universal healthcare

[Chesspiece_face]

Ok, 50 minus 12. :) That's 37 + Texas.State's AG's are typically lawyers and Governor wannabes. It is politically expedient for them to make a big name for themselves, usually at taxpayer expense.

As for the merits of the case... It's the SCOTUS... Who knows how this will turn out... I predict a 5-4 decision.

Sorry I read that wrong. I've not seen that information. I've seen the statement from 13 state's AG that are filing lawsuits claiming the mandate is unconstitutional.

[Jester]

Ok, 50 minus 12. :) That's 37 + Texas.

You're counting any state with a representative who proposes something like this as a state opposing the bill. That's dishonest. The states are democracies - you need a majority of the representatives to invoke their collective power. Just because some schlub proposes something does not mean it will go anywhere. Just look at all the crazy crap Dennis Kucinich has proposed over the years. Would it be reasonable to say "United States Congress Seeks to Impeach Cheney," just because it was proposed? I would say it is not, and nor is it reasonable to put this tally at 38.

Edit: At the very least, many of these states have Democrat-controlled legislatures. How exactly are the Republicans going to swing that?

Give me a ring when 38 states actually amend their constitutions to forbid this - then we'll have some real fun at the SCOTUS. Until then, this is just hot air.

-Jester

[Jester]

Once health care is a freely given away commodity (by the government), perhaps with some rationing even, I believe the populous will consume all that the government has to offer. The wages of care givers will be more or less fixed in that area, and so, as in other countries with socialized medicine, the number of care givers will never satisfy the demand. This is a recipe for price inflation for those that pay, and limited care and waiting lists for those who do not pay.

... do I even have to repeat the argument again? Look at the experience in other countries. Look at it on the whole, not just at anecdotes that confirm your presuppositions. Look at costs. Look at outcomes. They work. They are not drowning in a sea of Munchausen's patients, demanding MRIs and heart surgery three times a day.

We talked already about the anarchy of law, where it will cost $695 to break the law, or many thousands to follow the law. We talked about the budget gimmicks, double counting of savings, and other accounting shenanigans to create an entirely fictitious unbelievable CBO number.

Depending on how you parse the CBO numbers, and what you include as being part of the health care bill, the number is either slightly positive, or slightly negative. It is not "entirely fictitious [and] unbelievable," unless of course you've already concluded that this is going to cost a zillion dollars, and refuse to believe any number that says otherwise.

Of the 30 odd million uninsured, 9.6 million of them are in the US illegally.

Try 50 odd million, thanks to the recession. And that's just those uninsured for a whole year - the number for the transitionally uninsured at any given time is much higher. Your 9.6 million figure is for all immigrants, including legal ones. Check here.

12+ million will be added to the medicaid roles by raising the lower threshold of the % of the poverty level that qualify and the States are expected to pick up these additional costs. A $500 billion cut to medicare, which will result in fewer services, rationing and waiting lists for seniors. So the two huge deficit running government programs will get worse, both in driving up costs and offering poorer services.

They're set to reduce the growth of future spending on Medicare by $500 billion over 10 years. Is that a "$500 billion cut"? Maybe. It depends on how they go about containing costs. If the system is as terrifyingly inefficient as it seems to be, I have no trouble believing that there is $50 billion a year in excess cost growth that can be prevented. But we'll see.

Regardless, leaving aside "kill grandma" imagery, the quantity being spent to keep seniors alive cannot increase indefinitely. The question is, how much can you afford to spend, and what level of care can you get for that sum? The scary CBO projections involve the idea that you will spend almost limitless amounts, and get whatever care that buys. That's not a realistic way to look at the problem.

Some 8 or so million of the uninsured will be now covered by raising the age of what constitutes a child (for insurance purposes) to age 26, so ostensibly, children will remain on their parents insurance (while their plans remain solvent).

Great! 8 million more insured. Social costs go down, risk is dispersed more evenly.

Drug companies get richer by adding a bunch of new customers, and will be the beneficiary of the closure of the "donut hole".

Well, them and anyone paying for drugs in the "donut hole," right?

The government will implement one of the largest tax increases ever by by applying income tax rates to rent, interest, dividends. For rental income, this will be directly passed onto low income renters, and businesses that lease property.

Not onto high income renters? Landlords are fomenting a class war? Or just really hate the poor?

Regardless, the tax structure can be dealt with separately. For all useful purposes, federal government revenue is one big pot, and you can consider any dollar collected as going to any source. In practice, it's not quite so simple, but if they had any sense, it would be.

And, the mandate on employers to provide 100% coverage of face a minuscule fine ($2000 for the first 30 employees) will encourage rather than discourage employers (especially those that hire low income people) to skip providing health benefits and just pay the fines. Estimates are the up to 10 million people will lose their insurance due to employers ending their plans altogether. The non-partisan Lewin Group estimates that Obamacare will drive a total of 56 million people off their current health care insurance.

Providing insurance through employers was always a stupid idea. If this gets people off their current, employer-based insurance, that's a win for future reform. They'll still have insurance, thanks to the new system, and it will be easier to fix later.

The issue of the size of fines is a problem. I suspect fines large enough to work are also fines large enough to make the issue moot - just charge people/employers for the health care directly. I see this as one of the largest issues with the system, and a major argument for single-payer or government run health care.

