationing right now. Insurance companies decide what doctor you get to go to, what services are covered, whether you get a particular drug or some less-expensive alternative, how many tests you can have, etc. The difference is that the insurance companies are totally unaccountable: in many areas there is only one insurance company available, and even if there is choice in a geographical region, your employer likely offers only one company. So the totally unaccountable insurer rations your care -- based on profit potential for the insurer, which is directly contrary to your interests as an insured. I would rather have an elected body make the decisions -- based on re-electability. At least then the incentives are aligned.
7.20.2009 12:46pm
zuch (mail) (www):
BGatesLSounds like somebody's practicing to become a Government Health Care Allocator.... as opposed to a private, for-profit health care 'allocator'....

Cheers,
7.20.2009 12:47pm
dan:
Here is perhaps a more useful but incomplete set of criteria for judging health care systems:

1. Is the country a source or a destination for medical tourists? For example, do single payer citizens (Canadians) come to the US for breast cancer surgery (Stronach) or difficult pregnancies (Jepp), or is the flow the other way?
2. Is the breast cancer survival rate higher or lower?
3. Is the overall cancer survival rate higher or lower?
4. Is the wait for a hip replacement longer or shorter?
5. Are long waits for CAT and MRI equipment the norm?
6. Does the government hide or delay the availability of new and more effective but more costly treatments?


And here is your answer: America still is far worse, on the cancer survival metrics you provide, than many other countries like Portugal, Ireland, etc. See, e.g. http://www.newsweek.com/id/128635

And as far as medical tourism goes, I guess you should be advocating that we adopt the medical system of India or Indonesia, which are the hot destinations for Americans who are seeking affordable care. See, e.g., http://www.usatoday.com/money/
7.20.2009 12:54pm
pmorem (mail):
Only if you sign a waiver stating that if you are in an traumatic emergency without any/sufficient coverage (i.e. hit by an uninsured driver, stabbed by a mugger, ...) that the ER can let you die unless you can post a bond for the cost of treatment.

Otherwise, you are essentially freeloading off the rest of us that do pay for the E.R.


That doesn't sound so bad. How could I go about doing that?
Carrying "Catastrophic Medical Insurance" would probably be more reasonable, but as I understand it, that option would go away under "health care reform".

I do use medical services from time to time. I've had medical insurance at various times in the past, and enough samples both ways to make some evaluation of the result. What may come as a surprise is that I get better and cheaper (30% discount for cash) medical care when the doctors know I'm paying for it myself.
7.20.2009 1:02pm
A.C.:
I was one of the uninsured in my 20s, and it was the rational decision at the time. I was earning about $20K a year, and had savings of about $3,000. My health care expenses were usually in the range of $300 to $500 a year, depending on whether I got a cavity or needed new glasses. I figured I could dip into savings and/or work out a payment plan to cover anything up to about $5,000. Higher than that, I had no real idea. I would have purchased major medical if I could have gotten it for under $1,000 a year, but I couldn't.

And the thing is, I wouldn't have wanted anyone to interfere with the choices I made and the risks I ran at the time. My decision was not to carry health insurance that I probably didn't need, but rather to get an education that would allow me to earn a lot more money before I turned 30. That worked out fine -- I got the education, started getting better jobs, and made it a priority to get health coverage even before I moved from a futon to a real bed.

The notion that people who don't spend for insurance are just buying beer is an insult. Plenty of people can do the math and figure out that fully loaded health plans are a lot more coverage than they need. I'm in my 40s now, and I don't need (and never expect to need) at least 3/4 of what my current health plan covers. And some of the stuff I do need isn't covered, so I pay out of pocket anyway. I'm seriously considering moving back to a higher level of self-insurance, with a high-deductible plan and a medical savings account.
7.20.2009 1:03pm
wfjag:

BGatesLSounds like somebody's practicing to become a Government Health Care Allocator.... as opposed to a private, for-profit health care 'allocator'....

Or, how about a Qui Tam Litigator. See Medicare qui tam: a health care bill surprise by Walter Olson on July 17, 2009 at http://overlawyered.com/

It looks like those dasteredly Republicans got the provision removed from the House Version on Friday. But, maybe it will be slipped back in in the Senate-House Conference version -- and quickly passed before anyone reads the bill. I do love the race to the courthouse provision in the proposal, along with the guaranteed attorneys fees and required cooperation by Medicare in providing documents and information to Qui Tam Plaintiff's attorneys (which apparently is cooperation that attorneys representing injured persons whose med care was covered by Medicare will not receive, unless they agree to collect the fed's lien without cost to the US -- which is the current law). Looks like it will be a great boondoogle for those who know of it. Olsen's post is quite enlightening. Amazing what you find when you actually read the proposed Obamacare legislation.
7.20.2009 1:04pm
PLR:
Check out Drudge Report on reports on the Recovery.gov website -- the one that is supposed to be telling us how well the "stimulus" dollars are being spent:

RECOVERY.GOV // AWARDED: $2,531,600 FOR 'HAM, WATER ADDED, COOKED, FROZEN, SLICED, 2-LB'...

Drudge? Give me a break.
7.20.2009 1:04pm
Danny (mail):
Exactly, it's a rare Canadian who goes to the US for care. Certainly many more Americans go abroad to get medical care than the reverse (the American medical tourists abroad). Most of the foreigners who come to the US are very wealthy and after some experimental treatment available only at a particular hospital in the US (because the USA IS a leader in research still), but sometimes Americans have to go for an experimental treatment in Europe, depending on the problem. In either case we are talking about a small number of privileged people with specific circumstances. If you are going to have a regular operation you are often better off abroad (where you can find US trained doctors, too, anyway).
7.20.2009 1:06pm
zippypinhead:
"Wait several years."
Uh, huh... I don't know why, but upon reading this I immediately thought of that infamous 1923 quote from John Maynard Keynes, which (even for us non-Keynesians) seems particularly useful as a rejoinder to both this post and to various "solutions" being posited in the health care debate generally:

"In the long run we are all dead."
7.20.2009 1:07pm
Bruce Hayden (mail):
Not sure what you mean by "politically mandated coverages." Abortion services? Gender reassignment
Things like spending more on AIDs research than on heart attacks, though the later kills maybe 10x as many people every year. I can see mandating coverage for abortion and gender reassignment surgery, but denying coverage for knee replacements after a certain age.

We have seen this at the state level for years, with one coverage after another, most totally irrelevant to most of us, being mandated, one after another. The chiropractors were not that bad, all by themselves, but they also added aroma therapy, substance abuse treatments, mental health, and pretty soon, the premiums are skyrocketing.

My point here is that right now, to some extent, the market determines what is covered and what is not. It would of course do better at this, if there weren't state mandates. But when you go to a single, government, payer, the determination of what is covered and what is not, will to a great extent enter the political realm. If you want aroma therapies covered, then get together with a lot of people who have similar objectives, and bribe yourself some members of Congress.
7.20.2009 1:17pm
Bruce Hayden (mail):
The notion that people who don't spend for insurance are just buying beer is an insult. Plenty of people can do the math and figure out that fully loaded health plans are a lot more coverage than they need.
It wasn't aimed as an insult, but rather, to emphasize a point.

And, I have to admit, that a lot of those I know who don't carry health insurance do so for just the reason I gave. It is so bad sometimes that I remember one guy who refused a $5 a month accident policy provided by his employer, who worked at a ski area. And, of course, he was injured on his day off, and if he had had that accident policy, he could have gone back to work on skis. He didn't, and so couldn't get the CAT scan he needed, and spent the rest of the season riding the lift up and down to work. And that was the reason that all the rest of the guys he was working with weren't spending the $5 a month either - they believed themselves bullet proof, and had better places to spend that money.

Yes, there are those who make the decision rationally. I just don't think that I know any of them.
7.20.2009 1:22pm
Bruce Hayden (mail):
Exactly, it's a rare Canadian who goes to the US for care.
I am not sure how you know this. Over the last year, we have had a lot of people on our northern border tell of all the Canadians they see coming down here. I would guess that the debate is about anecdotes on both sides.

And, yes, Canadians travel to other countries too. For example, we have a ski guide who needed knee work. It is something that is often done immediately here, but he was told that it would be about two years before he got to the top of the list in Canada. And, given what he did for a living, that would have meant that he couldn't work for that time. So, he went to India to have it done. It was done quickly and professionally for an amount that was less than he would have lost by not working those two years.
7.20.2009 1:29pm
JK:

Drudge? Give me a break.

Thanks for the link PLR
7.20.2009 1:31pm
Houston Lawyer:
As far as politically mandated coverages, I recall several years ago that Washington State adopted a protocol setting forth priorities in health care coverage. Some of these protocols denied or limited coverage to those whose conditions were self inflicted, such as cirrhosis of the liver for alcoholics. They were forced to change these protocols because of the ADA.
7.20.2009 1:32pm
A.C.:
How would the CAT scan have fixed the guy in question? I assume there was some surgery or treatment involved that would have let him recover faster. That's the interesting variable... a CAT scan that leads to "stay off it for a season and let it heal" isn't going to break the bank.

I reckon that people who work at ski slopes may perceive risk a little differently than the rest of us, though. Not that it's horrifying. A lot of people are way too risk-averse for my tastes. But your sample might not be representative.
7.20.2009 1:35pm
Danny (mail):

Things like spending more on AIDs research than on heart attacks, though the later kills maybe 10x as many people every year.


Maybe because they are trying to develop a vaccine that could save lives. Are heart attacks really such a mystery as to justify such research? Aside from genetics, they are caused by the fat- and sugar-filled chemical "food" popular in America.

When I call home to the USA, my friends tell me of paying 500$, even 800$ to insure themselves and their kids. And in my home town the average per capita income (not the poverty level) was $20K per year. So people really cannot afford it.
7.20.2009 1:36pm
Anononymous314:
"Let the Democrats put forward three different health care reform proposals. Let the Republicans put forward two different proposals. Find five states to volunteer."

Right, under the 9th and 10th Amendments, the States have control over interior matters.

Each state adopts one of the proposals. Wait several years. See if any of these proposals worked out well, and if so, which one seems best, and why."

Right, the purpose of Federalism is to allow different States to try different methods, and if one State infringes too greatly upon the people's rights and liberties, the people may move to a better State.

"Learn from this trial and error, and then pass a national health bill, instead of trying an untested, one-size fits all solution for 20% of the American economy."

Um, what the hell...?
7.20.2009 1:37pm
33yearprof:
Here's a better proposal.
Here's a deal.

I'll support any national health plan that has these two structural elements designed to insure that it really is a good deal for all Americans. Neither I nor you can outsmart the congressmen or industry lobbyists writing this monster so let's harness the self-interest of those in power and in industry to everybody's horse.

1. The single national American Health Care plan must REQUIRE the President, Cabinet Members, Congresspersons, federal employees (and retirees) and their families, to participate in it with IDENTICAL options offered to ordinary citizens. "Equal protection" from injury and disease. It's only FAIR.

2. The single national American Health Care plan must ALLOW everyone -- those with current individual or employer coverage, those switching jobs, those who are self-employed, those who cease working temporarily or permanently, those new to employment, and anyone who wants to -- to FREELY select and pay for unrestricted private health care insurance through an HSA or otherwise. "Freedom of choice" regarding coverage. It's only FAIR.

3. [Reserved.] We'll see what other "special privileges" need to be extended to ordinary folk. It's a 1000+ page bill only now seeing the light of criticism. I can guarantee that there are both more "goodies" and "traps" hidden in the bill.
7.20.2009 1:48pm
Spartee:
How much of my life must I work to earn money to pay for another person's health care before I can keep what is left over?

A percentage, please, so I might decide now whether I want to bother working at all. Because until I know what my tax structure is going to be, why would I plan to invest much in my own future productivity?

I'm serious. To those proposing that I must first send my money earned to others, before I can spend it on myself and my kids, how much must I send to others?

I have never gotten an answer to that question, no matter how many liberals I ask. They seem to believe that it is offensive to even ask the question. To me, it seems like a perfectly obvious question any investor would ask--and we are all investors at some level.
7.20.2009 1:51pm
John Moore (www):


Things like spending more on AIDs research than on heart attacks, though the later kills maybe 10x as many people every year

.



Maybe because they are trying to develop a vaccine that could save lives. Are heart attacks really such a mystery as to justify such research? Aside from genetics, they are caused by the fat- and sugar-filled chemical "food" popular in America.


Research on heart attacks and related issues has resulted in dramatically extending the lives of a very large number of patients, and improving the quality of life for more.

The idea that we know all there is to know about the causes of heart attacks is extremely naive. For example, the idea that they are caused by the food in America is simply wrong in a large percentage of the cases. Genetics is more important than diet, but both are important.

For example,Jim Fixx was a well known advocate of healthy life styles, and practiced them extensively. He is one of the people responsible for the healthy food and exercise movement in the US. He died at age 52 of a massive heart attack. Perhaps his life style extended his life, but genetics won out in the long run.

Hence there is a lot of research yet to be done in the area. The pace of discoveries in the area of circulatory diseases is remarkable.

AIDS, on the other hand, is a disease of behavior (for most people). It also has a much lower incidence in the West than heart attacks. The huge amount of money diverted into AIDS research was directly driven by political pressure. Whether, in retrospect, that research was worth it remains to be seen (it had many benefits aside from its direct goal of making AIDS survivable).
7.20.2009 2:05pm
rarango (mail):
I keep seeing life expectancy and infant mortality trotted out as somehow they are measures of the health care system. Stop being lawyers and start becoming epidemiologists and you might get a clue. If you want a measure of the effective of health care, look at survivability rates following medical intervention. Life expectancy and infant mortality are crutches for the uninformed.
7.20.2009 2:06pm
Connie:
"The chiropractors were not that bad, all by themselves, but they also added aroma therapy, substance abuse treatments, mental health, and pretty soon, the premiums are skyrocketing."

And why shouldn't diseases of the brain be covered the same as diseases of the heart?! I propose we cover mental illness, and drop, oh, say, treatment of prostate disorders to balance out the spending.
7.20.2009 2:17pm
Danny (mail):

AIDS, on the other hand, is a disease of behavior (for most people).



So are heart disease, cancer and diabetes for most people, otherwise they wouldn't have shot up so much in recent years. But the gov't doesn't want to harshly criticize Americans' horrible, worst in the world eating and drinking habits because Americans want to be patted on the back and told they are the best
7.20.2009 2:17pm
Recovering Law Grad:
The cries of "rationing" are a total canard. As was aptly pointed out in the NYT over the weekend, we have have rationing now. Healthcare is allocated across the populace based on abilitiy to pay. Those who can't pay, don't get healthcare. Unfortunately, no conservatives want to discuss the implications of this because they are dishonest. If there's a Republican in Congress who is willing to say that people should die because they can't afford healthcare, please tell me who that person is.
7.20.2009 2:21pm
Danny (mail):
PS And especially they won't stop pandering to the corn lobby, subsidizing corn and corn syrup which makes the junk food artificially cheap compared to real food
7.20.2009 2:22pm
JK:
Spartee, the current tax code is available for your viewing pleasure. It's pretty complex, but an accountant could answer most of your questions, although there will be a hand full of ambiguities that even a tax lawyer couldn't answer completely. If you're talking about a definite promise of future tax codes, you might want to consider the ill, as well as beneficial, consequences of promising an unchanging tax code.

You may object to having your tax money spent on "other people," while I object to spending my tax money on military projects unnecessary to national defense. I don't see why you have some particularly meritorious claim to know the future costs of government spending in an area that you disagree with just because that money "goes to other people."
7.20.2009 2:23pm
fdcol63 (mail):
Quite simply - uncontrolled immigration will lead to uncontrolled spending in a universal health care system.
7.20.2009 2:27pm
Abdul Abulbul Amir (mail):


it's a rare Canadian who goes to the US for care


When I was last in Toronto, the local news reported that about 10 women a year were sent to the US with problem pregnancies due to lack of capacity. Yes, ten out of the population of Canada is rare. Universal health care is not universal if you have can't treat routine occurances in your own population. Problem pregnancies are not at all rare.



America still is far worse, on the cancer survival metrics you provide, than many other countries like Portugal, Ireland, etc.


But much better than other single payer countries. Ireland has a population of a bit over 4 million and Portugal is short of 11 million. Small populations almost always produce the outliers. Picking Ireland and Portugal only shows skill at cherry picking.


Cancer Survival Rates Improving Across Europe, But Still Lagging Behind United States
7.20.2009 2:36pm
JK:
AAA, you site a random local news report, and then accuse someone else of cherry picking?
7.20.2009 2:40pm
Bruce Hayden (mail):
The cries of "rationing" are a total canard. As was aptly pointed out in the NYT over the weekend, we have have rationing now. Healthcare is allocated across the populace based on abilitiy to pay. Those who can't pay, don't get healthcare.
There are several not quite truths in that statement.

First, health care is not allocated across the populace based on ability to pay. There are plenty of programs available to the poor and the elderly that make this statement inaccurate. Also, emergency rooms have to treat anyone who walks in their doors.

Yes, some of those with less money don't get as much care, and maybe do die a bit earlier as a result. But it isn't black and white, or even close.

So, why shouldn't those who work hard for their health care have better health care than those who don't? Those who went to college, then graduate school, instead of starting their families at 17 have some advantages and payback for their hard work and delayed gratification?

And why isn't the individual determination of all this superior to the unnamed bureaucrat, or bribed politician, making those decisions?

The reality is that there is not unlimited health care available. And the less we tie the amount supplied to the amount that people are individually (or through their insurance) are willing to pay for, the bigger the disconnect between supply and demand.

So, yes, I do think that those who put themselves in a position to pay for adequate health care should get better health care than those who don't. And if that means that they live a bit longer as a result, then that is to some great extent a consequence of life choices made by those who aren't paying for their own insurance.

I should also note that they also get to live in bigger houses, take more trips, have nicer cars, and send their kids to better colleges. I don't think any of this is the least bit unfair.
7.20.2009 2:41pm
Danny (mail):
@ Abdul

Nonsense
7.20.2009 2:44pm
JIm (mail):
How about 2 simple requirements to universal health care plan.

1. It is the one any only option for all federal emplyees.

2. It is totally funded by the users.
7.20.2009 2:49pm
dan:
How much of my life must I work to earn money to pay for another person's health care before I can keep what is left over?
...
To those proposing that I must first send my money earned to others, before I can spend it on myself and my kids, how much must I send to others?


Who, exactly, is proposing that? Personally, at the same time as I pay a huge % of my income to the state and feds, I also keep a huge % of my income to spend on "myself and my kids." In what fantasyland is someone proposing that you send all of your income to "to pay for another person's health care before [you] can keep what is left over"? I, and everyone I know, already gets to "keep what is left over" every 2 weeks (or quarterly for you SBOs).
7.20.2009 2:50pm
Thorley Winston (mail) (www):

Quite simply - uncontrolled immigration will lead to uncontrolled spending in a universal health care system.



I don’t know about that, although it is worth noting that whenever someone says that there are “46 million people in the United States without health insurance” they’re including about 9-13 million illegal aliens in that number. And about 10 million people who are already eligible for Medicaid or SCHIPS but don’t enroll in the program until they need or decide to go to the doctor.
7.20.2009 2:50pm
Baserunr (mail):
I know it sounds dumb, but just where in the Constitution is the Federal Government granted the ability to Nationalize Healthcare?
7.20.2009 2:51pm
Recovering Law Grad:
Baserunr -

You're right - it sounds dumb.
7.20.2009 2:53pm
rarango (mail):
Danny: nonsense is using life expectancy and infant mortality to make inferences about the health care system. I am guessing you are not an epidemiologist.
7.20.2009 2:56pm
Here:
Why doesn't anyone mention Singapore's health system as a model? Isn't it the most efficient in the world and one of the most highly rated? Man that's a tough question. I wonder what the answer is?
7.20.2009 2:57pm
Anon1111:
<blockquote>
@ Abdul
Nonsense
</blockquote>

Did you mean to link to that article? Abdul was talking about cancer survival rates, and you refuted his claim with a link to WHO rankings which are: (1) politically driven, (2) inaccurate since they don't account for behavioral differences like driving and playing with guns and such, and (3) even if you dispute (1) and (2), are based on total medical performance, not cancer survival rates.

<blockquote>
AAA, you site a random local news report, and then accuse someone else of cherry picking?
</blockquote>

Citing a "random local news report" that represents a broad survey of data isn't the same thing as picking two outliers in a data set and basing an argument on that.

Picking Portugal and Ireland, saying that they have better cancer survival rates than the US and therefore, US medical care is bad is like saying that Tiger Woods sucks at golf because he couldn't even make the cut at the 2009 British Open when even 59 year old golfers that won their last major last century can make the cut.

There is no serious dispute that in general, if you have cancer, you will live longer in the US than anywhere else. Maybe that isn't important, maybe keeping 62 year old retirees alive an extra 10 years isn't as important as controlling costs.
7.20.2009 2:59pm
dan:
Bruce:


The cries of "rationing" are a total canard. As was aptly pointed out in the NYT over the weekend, we have have rationing now. Healthcare is allocated across the populace based on abilitiy to pay. Those who can't pay, don't get healthcare.



There are several not quite truths in that statement.
...


I agree that allocation by ability to pay is not an absolute rule in the U.S.

But there is tons of healthcare rationing in the U.S., even for those who have the best health insurance available:
For every single procedure, an insurance company bureaucrat gets to decide whether you get the procedure, what tests it will allow to be performed, what prescriptions you are allowed to take, how many days you are allowed to stay in the hospital, what doctor you can see, etc. That's rationing! And these decisions are made not by doctors, but by profit-motivated bureaucrats.

Health care is already heavily rationed in the U.S. I would rather it be rationed by an elected panel than an unaccountable bureaucrat seeking to increase profits for a non-competitive monopoly.
7.20.2009 3:00pm
PQuincy1:
JHU BME claims it is economically rational for him/her to eschew health insurance, and self-insure on the basis of his/her evidently substantial personal fortune.

But it's not economically rational, because under the current system, individual patients are billed bizarrely inflated costs per procedure -- costs that the insurance carriers of insured individuals pay only about 20% of (judging from the billing statements I suffered during my one year on commercial insurance rather than Kaiser, recently).

I had a preventative procedure (which was misbilled as diagnostic, and which the insurance company refused to correct, costing my employer hundreds of extra dollars, by the way): the bill showed billings on the order of $4000, and payments of about $800. I was not billed for the difference, notably.

Is it rational to expose one's (apparently) sizeable personal fortune to the possibility of an expensive accident or disease, while also paying 400% of the actual market cost for every little thing that takes one to the doctor?

Face it, our current health care finance system is spectacularly broken. This doesn't tell us what direction of reform would be optimal, but neither manly conservative self-reliance nor another five years of delay for more 'studies'(Bernstein's suggestion) are realistic answers.
7.20.2009 3:02pm
Squid (mail):
The constant arguments over costs and efficiencies and fairness are beside the point. Even if one could prove conclusively that insurance provided by the idiots in Washington DC was objectively better, it wouldn't change the fact that the idiots in DC don't have the authority to provide such coverage. Just because we've grown used to government over-reach in the past few generations doesn't mean that this over-reach is legal or acceptable.

I don't care how good the promised coverage might be. Until somebody shows me where the federal government is granted the power to provide health care, the argument is a non-starter.

Don't let arguments about numbers distract you from arguments about principle.
7.20.2009 3:03pm
Not-so-random observer:
I recently had surgery to remove a benign tumor; the hospital's charge was $47,000. This didn't include the surgeon's or the anesthesiologist's bills nor all the other charges for tests, medications, supplies, etc. etc. Nor did it include the pre-op doctor visits, CT scans and other diagnostic procedures.


Sooo . . . you made someone else cough up fifty grand for an ailment that wasn't even life-threatening?
7.20.2009 3:03pm
PlugInMonster:
Actually we already have national health care with Medicare/Medicaid and all emergency rooms mandated to treat anyone. What the Alinskyites want is to make it universal national health care.
7.20.2009 3:05pm
Lior:
A few remarks:

1. As far as I can see, the main point of a single-payer system is social welfare (=redistribution of wealth). A national system based on the idea of each person paying their own (actuarial) costs is simply wasteful.

2. There is certainly disagreement on whether social welfare (me paying your medical costs) is just or justified -- and this is whether most the debate should start. In particular, Peter Singer's excellent article describes the two alternatives: rationing by ability to pay compared to rationing by willingness of others to pay.

3. For those discussing the Canadian system: do you realize that in Canada it's illegal for doctors to charge for covered treatments? In other words, if the government medical system covers treatment X for condition Y, and there is a long waiting period, then no doctor is allowed to sell his service giving treatment X. Of course, he is allowed to give treatment X' instead, as long as X' is not covered by the government plan (say because X' is more expensive than X). Once governments become market players, they immediately start using government powers to interfere with the competition, and the same will happen in the US. For example, the proposed legislation would require insurersto cover all applicants, and forbid them from limit coverage for those with pre-existing conditions. This is being sold as "helping those with private insurance" but amounts to increasing the costs on private insurers who wish to compete with the government.

4. On the other hand, the US as whole has a much more generous social-welfare system than Canada; so I'm not sure it's right to treat the health-care system in isolation.

4. The social-welfare aspect is why DB's idea isn't going to work as a trial for a national plan: if a generous plan is only implemented in one state, there will be an incentive for the poor to move there to take advantage of this coverage, especially for those with existing medical conditions. The resulting bias will invalidate any results one would hope to draw from the experiment.
7.20.2009 3:06pm
dan:
Anon111:

There is no serious dispute that in general, if you have cancer, you will live longer in the US than anywhere else.


Maybe among those who only read Drudge or Fox News, there is no serious dispute on this issue. Then again, there is no serious dispute on any issue for you people.

Try doing some research about cancer survival rates before spouting off next time. For instance:

The [U.S.] five-year survival rate for cervical cancer? Worse than in Italy, Ireland, Germany and others, finds the OECD. The survival rate for breast cancer? You'd do better in Switzerland, Norway, Britain and others. Asthma mortality? Twice the rate of Germany's or Sweden's.

http://www.newsweek.com/id/128635
7.20.2009 3:07pm
PQuincy1:
@ Bruce Hayden, who says: "So, yes, I do think that those who put themselves in a position to pay for adequate health care should get better health care than those who don't."

In what universe will this not be the case after whatever health care finance reform we get is in place? It's clear that both universal mandates and public options would put in place a standardized minimum level of care, but why would either block those who worked hard or who inherited wealth from spending more on their own? Even in Great Britain, with one of the more socialized single payer plans in existence, private physicians who charge their patients continue to thrive, from all I hear.

The claim that universal care would prevent the wealthy from spending more of their own money -- in the United States! -- is absurd. The question of what goes into the standard obligatory plan is a genuine one, I agree...and the political pressure from doctors, pharmaceutical companies, the AARP and others to stuff with every possible goodie will be large, I also agree. But even if we get a fairly rich standard plan, I find it inconceivable that the legislature would ever pass, or the courts uphold, a plan that prevented people from spending their own money beyond that plan.
7.20.2009 3:09pm
PlugInMonster:
I like how the leftists cite health stats from EU countries without adjusting for demographics and the obestity epidemic in America. You can't imagine how much disease in America is caused by obesity or near-obesity. That has nothing to do with what kind of health-care system you have. That's just basic education failure and/or a moral failure on the part of Americans.
7.20.2009 3:13pm
rarango (mail):
The problem with aggregate statistics like infant mortality and life expectancy is the heterogenity of the US population. The basic principle in epi is to compare like numerators and demnominators. Similarly the infant mortality stats assume all nations use the WHO standard (which is a gasp or movement in the neonate). These criteria occur as early as the 6th or 7th month of gestation. There is considerable divergence among nations in reporting live births and the WHO does not do any investigative work--they merely accept the data provided.

For those who are wedded to Google as the sina qua non of search engines, pub med is a much better resource for medical and health care issues--and only about 50 percent of their citations end up in google.
7.20.2009 3:15pm
Constantin:

1. The single national American Health Care plan must REQUIRE the President, Cabinet Members, Congresspersons, federal employees (and retirees) and their families, to participate in it with IDENTICAL options offered to ordinary citizens. "Equal protection" from injury and disease. It's only FAIR.


Barack already promised us something like this the day before the election. And when he makes a promise, you can take it to the bank. To believe otherwise would be cynical, and he and his wife promised (!) that the age of cynicism in politics was over.
7.20.2009 3:20pm
Bruce Hayden (mail):
For every single procedure, an insurance company bureaucrat gets to decide whether you get the procedure, what tests it will allow to be performed, what prescriptions you are allowed to take, how many days you are allowed to stay in the hospital, what doctor you can see, etc. That's rationing! And these decisions are made not by doctors, but by profit-motivated bureaucrats.
Sure, but you seem to be suggesting that the rationing will somehow be less when it is done by budget obsessed government bureaucrats. And I don't think it will, by any stretch of the imagination.

First, those "profit-motivated bureaucrats" are not operating in a vacuum. At least for larger companies, etc., denying benefits that look to have been reasonable too much will often result in that company being dropped next year when contracts are renewed or relet. Everyone knows that an insurer can drive down its costs by denying coverage. But the purpose of coverage is to pay for needed health care, and if the costs are driven down too much by not paying for what is most needed, that company and its policies are liable to be dropped.

Secondly, if the denial is really unreasonable, then the insured has legal recourse when it is a private plan, but much less when it is public.

When my SO's insurance carrier tries to get her on another, cheaper drug, we fight it by showing that it doesn't work as well, and inevitably win. Same with procedures that they initially deny. Yes, we have had to go through some things that we knew wouldn't work. But in the end, after over a million dollars in health care costs, we have ultimately gotten everything she needed. Of course, having both lawyers and doctors working to make it happen helps.

But no matter how hard we tried, we couldn't get Medicare to pay for some procedures for her father, and so we went out of pocket. We had no leverage because it was the government.
7.20.2009 3:22pm
Danny (mail):

Danny: nonsense is using life expectancy and infant mortality to make inferences about the health care system. I am guessing you are not an epidemiologist.


I certainly am not. I can only comment as a non-expert but as someone who has lived in both systems.


do you realize that in Canada it's illegal for doctors to charge for covered treatments? In other words, if the government medical system covers treatment X for condition Y, and there is a long waiting period, then no doctor is allowed to sell his service giving treatment X. Of course, he is allowed to give treatment X' instead, as long as X' is not covered by the government plan (say because X' is more expensive than X). Once governments become market players, they immediately start using government powers to interfere with the competition, and the same will happen in the US.


This is not true in Europe (the countries I know at least). In most EU countries there is a single payer system AND there are private doctors offering similar procedures for people who don't want to wait. I thankfully haven't had many medical problems issues that would put me in frequent contact with doctors, but the times I have gone I have never experienced an inconvenient delay, nor has my boyfriend or his parents or any of my friends. My income taxes are slightly higher than in the US, but in the USA having to pay for social security and health insurance means that in the you get to keep less money for yourself in the USA.

I can hardly even find the interest to debate it, since for me it is so clear. Health care is on everyone's lips in the US. People are dissatisfied. In the European countries I have lived in there are all sorts of economic problems and debates, but one thing you never hear people complain about is health care. Nobody left-wing or right-wing ever says "wow, I wish we had things like in the US". I am not even tempted to scold people whose minds are closed to public health care as self-defeating, small minded nationalists, because having American-style health care is its own punishment.
7.20.2009 3:24pm
PlugInMonster:
rarango - I've tried to explain the heterogenity argument to a hippie-dippie liberal type. But it falls on deaf ears. They believe what they want to believe.
7.20.2009 3:25pm
Danny (mail):
Ack I need to stop re-editing my posts for forgetting to delete words
7.20.2009 3:25pm
Anon1111:
<blockquote>
Anon111:


There is no serious dispute that in general, if you have cancer, you will live longer in the US than anywhere else.



Maybe among those who only read Drudge or Fox News, there is no serious dispute on this issue. Then again, there is no serious dispute on any issue for you people.

Try doing some research about cancer survival rates before spouting off next time. For instance:


The [U.S.] five-year survival rate for cervical cancer? Worse than in Italy, Ireland, Germany and others, finds the OECD. The survival rate for breast cancer? You'd do better in Switzerland, Norway, Britain and others. Asthma mortality? Twice the rate of Germany's or Sweden's.


http://www.newsweek.com/id/128635
</blockquote>

Come come, no need to be so grouchy. I have done the research, and I know better than to cite a paragraph from a Newsweek op-ed column as evidence, and incomplete evidence at that. Saying that country X has a higher cancer survival rate than countries A, B, C... doesn't mean that country X has a higher 5 year survival rate than each and every country A, B, C... for each and every kind of cancer. Your op-ed just picks out a few countries and few kinds of cancers. We can play that game all day long and end up with absurd results (e.g.; Tom Watson is a better golfer than Tiger Woods, Raphael Palmeiro is a better Baseball player than Babe Ruth - after all, Palmeiro is the only baseball player in history with 8 or more seasons of 38 HRs and 100 RBI).

Overall, in general, US 5 year cancer survival rates than other countries, even those with single-payer systems. Just google "cancer survival rates by country" and the results are there, from a bunch of different studies.

<b>Besides</b>, the issue to begin with was life expectancy and how not correcting for homicide and car accidents and such and then comparing the results is silly. If you remove death from non-medical reasons, the US has a longer life expectancy than:

Australia
Austria
Belgium
Canada
Denmark
France
Germany
Iceland
Italy
Japan
Netherlands
Norway
Sweden
Switzerland
UK

Make all the arguments you want for single payer, but the idea that people will have better medical care outcomes on average is just not believable.
7.20.2009 3:28pm
Recovering Law Grad:
Bruce:

Do you believe we should do away with public transportation?
7.20.2009 3:33pm
JK:
Anon111, could I get a link to the life expectancy after removing death by homicide and car accidents? I'm not getting much from Google.
7.20.2009 3:34pm
PQuincy1:
@ Lior: "A national system based on the idea of each person paying their own (actuarial) costs is simply wasteful."

You've captured the dilemma of all insurance, which does indeed seek social welfare through redistribution -- but not from the rich to the poor, as you imply, but from the unlucky to the lucky. The key purpose of all insurance, as I see it, is simply risk pooling: I can't possibly save enough to cover the cost of a rare but possible affliction, whether a severe accident of some kind, or a serious medical problem. With very few exceptions, no one can do so.

Thus, redistributing medical risk among large pools of people -- the larger the better -- leads to a smoothing of that hard reality. Without insurance of some kind, whether private, public, or by decree opening emergency rooms to everyone, many people will simply die when they get injured or sick, because they will not be able, as individuals, to pay for the needed treatment.

Insurance allows distribution of risk: if it does more, it can and should be criticized and debated.

The dilemma, though, is in your word "actuarial". Imagine a world in which some sort of mega-Google allowed insurers to know the actual risk that each individual faced, precisely. Such an insurer, if a private company, would rationally charge that insured exactly as much as the risk was, making the insurance, as you note, meaningless and inefficient.

I therefore conclude: useful insurance depends on limited knowledge on the part of the insurer, who forgoes making the most precise possible calculation of each individual's risk.

How imperfect insurer knowledge should be for health insurance -- should age be an actuarial factor? zip code? weight and blood pressure? -- are essentially political problems that hinge on how much you want to favor the unlucky at the expense of the lucky.

Note: if I am lucky enough not to suffer major medical problems before I die, then the cost of my insurance will seem like a minor quibble. And if I'm unlucky enough to get a very expensive but treatable cancer, or get seriously injured in an accident I did not cause, then the redistributive mechanism of insurance will seem a godsend.

That's the calculation: the lucky get their luck, although they overpay for insurance; the unlucky get medical treatment that they could not otherwise pay for.

(Of course, politics also threatens to corrupt any system, public or private, as we can well see already: that's a separate, but important problem.)
7.20.2009 3:35pm
Bruce Hayden (mail):
The claim that universal care would prevent the wealthy from spending more of their own money -- in the United States! -- is absurd. The question of what goes into the standard obligatory plan is a genuine one, I agree...and the political pressure from doctors, pharmaceutical companies, the AARP and others to stuff with every possible goodie will be large, I also agree. But even if we get a fairly rich standard plan, I find it inconceivable that the legislature would ever pass, or the courts uphold, a plan that prevented people from spending their own money beyond that plan.
Why, because you don't want it to happen?

The problem with your "rich" standard plan with all the goodies in it, is that the money for all those goodies comes from some where, and that some where will inevitably be the denial of other health care that is not as politically connected.

My understanding of what has been proposed is that in order to provide a "market" for health care insurance, choice in policy provisions will be essentially eliminated. So, maybe, just maybe, you might be able to pay for your own procedures out of your own pocket, but you won't be able to carry a policy that pays out better. Or, indeed, one that pays out worse, such as the type of high deductible policy that I have right now with my HSA. The idea seems to be that in order for consumers to compare policies based on price, they have to be identical. They will then be able to compare apples to apples, since they know that there aren't any high priced oranges in their basket.
7.20.2009 3:35pm
Bruce Hayden (mail):
(Of course, politics also threatens to corrupt any system, public or private, as we can well see already: that's a separate, but important problem.)
No, it is not separate, and trying to separate it out is naive.
7.20.2009 3:37pm
Oren:


Only if you sign a waiver stating that if you are in an traumatic emergency without any/sufficient coverage (i.e. hit by an uninsured driver, stabbed by a mugger, ...) that the ER can let you die unless you can post a bond for the cost of treatment.

That doesn't sound so bad. How could I go about doing that?

Somehow I imagine that if you are actually stabbed you will find a way to rationalize life-saving care.


Carrying "Catastrophic Medical Insurance" would probably be more reasonable, but as I understand it, that option would go away under "health care reform".

I don't see why -- in fact, I imagined the sort of baseline level of insurance would be catastrophic.


I do use medical services from time to time. I've had medical insurance at various times in the past, and enough samples both ways to make some evaluation of the result. What may come as a surprise is that I get better and cheaper (30% discount for cash) medical care when the doctors know I'm paying for it myself.

Of course, they were also taking the risk that you might skip on the bill. Or die before getting around to paying it.
7.20.2009 3:37pm
Oren:

There is no way that saving $1,500 a year can adequately protect your financial well being if you end up in the hospital.

Screw their financial well-being, why can't the rest of us be angry with him as part of the representative class of people that routinely skip out of the bills and thus drive up the cost for the rest of us?
7.20.2009 3:39pm
dan:
Bruce:


When my SO's insurance carrier tries to get her on another, cheaper drug, we fight it by showing that it doesn't work as well, and inevitably win. Same with procedures that they initially deny. Yes, we have had to go through some things that we knew wouldn't work. But in the end, after over a million dollars in health care costs, we have ultimately gotten everything she needed. Of course, having both lawyers and doctors working to make it happen helps.


And you are standing up for this system? Damn. I have had a similar situation -- over $1.2 mil. in health care costs in 1 year for my son. Got outrageous bills that the insurer refused to pay. Spent months of my own time fighting to get it covered.

I just don't think it should be that hard to get what I pay for in insurance. And after my experience, unfortunately, yes: I trust the government far more than private insurers. They're nothing but crooks and liars.
7.20.2009 3:44pm
Bruce Hayden (mail):
How imperfect insurer knowledge should be for health insurance -- should age be an actuarial factor? zip code? weight and blood pressure? -- are essentially political problems that hinge on how much you want to favor the unlucky at the expense of the lucky.
First, you are presupposing that the big difference here is between the lucky and unlucky. But I would suggest that as much, it is between the prudent and the imprudent. Some people work out every day, and by my age, I know people who didn't, and are now carrying so much extra weight that they are on O2.

Why am I lucky that I (and likely most here) delayed gratification through college and graduate school? I didn't start having kids at 17, but rather waited until I had finished several graduate degrees, was established in my career, etc. And, yes, I can afford better health insurance as a result. Sure, some luck was involved, but much of it was hard work and delayed gratification.

Also, keep in mind that one of the biggest underwriting criteria is age, when it comes to health insurance. Young males are almost free, when it comes to the disease side of health insurance. But they are also often least able to pay for their health insurance, because they often haven't gotten their careers going yet. On the other hand, those of us at our peak earning potential, tend to cost a lot more money from a health insurance point of view. Eliminating age rating would tend to have the young paying for the middle aged (and all of us pay for the old already, who, as a group, have the most money, and actually need the help the least financially).
7.20.2009 3:46pm
Dan Weber (www):
Imagine a world in which some sort of mega-Google allowed insurers to know the actual risk that each individual faced, precisely. Such an insurer, if a private company, would rationally charge that insured exactly as much as the risk was

That would be an awesome world. They know that I'm going to be hit by a car? They know I'm going to get liver cancer when I'm 81?

Fire insurance companies don't know whose houses will burn down, but they do know that houses made of brick are less likely to burn down than houses made of newspaper and wood.

It's just as much of a fantasy to think that an insurance company will know exactly who will come down with cancer or get hit by a car.

I'm not trying to argue for a total-free-market of health insurance, because there are 2 or 3 specific problems with that. But lots of insurance markets work fine where different people have different risks and pay different rates.

And one's health does not come down 100% to "luck."
7.20.2009 3:51pm
Thorley Winston (mail) (www):


There is no serious dispute that in general, if you have cancer, you will live longer in the US than anywhere else.




Maybe among those who only read Drudge or Fox News, there is no serious dispute on this issue. Then again, there is no serious dispute on any issue for you people.




Yep because apparently the Lancet Oncology Journal, the Economist and WebMD Health News are all affiliated with the Drudge Report and Fox News. Who knew?
7.20.2009 3:52pm
Joan in Juneau (mail) (www):
We are just looking at mandated health care as the only option to fixing the need for everyone to have coverage. I think it is looking at the situation with blinders on. It is not fixing a problem but creating a new one just as creating Fannie Mae and the welfare system hav created more problems than they have solved in the long run.

Yes, the cost of health care is ridiculous and we need to find ways to bring those down. Limit liability lawsuits and lower insurance costs for doctors, max. amount that can be collected and if the doctor messes up a 2nd time, his license is pulled. Labor unions need to be put in their place and much of their power taken away, close loopholes for illegals coming across the border to give birth, refuse medical care to all illegals and send them home and the ones here now... no amnesty or citizenship, they broke the law in coming here and don't deserve citizenship. Reform the welfare system... I know several on it and they abuse the medical part more than the general public, Why should gov't employees have a special health care system? A job is a job, they should not be considered above the person they serve or are supposed to be serving. If we take care of these areas and reduce the free payout of medical care to illegals and put the welfare people at the back of the line, even require everyone on welfare to take a drug test every 3 months and deny benefits to any who test pos. and make it a system they want to get out of instead of a way of life it will go a long way in solving some of the problems. Drug, hospital, insurance, and physician costs need to come down but not at the expense of my life, liberty or pursuit of happiness.
7.20.2009 3:53pm
Bruce Hayden (mail):
And you are standing up for this system? Damn. I have had a similar situation -- over $1.2 mil. in health care costs in 1 year for my son. Got outrageous bills that the insurer refused to pay. Spent months of my own time fighting to get it covered.
Yes. Because you can usually get it covered if you work hard enough. My experience with Medicare is that you can't, despite how much you work at it.
I just don't think it should be that hard to get what I pay for in insurance. And after my experience, unfortunately, yes: I trust the government far more than private insurers. They're nothing but crooks and liars.
Sure, I don't think you should either. But you are more likely to with a private plan than a government one. Why would you trust government that has given us the IRS, Medicare, and the DMV?

Also, at the end of the year, the insurance company is going to have a claims/loss ratio for its insureds. Over time, it had better be less than one, or they won't stay in business. But if they are too tight, then they will lose customers, and often get in trouble with their state insurance commission. So, for the most part, that money that they don't pay to one insured, goes to another one.
7.20.2009 3:53pm
Oren:
JiJ, I defy you to get even 25% of Americans on board with letting illegals die on the ER lawn. Deport them afterward, absolutely supported, but the vast majority of this country will not tolerate such rank disrespect human life.
7.20.2009 3:57pm
Ron Mexico:
If you seriously believe that $1,500 is an amount of money of ANY consequence (especially regarding something like health insurance), then you surely cannot afford any type of above-minimal medical care. When you get sick or get in an accident (despite your proclaimed risk-averse behavior), you will be a gigantic drag on the system and I will be stuck paying your bills. You're playing russian roulette with other people's money (whether you want to or not)
7.20.2009 4:00pm
Dan Weber (www):
My understanding of what has been proposed is that in order to provide a "market" for health care insurance, choice in policy provisions will be essentially eliminated.

As I read the House bill, the Commissioner would set up several categories. It would not be one-size-fits-all, nor would it be a free-for-all. It would probably be easy to get extra care in this market, although I understand your skepticism.

Or, indeed, one that pays out worse, such as the type of high deductible policy that I have right now with my HSA.

The House bill allows for grandfathering. I expect that healthy people will grab them before any plan goes into effect.

(Note that the House bill could be very different from what actually passes. Obama seemed unhappy with it.)

> Eliminating age rating would tend to have the young paying for the middle aged

Going once more to the House bill, age is one of the few risk factors they would let insurance companies use. But only to a limited degree--I think the premium on age cannot vary by more than a factor of 2.

My gut is that people should pay into health insurance in roughly the amount that they expect to receive. But I recognize that this is unfair to people who have chronic genetic conditions and so I only use it as a first approximation. Some economists have called for these people getting specific lump-sum payments to offset their insurance, and while I can see such a thing working in theory, it sounds really hairy and ugly to try to work out.
7.20.2009 4:02pm
rarango (mail):
danny: it is abundantly clear you are not an epidemiologist--so why do you continue to drag in epi stats that you clearly do not understand (from newsweek no less) to bolster your arguments? Similarly, anecdotal evidence about country A's versus Country B's health care shed no great light on the issue.

There are very good arguments for improving the health care system that can be made--but they are ultimately in the realm of policy choices, societal values, and cost benefit analysis between alternative approaches. And quite frankly in those areas epi data is only marginally useful.
7.20.2009 4:02pm
John Moore (www):
JHU BME shows critical problems with current private insurance, writing:

I am uninsured and happy to be so

Others have shown one problem with this: JHU BME becomes a free rider if he develops an illness he cannot pay for. There are other problems also illustrated by his behavior.

First, very accurate observation by PQuincy1:

The key purpose of all insurance, as I see it, is simply risk pooling: I can't possibly save enough to cover the cost of a rare but possible affliction, whether a severe accident of some kind, or a serious medical problem. With very few exceptions, no one can do so.

Thus, redistributing medical risk among large pools of people -- the larger the better -- leads to a smoothing of that hard reality. Without insurance of some kind, whether private, public, or by decree opening emergency rooms to everyone, many people will simply die when they get injured or sick, because they will not be able, as individuals, to pay for the needed treatment.

Insurance allows distribution of risk: if it does more, it can and should be criticized and debated.


A major policy problem is that allowing people (Johns Hopkins University Biomedical Engineer, for example) to opt out of insurance only works if insurance companies are allowed to deny people who are risks. Otherwise, the asymmetry of the situation leads to adverse selection.

Adverse selection was a huge problem in the Massachusetts experiment. The penalties for not having insurance were quite small compared to the cost of buying insurance. Hence many people only bought insurance when they knew they had a major expense coming up. This is shown statistically by the fact that people who bought and dropped insurance after a short time had FOUR TIMES the expenses of those who bought and held insurance, and of course those holding insurance were already statistically more expensive, since they were more likely to be sick.

What the insurance companies' natural response to adverse selection is medical underwriting. This leads to a large number of people who cannot buy individual insurance AT ANY COST, because the insurance companies detect risk, or people who can only buy insurance that doesn't cover their most likely problem (have high blood pressure, your heart attack and stroke are not covered).

The trigger for this refusal to cover can be very low - at one time, Blue Cross/Blue Shield would not offer private insurance to anyone who had EVER taken Prozac. Note that most of those who cannot get individual insurance do not show up in the uninsured statistics, because they have jobs, where the larger employer pool allows their risk to be spread. Hence the "4x million uninsured" understates the problem.

These people then suffer from job lock, health insurance (and resulting care decisions) dictated by their employer, and a constant fear of losing their health insurance if they lose their jobs. They cannot start or even join a small company without risking all of their assets to a medical problem (bye bye entrepreneurship). This situation also leads to age (and other health risk) discrimination in hiring, which is one reason engineers over 50 cannot normally get jobs.

The social and economic costs of this insanity has to be very high, even if this particular issue is rarely mentioned.

Another problem with allowing JHU BME to not buy insurance is the strong tendency of people, especially young (and hence usually healthy) ones, to underestimate their lifetime risk. JHU BME is at low risk, but JHU BME has a high probability of incurring significant medical expenses later in life. JHU BME paying into an insurance pool subsidizes older people - and some day, hopefully, JHU BME will be an older person. Thus:

Generational income transfer is necessary in our modern society:

-people don't save enough when young to support their medical costs (or much else) when older

-traditionally, in society, the young cared for the elderly; in a society where care is mostly by specialists who have to be paid, the young probably should do that.

Republicans offer HSA's to offset this issue, and in theory, they would help a lot. However, it takes a long time for the HSA's to build up enough money for them to become the primary form of individual medical insurance, and in the meantime, the current system is coming apart.

Many favor maintaining the status quo, which indeed does deliver superior care to a lot of people. The current system will not survive. The individual insurance market has failed completely in the US. Only a very small number of people are covered by it - and the issues above show that just equalizing tax coverage on premiums will not help. Medical underwriting will gurantee that.

Hence I support a system that requires JHU BME to buy insurance, in a large pool that others with risks are also required to be in (obviously there can be a lot of these pools - as there was in Massachusetts). Mandated individual private insurance, morphed into pools, would do this without bringing mama government nearly as deeply into our lives as would single payer plans or the Obama kludge.
7.20.2009 4:09pm
Joan in Juneau (mail) (www):
This may be true. I am not saying let them die but then after all we do have an abortion law.

I am saying put Americans and America first and close the loopholes in the citizenship law that allows the US born children of illegals have free healthcare and close the borders. If it takes a Great Wall of USA to do it, close the border. Make welfare a place you don't want to be unless there is no other choice. Stop funding abortions and most health care in other countries at least until the American people are taken care of. Put Americans first in America.
7.20.2009 4:09pm
Gordo:
There are three problems with Professor Bernstein's proposal:

First, with the "right to travel" enshrined in the constitution, a more generous state benefit package (or at least one perceived as such) could be inundated with new arrivals, resulting in skewed burdens. The "experiment" would be fatally compromised.

Second, despite the myth that the rest of the world has monolithic "socialized medicine," there is in fact quite a bit of variance among the guaranteed health plans in other developed nations. We already have a pretty good sample size for several variations.

Third, on the emoitional level, how many people have to die or suffer needless illness, or become employment-immobile, while we "experiment?"
7.20.2009 4:11pm
Leo Marvin (mail):
rosetta's,

How can you claim that we've had "federalized" health care? The federal government provides about 60% of the health care in this country, by some calculations.

We had federalized health care for about 190 years. That worked fine for most, but it was an unconscionable disaster for enough others that Congress had to step in with Medicaire and Medicaid. The result, our current bastardized system, has enough centralized and federalized for each side to blame the other for what's broken. That's a recipe for failure, which is why I have little hope for the tweaks Congress is considering. I think the only solution is single payer, which despite the demagoguing works better where it's done right, e.g., France and Germany, than anything we've tried, most of which was federalized.
7.20.2009 4:11pm
Lior:
@PQuincy1:

You've captured the dilemma of all insurance, which does indeed seek social welfare through redistribution -- but not from the rich to the poor, as you imply, but from the unlucky to the lucky. The key purpose of all insurance, as I see it, is simply risk pooling.


I think you missed my point. That the key point of insurance as such is risk-pooling goes without saying. The question here, however, is not whether insurance by itself is a good idea but whether government-provided medical insurance is a good idea.

My discussion assumes that private risk-pooling is available, where everyone pays their actuarial costs. In that situation I would consider government-run health insurance with risk-based premiums simply a waste of resources. Private insurers are likely to do a better job, and that is the "waste" I was referring to.

There is one thing, however, that the government can offer and the private insurers cannot: redistribution of costs from the wealthy to the poor, and thus a rationing of services not based on the market (that is, on the ability to pay). To me this is where the main argument for and against government-run healthcare should arise.
7.20.2009 4:13pm
John Moore (www):
Oren writes:
Oren:

JiJ, I defy you to get even 25% of Americans on board with letting illegals die on the ER lawn. Deport them afterward, absolutely supported, but the vast majority of this country will not tolerate such rank disrespect human life.

This is absolutely correct.

It is also a very good reason to get our immigration system under control. Mexico, the source of our immigrants, will not allow their own immigrants free care unless those immigrants are healthy when they apply for status. The same is true of many countries (most? all?) with public health insurance.

Since we are humanitarian, we can't do that - so we have to stop the immigrants who will be a net economic loss from getting here in the first place (except for special humanitarian cases, like the Hmong), and we have to get rid of birthright citizenship.
7.20.2009 4:14pm
Leo Marvin (mail):
Bruce Hayden:

For any proposing a single payer system, or something close, I am interested in your reasons why you think that there would not be both rationing and politically mandated coverages that bear little relationship to actual need or economics.

Of course there would be rationing. There's rationing right now under private care. And in the end, only those wealthy enough to afford additional private coverage will escape it. Just like now. The difference is a more conscionable and I believe efficient allocation (or "rationing" if you prefer) for everyone else. See Litigator-London's comment, above.
7.20.2009 4:16pm
John Moore (www):

My discussion assumes that private risk-pooling is available, where everyone pays their actuarial costs.

That will not fly. We already have that situation - it's called individual health insurance. So if you're 60 and of average health for that age, and you lose your job, and there's no Medicare waiting down the road, what do you think your actuarial cost will be (hint - more than you can afford). If you are unlucky enough to have a genetic tendency towards an expensive illness, then what does your system offer.

Nope - been there, tried that, and it's failing all around us. Right now it's so "successful" that only 4% of Americans are covered by it!
7.20.2009 4:17pm
Mark Buehner (mail):
Federalism! Get the torches!
7.20.2009 4:18pm
Mark Buehner (mail):

JiJ, I defy you to get even 25% of Americans on board with letting illegals die on the ER lawn. Deport them afterward, absolutely supported, but the vast majority of this country will not tolerate such rank disrespect human life.

We won't deport illegals after they commit felonies, I don't suppose we will deport them after treating their illnesses.

I am very surprised there isn't more political traction for border enforcement. Talk about shovel ready jobs- I got the feeling there are plenty of unemployed folks in the Southwest willing to dig a trench for a good days wage. Unfortunately most of them are probably illegals.
7.20.2009 4:24pm
Lior:
@PQuincy:
Imagine a world in which some sort of mega-Google allowed insurers to know the actual risk that each individual faced, precisely. Such an insurer, if a private company, would rationally charge that insured exactly as much as the risk was, making the insurance, as you note, meaningless and inefficient.


No so. You confuse expected monetary value with expected utility. In fact, insurance is valuable even when the risks and costs are known in advance.

Assume that, with probability 1/1000 (say based on the outcome of a truly random event), I might be required to pay $100,000 next week. In expectation this is a monetary liability of $100, something I can (say) easily afford. However, I do not have $100,000, and being required to pay that sum will ruin my life. Thus my expected loss is actually far greater than $100. The insurance company, on the other hand, has large capital resources and can afford a one-time loss of $100,000. From their point of view the gamble really does have expected value -$100. I am thus very happy to pay the insurance company $150 (say) to take the risk instead.

The $50 "premium" paid here is not in any way wasted. Having $50 today is for me less useful than risking having to pay $100,000 next week. Having $50 for the insurance company is their way to generate return on the capital they must hold to cover the potential loss.
7.20.2009 4:24pm
Kazinski:
Why not go with universal catastrophic health insurance, rather than the whole ball of wax? The policy would kick in at 3000.00 per individual, and 10,000 per family, and would cover one annual checkup at 100%. The advantages would be that it would still leave 80-90% of health care decisions in private hands, it would allow families to decide whether to go naked for the first 10,0000, or buy supplemental insurance. Since insurance for a family of 4 is currently more than 10,000 a year, then that should be reasonable, especially with an MSA.
7.20.2009 4:25pm
Adriane (mail):
Oren -

get the Government out of Health Care period, amen. And reduce the tax burden accordingly.

1)The rational // cost-benefit analysis for not carrying personal insurance changes immediately.

2)The American People are very generous with charitable dollars to help people, illegal aliens included that are desperate for some form of medical treatment completely beyond their means.

3)Beyond that, life (health?) is not fair, as Jim Fixx' heart attack demonstrates, and nothing the government does, will ever change that...
7.20.2009 4:26pm
Thorley Winston (mail) (www):

The 1st rate is about 3-times greater than the 2nd rate. This is statistically significant. Sorry.


I don’t think so. When you have statistical measurements so small to the point where the countries in question are each reporting infant mortality rates that are literally less than a fraction of a percent, it doesn’t take that much of a variation in data collection methods or non-health care system related factors like ethnicity or lifestyle choices to affect their rankings.

Put it this way, if the people who drag out infant mortality rates as a reason for supporting “health care reform” ever said “the United States has an infant mortality rate of just over six tenths of a percent and there are countries which have an infant mortality rate of just over two-tenths of a percent and this difference is one reason why we need to change our health care system” they would probably not persuade very many people.
7.20.2009 4:26pm
Leo Marvin (mail):
John Moore,

It is also a very good reason to get our immigration system under control.

Agreed. The problem is overcoming the strange bedfellows alliance between some on the left who don't care how much illegal immigration costs, and some on the right who care only about how much it profits them personally.
7.20.2009 4:26pm
Seattle Law Student (mail):


Joan in Juneau -
I am saying put Americans and America first and close the loopholes in the citizenship law that allows the US born children of illegals [to] have free healthcare and close the borders.


Those kids are Americans. Has been the case pretty much since 1776. Are you advocating changing the way we determine who is and isn't a citizen?
7.20.2009 4:29pm
John Moore (www):

Agreed. The problem is overcoming the strange bedfellows alliance between some on the left who don't care how much illegal immigration costs, and some on the right who care only about how much it profits them personally.

Errr.. who is that on the right that you are referring to? I know of libertarians (right?) who believe in open borders. However, conservatives do not.
7.20.2009 4:43pm
Joan in Juneau (mail) (www):
Those kids are Americans. Has been the case pretty much since 1776. Are you advocating changing the way we determine who is and isn't a citizen?

That is exactly what I am suggesting. The mothers broke the law in coming here to give birth. Why should we reward that? If the father is a legal American, then that is different but close that blasted border. It would not only help with the health care problem but may help with the drug problem a little too.

Send all the illegals home and if they still want to return, let them apply thru the proper channels.

Things have changed a lot since 1776 so perhaps more needs to change.
7.20.2009 4:44pm
Lior:
Thorley Winston: You realize that a difference of 0.4% is one out of every 250 babies? When it comes to risks to human life, I wouldn't call 0.002 a small fraction.
7.20.2009 4:45pm
Leo Marvin (mail):

Errr.. who is that on the right that you are referring to? I know of libertarians (right?) who believe in open borders. However, conservatives do not.

You may not want them, but most libertarians lean and vote right. See, for example, a little website called The Volokh Conspiracy.
7.20.2009 4:58pm
BGates:
So those who can earn enough to pay for an education are more likely to deserve to have an education, because they would benefit from it?

No, those who can earn enough to pay for an education are more likely to benefit from it. Deserve's got nothing to do with it.

Is this even controversial? It's absurd to claim college as a universal entitlement (while claiming housing as a luxury good, as the poster I responded to did), because there are people who wouldn't benefit from going to college. Some of those people have trouble holding down a job, and for the same reasons - drug abuse, lack of mental capacity, etc.
7.20.2009 5:07pm
John Moore (www):
Seattle Law Student (mail):

Those kids are Americans. Has been the case pretty much since 1776. Are you advocating changing the way we determine who is and isn't a citizen?


yes
7.20.2009 5:08pm
John Moore (www):

You may not want them, but most libertarians lean and vote right. See, for example, a little website called The Volokh Conspiracy.

Most libertarians would reject the idea that they are to the right. They don't accept a one dimensional scale.

It is true that there is a strong libertarian-conservative movement (Barry Goldwater was an early member and WFB had some libertarian ideas such as ending the drug war), but I don't know of any prominent conservatives who are for open borders. That is a position found almost exclusively on the left.
7.20.2009 5:11pm
BGates:
Another problem with allowing JHU BME to not buy insurance is the strong tendency of people, especially young (and hence usually healthy) ones, to underestimate their lifetime risk.

There's also a strong tendency among people to underestimate the cost of laws enacted by the legislators they elect.

It's dangerous to allow people to make their minds up about all sorts of things. Best to choose for them, and then coerce them into behaving the way you want.
7.20.2009 5:14pm
Dan Weber (www):
First, with the "right to travel" enshrined in the constitution, a more generous state benefit package (or at least one perceived as such) could be inundated with new arrivals,

Just because a state gives medical care to all of its citizens as of 2009 doesn't mean it has to give it to people who move in later. They could require a buy in for immigrants.

Third, on the emoitional level, how many people have to die or suffer needless illness, or become employment-immobile, while we "experiment?"

I don't know. Is it the same number who had to die in Saddam's death camps while the UN dithered around with sanctions?

The US's health care system is horrible, and I like some parts of some the bills going around Washington. But this system can be made worse.

I'm not comfortable with having the young subsidize the middle-aged. If we require the young to have insurance (which isn't that bad of an idea), they should pay less. Maybe age should be the sole determinant of a plan's premiums. The healthy 21-year-olds would subsidize the sick 21-year-olds, but they would still be paying much less than the 50 year olds.

Right now it's so "successful" that only 4% of Americans are covered by it!

I'm not sure it's a fair comparison when it is so incredibly tax disadvantaged to buy a private plan.
7.20.2009 5:17pm
Floridan:
Republicans offer HSA's to offset this issue, and in theory, they would help a lot. However, it takes a long time for the HSA's to build up enough money for them to become the primary form of individual medical insurance, and in the meantime, the current system is coming apart.

Expect in a few cases, HSA's are useful only for covering deductibles and co-pays.

I really wonder if many of the people here realize how expensive almost any procedure that requires hospitalization might be. A simple appendectomy will lead to bills of $20,000 or more (probably more).

I suppose a HSA could be worthwhile if you cannot get insurance to cover a pre-existing condition -- but, if its a serious pre-existing condition, you're likely screwed; most people cannot save enough money to cover major medical treatments.
7.20.2009 5:18pm
Joseph Slater (mail):
Rosetta's:

Re zombies, I will direct you to this excellent legal blog post by my colleague whose office is -- coincidentally? -- next to mine.

If I said more, I would be forced to have you killed.
7.20.2009 5:26pm
Joseph Slater (mail):
Oh dang, wrong thread, apologies.
7.20.2009 5:27pm
John Moore (www):

I suppose a HSA could be worthwhile if you cannot get insurance to cover a pre-existing condition -- but, if its a serious pre-existing condition, you're likely screwed; most people cannot save enough money to cover major medical treatments.

Which is why I, a conservative Republican on most things, think the Repubs are ultimately clueless on this issue, as are the Libertarians and Democrats!
7.20.2009 5:48pm
John Moore (www):
This should have been on the end of the previous post.

We seem to have the blind men and the elephant syndrome with health care (really, health care payments).

Liberals see only the benefits of universal coverage controlled by the government, without the downsides.

Republicans see only the benefits of a partially free market, without the downsides.

Libertarians don't see the elephant at all.
7.20.2009 5:49pm
Thorley Winston (mail) (www):

Thorley Winston: You realize that a difference of 0.4% is one out of every 250 babies? When it comes to risks to human life, I wouldn't call 0.002 a small fraction.



As heartbreaking and tragic as it is, the fact is that there have always been babies who die soon after being born. Sometimes prenatal care makes the difference. Sometimes the doctor makes a mistake. Sometimes the mother doesn’t do what she’s supposed to or does something she shouldn’t that affects her pregnancy. Sometimes the baby is born with a problem that can’t be corrected in time to save their life. Sometimes we don’t know the reason why they die.

We can/have/should try to minimize the number who die but after you reach a certain point (and less than one in 100 seems pretty low) at a certain point the law of diminishing returns kicks in and you have to weigh the costs that additional measures would have in certain areas.

In this case our country loses about one out of every 160 babies that are born whereas the best any other country claims to have achieved is one out of every 302 babies. The people who like to cite our “high” number have proposed as a “solution” that (a) amounts to a federal takeover of healthcare that includes (b) borrowing or taxing additional trillions of dollars (during a recession no less), (c) displacing tens of millions of Americans from their private health insurance and (d) potentially stifling medical innovation in order to “control costs.”

Even if I thought that this was all necessary to reduce our infant mortality rate and I don’t believe it would create any significant improvement, I think that the cost is too high.
7.20.2009 5:57pm
Seattle Law Student (mail):
Joan From Juneau &John Moore -

Good Luck with that. You'd need a constitutional amendment for one thing. Liberals &Conservatives alike would have an easy time creating an equivalence between such an amendment and racism, whether that is true or not. It would never get out of congress, much less have enough state support to pass.
7.20.2009 6:03pm
sbowers3:
Food and housing are even more important than health care. And there are over 300 million Americans without food insurance. Oh, the tragedy, how are they able to buy food without food insurance? And housing is so important that the gov't should build public housing. Oh wait, we tried that.
7.20.2009 6:05pm
Joan in Juneau (mail) (www):
Seattle-

I don't see it as needing an amendment. Just closing a loophole in a current one. If they can create or close tax loopholes to fit their wants or needs, then this one shouldn't be too difficult for them. They know it exists and turn a blind eye.

Maybe we can offer a deal... say give CA back to them along with Pelosi and Boxer if they will just stay home. :)
7.20.2009 6:12pm
Leo Marvin (mail):
John Moore:

You may not want them, but most libertarians lean and vote right. See, for example, a little website called The Volokh Conspiracy.

Most libertarians would reject the idea that they are to the right. They don't accept a one dimensional scale.

No one with a brain accepts a one dimensional scale. But when presented with a forced choice between one or the other, most libertarians choose "right." Poll the bloggers on this site if you disagree.
7.20.2009 6:18pm
John Moore (www):
I am aware it would require an amendment. I also know that it would be very difficult under current circumstances to get one through. As for racism, that is utter nonsense, but you are right that conservatives would get charged with it. Heck, we always do.
7.20.2009 6:18pm
pmorem (mail):
In this case our country loses about one out of every 160 babies that are born whereas the best any other country claims to have achieved is one out of every 302 babies.

My understanding is that this is an apples to oranges comparison. IIUC, one of the differences is in what constitutes a "live birth", particularly regarding severe preemies.
7.20.2009 6:18pm
Bruce Hayden (mail):
As I read the House bill, the Commissioner would set up several categories. It would not be one-size-fits-all, nor would it be a free-for-all. It would probably be easy to get extra care in this market, although I understand your skepticism.
I think that to be wishful thinking, not supported by the facts or the bill. Rather, in order to provide for comparison shopping, almost all variation between plans is being eliminated.

I was struck by all the provisions that are being locked into the actual law, and not being left to any commissioner, czar, or bureaucrat, such as the maximum yearly out of pocket.
Or, indeed, one that pays out worse, such as the type of high deductible policy that I have right now with my HSA.
The House bill allows for grandfathering. I expect that healthy people will grab them before any plan goes into effect
Well, yes, and if you aren't in your plan by the end of the year that the law becomes effective YOU CAN NEVER JOIN IT. If you join a company with a grand fathered plan, you won't be able to join it, etc.

Part of the problem with grandfathering in this regard is that over time, any plan will become cost prohibitive due to its claims/loss through adverse selection and aging of its policy holders. Thus, over time, whatever little variation left open by this grandfathering will disappear. And, so, while I may not need to move to a standard plan the first year, I will have to eventually, when I change employers, or it just gets too expensive.
(Note that the House bill could be very different from what actually passes. Obama seemed unhappy with it.)
Well, is there any reason, besides wishful thinking, to believe that he is unhappy because it provides too few choices? Maybe it provides too many for his liking.
Eliminating age rating would tend to have the young paying for the middle aged
Going once more to the House bill, age is one of the few risk factors they would let insurance companies use. But only to a limited degree--I think the premium on age cannot vary by more than a factor of 2.
2/1 isn't really all that great, but is better than nothing. I think that it is at least 5/1 by the time guys are ready for Medicare.
My gut is that people should pay into health insurance in roughly the amount that they expect to receive. But I recognize that this is unfair to people who have chronic genetic conditions and so I only use it as a first approximation. Some economists have called for these people getting specific lump-sum payments to offset their insurance, and while I can see such a thing working in theory, it sounds really hairy and ugly to try to work out.
Well, my gut feeling from reading the bill is that nothing of the sort is in the expectations of its drafters. Rather, it seems to be pushing for maybe two different plans for everyone. A one size fits all approach, based on the assumption that that sort of homogenization is required to provide markets for each of the few plans available. Also, it appears that the drafters seem to think that the vast array of plans available right now confuse those out comparison shopping, and thus the variation must be eliminated so that they can compare apples to apples and oranges to oranges, by mandating that no plan could have both apples and oranges in the same plan.
7.20.2009 6:27pm
Danny (mail):

And there are over 300 million Americans without food insurance.


Absolutely untrue. Welfare, foodstamps, etc.
7.20.2009 6:35pm
Thorley Winston (mail) (www):
In this case our country loses about one out of every 160 babies that are born whereas the best any other country claims to have achieved is one out of every 302 babies.


My understanding is that this is an apples to oranges comparison. IIUC, one of the differences is in what constitutes a "live birth", particularly regarding severe preemies.


I agree that’s part of it in some cases. However even if we were comparing apples to apples (and I agree that we’re not in many cases), my point is that we would still talking about a very small difference among developed countries in terms of what we each report as our infant mortality rate. It’s frankly not that large of a statistical difference – even discounting all of the other factors which affect infant mortality rate which aren’t part of a country’s health care system or how the numbers are calculated – to support such a radical change in our health care system IMO.
7.20.2009 6:38pm
sureyoubet:
"The claim that universal care would prevent the wealthy from spending more of their own money -- in the United States! -- is absurd"

If the health care bill made it a felony for any member of Congress, the President, Federal judges, and senate-confirmed political appointees to spend any of their own money for heath care for them or their families beyond what is offered by the "public option" then I'll be ready to get on board. Until then, garbage like the Ted Kennedy editorial today is just that.
7.20.2009 6:50pm
Leo Marvin (mail):
Thorley,

[M]y point is that we would still talking about a very small difference among developed countries in terms of what we each report as our infant mortality rate.

A three times greater rate resulting in 28,000 U.S. infant deaths per year means a difference of more than 18,000 annual deaths. Even adjusting for all the possible anomalies in causation and reporting, it still leaves a difference of several 9/11's per year. That's not enough to justify some serious policy changes?
7.20.2009 7:11pm
John Moore (www):
Leo Marvin,

That's not enough to justify some serious policy changes?

Yeah, but WHICH ONES? How many of those deaths are due to differences in health systems, rather than behavior? The US has long had ghettos where behavior is strongly against infant survival: illegal drug use, failure of mothers to seek care, teen pregnancy (better biologically but more likely to have behavior related issues), etc.

It is not clear what policy changes would be best, but they wouldn't likely be related to health care.

Again, if one is going to use statistics, one has to take into account confounding variables. Raw infant mortality numbers is a very, very poor proxy for level of infant care.
7.20.2009 7:49pm
Brian K (mail):
Whenever you see life expectancy used to compare health care systems you know that you are being played for a sucker.

Here is perhaps a more useful but incomplete set of criteria for judging health care systems:

1. Is the country a source or a destination for medical tourists? For example, do single payer citizens (Canadians) come to the US for breast cancer surgery (Stronach) or difficult pregnancies (Jepp), or is the flow the other way?
2. Is the breast cancer survival rate higher or lower?
3. Is the overall cancer survival rate higher or lower?
4. Is the wait for a hip replacement longer or shorter?
5. Are long waits for CAT and MRI equipment the norm?
6. Does the government hide or delay the availability of new and more effective but more costly treatments?


Whenever you see a list like this you know the person has been taken for a sucker. 1) the number of canadians coming to the US as reported in actual peer reviewed studies is much lower than your brainwashed conservative would have you believe. and it completely ignores that fact that a not insignificant number of US citizens get healthcare in other countries because they can't afford it here. 2) it is obvious that the author of said list has no concept of lead time bias. 3) it ignores the fact that the US has significant wait times for certain services in certain areas...just like every other country. ever wonder why hip replacements are the most common procedure brought up when talking about wait times? of course not, you're a sucker. 4) you assume that every CT and MRI we do is medically necessary...a BIG assumption! 5) you mean like the way private insurance companies avoid or flat out refuse to pay for expensive treatments? here's a tip...not every treatment labeled "experimental" by insurance companies is really experimental (because they don't pay for experimental procedures.)

to use your own words "you should be ashamed"
7.20.2009 7:50pm
Daniel Chapman (mail):
"The cries of "rationing" are a total canard. As was aptly pointed out in the NYT over the weekend, we have have rationing now. Healthcare is allocated across the populace based on abilitiy to pay."

All economics is the allocation of scarce resources. I'm perfectly honest saying that we're talking about GOVERNMENT rationing, which is what most people object to. Go try peddling that "we're rationing now!" argument with Joe on the Street without the shell game of calling the free market "rationing." See how far it gets. Sheesh.
7.20.2009 7:54pm
Brian K (mail):
Some people work out every day, and by my age, I know people who didn't, and are now carrying so much extra weight that they are on O2.

i hate to break it to you, but supplemental oxygen is not a treatment for obesity.
7.20.2009 8:11pm
neurodoc:
Floridan: I recently had surgery to remove a benign tumor; the hospital's charge was $47,000...
Not-so-random observer: Sooo . . . you made someone else cough up fifty grand for an ailment that wasn't even life-threatening?
Because it was a "benign tumor" does not mean it "wasn't even "life-threatening." Sometimes, as with real estate, location is all-important, that often times the case with brain tumors.
7.20.2009 8:21pm
John Moore (www):

Floridan: I recently had surgery to remove a benign tumor; the hospital's charge was $47,000


Note that if Floridian had no insurance, the hospital would demand the full $47,000. With insurance, the hospital would demand much less. In the case of a relative of mine, hospital charge $50,000 but was satisfied with insurance payment of $14000.

That imbalance is clearly a defect in our current system and has everything to do with who has the most power to bargain - the big insurance company's PPO plan, or the individual consumer.
7.20.2009 8:27pm
Leo Marvin (mail):
John Moore,

Again, if one is going to use statistics, one has to take into account confounding variables.

Was it too tempting to ignore that I said,

"Even adjusting for all the possible anomalies in causation and reporting"

?
7.20.2009 8:54pm
Joan in Juneau (mail) (www):
John Moore-

You make a good point. Bargaining Power. Thing is, that book the gov't publishes that tells the medical community how much they will pay for a certain procedure has raised costs to all but the medical profession has also said that if tht is done away with that they will turn away Medicare patients. Perhaps that is where the issue should be taken along with getting the nation healthier on the whole with incentives in those areas. Tax junk foods and sodas, encourage healthier eating, tax breaks for companies that create workplace fitness centers, breaks for those tht participate and can prove it has helped, even businesses that have their own clinic. Prevention and catching things early. Let the businesses run the triage part to decrease the hospital load and costs.

I know some of these things sound 'way out there' but I think they would reduce health care costs and make for a healthier nation.
7.20.2009 8:58pm
neurodoc:
John Moore, I agree with your answer to Leo Marvin about infant mortality rates as a misleading measure of the quality of our health care system for the "non-medical" reasons you cite.
7.20.2009 9:00pm
neurodoc:
John Moore, I agree with your answer to Leo Marvin about infant mortality rates as a misleading measure of the quality of our health care system for the "non-medical" reasons you cite.
7.20.2009 9:00pm
Seerak (mail) (www):
This was a stupid suggestion when Arnold Kling made it, and it's just as stupid now.

Socialism fails because it is socialism.

The defect in the concept of socialized anything, is the fact that it is socialized.

We have the entire twentieth century behind us to demonstrate this fact.

This even remains true for those epistemological primitives who, incapable of grasping principles, would respond by saying "but we're talking about socialized medicine, not wholesale socialism": we also have the data of experience from plenty of these experiments with socialism-by-industry as well -- including one I've lived in, Canada -- and more than enough results are in.

Jesus H. Christ in a spittoon, what's it going to take for you to figure it out, people? Another hundred million plus bodies?
7.20.2009 10:29pm
Desiderius (mail):
zuch,

"Elections have consequences."

Go through with this shotgun wedding of a health plan, and I think you'll see in November, 2010 that consequences have elections as well.
7.20.2009 10:37pm
Oren:

get the Government out of Health Care period, amen. And reduce the tax burden accordingly.

Again, Americans will not accept a situation in which anyone dies in the E.R. waiting room because they cannot post funds sufficient for their treatment (especially if the injury was not their fault -- for instance, they are the victim of some violent crime). It just doesn't seem very Christian to turn the victim away and it won't sell under any circumstances.
7.20.2009 11:41pm
Desiderius (mail):
Oren,

"It just doesn't seem very Christian to turn the victim away and it won't sell under any circumstances."

The "Christian" element - a very real one - makes the irony that the lion's share of expenditures go to ward off late-life mortality all the more poignant.

Were our present Christians as confident in the world that awaits as our forebears were, the financial crisis would be less acute.
7.20.2009 11:57pm
Oren:
D, interesting that perhaps these nuns are the only ones with enough credibility to push things along.
7.21.2009 12:02am
Leo Marvin (mail):
neuro,

Does that mean you think the non-medical reasons account for the whole discrepancy?
7.21.2009 12:03am
Abdul Abulbul Amir (mail):

1) the number of canadians coming to the US as reported in actual peer reviewed studies is much lower than your brainwashed conservative would have you believe.


The fact remains that Canadian women with difficult pregnancies are routinely sent to the US due to lack of capacity in the Canadian system. The numbers are not large, and it makes cost control sense for the Canadians to do that. Eliminating reserve capacity reduces cost and when a demand spike occurs it can be addressed south of the border.

The point is that system works for the Canadians because there is reserve capacity available next door. However, we can't play that same game for the obvious reason.
7.21.2009 12:33am
John Moore (www):
Leo Marvin (mail):
John Moore,
Leo Marvin:
Was it too tempting to ignore that I said,
"Even adjusting for all the possible anomalies in causation and reporting"

No, Leo - I simply throw out assertions based on magical thinking, since there is no reason to believe that this adjustment has been made.
7.21.2009 12:49am
Joan in Juneau (mail) (www):
Abdul,

This IS Canadian HealthCare
http://tinyurl.com/nbko47
7.21.2009 12:58am
DJ (mail):
Heath care debates get so stupid. Pointing to hospital charges as evidence of the cost of care is silly. And pricing for health care services in a world without the current system of capitated Medicare payments and cost-based Medicaid schedules is almost impossible. Who can say what hospitals would charge for a stay if existing state and federal financing programs went away?

And Daniel Chapman is right. This "we're already rationing meme" is jive. "Rationing," after all, is the act of distributing shares--usually as determined by supply. Somebody inventories the supply of goods or services and hands it out based on some criteria. By definition, it requires agency and intent. And that's attributing an awful lot to the Invisible Hand.
7.21.2009 1:08am
Brian K (mail):
The fact remains that Canadian women with difficult pregnancies are routinely sent to the US due to lack of capacity in the Canadian system.

somehow i don't think "routinely" is the word should be using here. but then i also don't think you particularly care...you are pushing a specific agenda, regardless of what any evidence* might show.

*note: anecdotes are not evidence. it is obvious that way too many people never learned this simple distinction.
7.21.2009 1:50am
Brian K (mail):
oh...and again you are ignoring travel in the opposite direction. how many americans go to canada to get medication they can't afford here? both systems have their flaws.

it's easy to make yourself appear right when you completely ignore any countervailing evidence...but it makes for an essentially worthless argument.
7.21.2009 1:52am
Abdul Abulbul Amir (mail):

somehow i don't think "routinely" is the word should be using here.


It is exactly the right word. If there is lack of capacity, the patient is not forced to deliver a baby on the sidewalk, but is sent to a hospital that does have capacity. That is the routine. That multiple women are sent to the US year after year to find that capacity is a measure of Canadian capacity.
7.21.2009 8:52am
Oren:

how many americans go to canada to get medication they can't afford here? both systems have their flaws.

Doesn't the AARP organize bus trips for seniors to do just that?
7.21.2009 10:04am
John Moore (www):

oh...and again you are ignoring travel in the opposite direction. how many americans go to canada to get medication they can't afford here? both systems have their flaws.

Please explain how the Canadian system makes the medications less expensive and the American system makes them more expensive!
7.21.2009 1:38pm
Desiderius (mail):
Oren,

"D, interesting that perhaps these nuns are the only ones with enough credibility to push things along."

No, just to cease pulling so damn hard.
7.21.2009 2:04pm
wfjag:
@ dan:


And you are standing up for this system? Damn. I have had a similar situation -- over $1.2 mil. in health care costs in 1 year for my son. Got outrageous bills that the insurer refused to pay. Spent months of my own time fighting to get it covered.

I just don't think it should be that hard to get what I pay for in insurance. And after my experience, unfortunately, yes: I trust the government far more than private insurers. They're nothing but crooks and liars.

You should study outcomes under Louisiana's Charity Hospital System (which, until recently, provided free med care for anyone who'd come in for treatment) before deciding that you can trust the gov't more than private insurers. While the Charity system provided "free" care, the Louisiana Legislature systematically underfunded it. The outcome was what you'd expect -- for example, in about 1989 the Louisiana Dept. of Health and Hospitals published a study on cancer incidence and mortality in Louisiana. Except for lung cancer due to smoking (which is much higher in Louisiana than most of the US), cancer incident rates were at or below national rates. However, cancer mortality rates were much higher, especially among populations served by the Charity system. But, for populations served by private med care providers and hospitals, cancer mortality rates were at or below national averages for nearly all types of cancers.

IF you agree to a national system, you are thereby depending on Congress to adequately fund that system, and also to not fiddle with training programs for providers based on reasons unrelated to producing the best providers. You are turning over health care availability to the same group who gave us Fannie Mae and Freddy Mac, but, expecting them to act differently when even more money is available to be funnelled to friends and supporters.

With private insurance you retain some ability to purchase insurance from another insurer, and to seek out the best providers -- and, when the insurer denies coverage for a covered treatment or procedure, to sue (and, in most states seek attorneys' fees, statutory penalties and bad faith damages). I'm not saying it's not a hassle. Rather, you at least have options and can fight the denial.

With the federal government, assuming that there has been a waiver of sovereign immunity so that you even have a remedy, you'll first have to exhaust administrative remedies, and then whatever judicial remedies you'll have will likely look like those available under the Federal Tort Claims Act (which provides for money damages only) or the Tucker Act (for which the exclusive jurisdiction for claims in excess of $10K in damages and for breach of contract claims is in the US Claims Court in Washington, DC).

So, with a national system you likely won't have to contend with "dishonest" decision makers, you will have to put up with those who are disinterested in the outcome in your case, and who, unlike employees of private employers that can be terminated on customer dissatisfaction grounds or with or without a reason, are federal employees who are pretty much protected against any complaints you have against them -- whether or not your complaints are justified.

There are many who claim that the US system is broken. I've not see evidence that supports that conclusion. Yes, there are problems. Still, with 85% of the US population covered by private insurance and/or some gov't program, and 80% of those expressing satisfaction with their own coverage, it is clear that overwhelmingly the US system works well enough. That doesn't mean that there aren't improvements that can and should be made. However, be very careful before you support completely scrapping the current system and opting for a very complex set of proposals, each over 1,000 pages in length, that have not been thoroughly and publicly analyzed, since they are being drafted behind closed doors and rushed through committees without discussion or the opportunity for even members of Congress to read, much less analyze, them. Be careful what you wish for. "Change" does not imply that there will be an improvement. While you had to spend months to get your insurer to cover your son's treatment, under the current system you had the opportunity to do that. I've seen nothing in any of the current proposals that provide a similar opportunity to contest a denial -- and, in all of those proposals it is not a denial of payment for a treatment, it is a denial of treatment in the first place. Accordingly, you have to fight the decision to deny the treatment, rather than fight to get payment for a treatment already received.
7.21.2009 6:23pm
Brian K (mail):
Please explain how the Canadian system makes the medications less expensive and the American system makes them more expensive!

i didn't think anyone could seriously be that.misinformed. i guess the old saying is true...never attribute to malice what can be attributed to stupidity.
7.21.2009 9:05pm
Brian K (mail):
Doesn't the AARP organize bus trips for seniors to do just that?

at one point they did. i'm not sure if it is still going on since i vaguely recall that the government cracked down on that practice several years ago.
7.21.2009 9:08pm
Brian K (mail):
It is exactly the right word. If there is lack of capacity, the patient is not forced to deliver a baby on the sidewalk, but is sent to a hospital that does have capacity. That is the routine. That multiple women are sent to the US year after year to find that capacity is a measure of Canadian capacity.

I see what you're doing here. you're either 1) not the sharpest knife in the drawer, 2) know absolutely nothing about medical care in the US or 3) assume that everyone else is an idiot. when a service at any hospital can no longer accept new patients, those patients get shunted to the nearest hospital that can accept them. this is standard practice in american hospitals and, i would assume, hospitals all over the world. i'll give you three examples to show how weak your argument is. 1) i'm currently rotating through a busy cardiothoracic surgery practice. just today we were consulted on a patient who had a heart attack and needed urgent surgery. but we won't have a free operating room or available surgeon until friday. what happened to the patient? we sent him to a major academic institution that was able to handle him. 2) the ER i worked at was on bypass about half the time because our resources were swamped with trauma and/or otherwise emergent patients. what happened to new patients? they went to a different ER about 10 miles away. 3) when i worked in chicago we routinely had patients transferred from the indiana border area (yes, across state lines despite these being indiana public aid patients) because we were the closes hospital.

so if you think canada's system is bad because they occasionally refer patients to other hospitals, you must think the american system is absolutely atrocious! in fact, the entire american system is built on referring patients to other hospitals. if a community hospital can't handle a patient they are sent to the nearest tertiary care center, which are most often government funded academic centers.
7.21.2009 9:23pm
John Moore (www):
Brian K, who prefers insults to debate, writes:

Please explain how the Canadian system makes the medications less expensive and the American system makes them more expensive!
i didn't think anyone could seriously be that.misinformed. i guess the old saying is true...never attribute to malice what can be attributed to stupidity.


Either spell out the answer to the question, or shut the hell up. Your insults contribute nothing, and the NYT link is not an answer.
7.22.2009 12:57am

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