New federal regulations and punitive taxes on high-ticket medical expenditures such as medical devices, prescription drugs, and high-cost insurance plans will drive up the health insurance premiums, particularly in the individual market.

We'll see about that. Insurance premiums should not respond to taxes on insurance - that makes no sense. Why would people pay more (retail) for something because they have to pay more tax on it? That should drive down prices, not up.

Regulation may have the effect of raising premiums. I haven't seen this in the predictions, but perhaps they are not considering it.

The whole risk aspect of health insurance disappears due to removing the lifetime cap on benefits, and the denial of people with pre-existing conditions. Group health plans will need to jack up their prices to cover chronically ill people now. And, yes, this does sound great when you are envisioning people with diabetes. I too thought it was pretty lame to offer insurance to those who didn't actually need it.

I'm not sure what you mean by the "risk aspect of heath insurance disappears". Risk is the entire point of insurance. Are people no longer going to get sick at different times, to different extents?

Somehow, a functional insurance system has to have the currently healthy subsidize the currently sick, in exchange for protection against future illness. You get to breathe easy, but the costs are distributed evenly across time and across people. Overwhelmingly, people who have such a system appreciate it. However, the young and stupid have a short-run, selfish incentive to defect from the system while it is less likely they need it. Another great argument for just making the whole system single payer - you don't have to bother playing this game, and you don't suffer the consequences of playing it wrong.

But then, what about the epidemic of restless leg syndrome diagnosed in California which qualifies one to get prescriptions for pot?

Easy solution to that - legalize it.

I really do want people who need health care to be able to get it, but the bulk of the cost will be consumed by this kind of general abuse by the not so sick. Yes, so we will stick it to those greedy insurance groups who make the measly 3.5% profit now, and drive them out of business. What's making us sick is an epidemic of diagnoses

The notion that the "bulk" of cost is consumed by people who do not need treatment is absolutely wrong. Show me one study that concludes anything even close to that. By my understanding, chronic conditions make up the bulk of expenditure.

The changing social nature of diagnosis has raised costs substantially, although it has also improved outcomes. That diagnosis cannot continue to increase forever and ever is one of the things that makes me skeptical of the projections for perpetually increasing medical costs. However, curbing this problem will be difficult if not impossible if doctors are selected for "customer service" in a free market system, rather than for medical competence in a system driven by professional ethics. People don't want to hear that treatment really wouldn't be worth it. They want to hear that there is a magic cure. Doctors make money off of providing that cure, whether it really works or not. The actual medical logic behind it is quite secondary, and this drives up costs.

I don't believe it will fix what is wrong with the US health insurance market, and it is not a baby step in the right direction unless you believe that perhaps destruction of the market is the correct first step.

Replacement of the market with a single-payer system absolutely strikes me as the correct first step. This goes halfway, and it is still unclear what the results will be. I predict moderate gains in outcomes, and small reductions in costs. Further reform should focus on costs much more heavily.

This all but guarantees that health care costs and spending will continue their unsustainable path. And that is a path leading to more debt, higher taxes, fewer jobs and a reduced standard of living for all Americans."[/i][/indent]

Classic Cato, ignoring any sense in which (all together now) HEALTH CARE IS NOT LIKE OTHER COMMODITIES!

I have personally been the beneficiary of two different single-payer health care systems. I use them almost never. Were I more rational, I would probably go to the doctor slightly more often than I do, for checkup and preventative things. But I don't like doctors. Very few people do. My family does not overuse health care. My friends do not overuse health care. It's just not what people do. We do not think of it in that way.

But, if Cato is to be believed, I should be consuming as much health care as I can get my hands on. This is not how people act, it's not how I act, and it's a stupid assumption that drives conclusions contradicted by the evidence from the entire OECD for the last fifty years. Taking one's ideology over empirical reality is living in a fantasyland, not that this has ever stopped the Cato Institute.

-Jester

[TheDragoon]

Edit: At the very least, many of these states have Democrat-controlled legislatures. How exactly are the Republicans going to swing that?

Give me a ring when 38 states actually amend their constitutions to forbid this - then we'll have some real fun at the SCOTUS. Until then, this is just hot air.

Washington state is one of the states noted above and I would tend to agree with Jester on this. The Washington AG, Rob McKenna, is one of the 13 AGs that are in on the original lawsuit. However, his joining in on that was against the wishes of the rest of the state government. Right now, the state lawmakers are looking for ways to force him to drop the issue so we shall see if he will be able to continue the grandstanding or whether he will be compelled to stop. In addition, given the liberal majority in the state I would expect that he will not have any power to advance legislation within the state, so he would be stymied in that avenue.

Contrary to Kandrathe's assertion earlier that the state AGs are out to make a name for themselves using public money, I would expect that McKenna's actions could end up being political suicide. McKenna has been able to be one of the lone conservatives elected in this liberal state due to the fact that, in the past, he has been pragmatic and effective without embracing conservative ideology. Now that he has shown a more partisan conservative nature I would expect to see him lose a lot of the liberal and moderate votes that put him in office.

[--Pete]

Hi,

Washington state is one of the states noted above and I would tend to agree with Jester on this. . . .

Contrary to Kandrathe's assertion earlier that the state AGs are out to make a name for themselves using public money, I would expect that McKenna's actions could end up being political suicide. . . .

I think you're 100% correct. Most of the people I've talked to don't like the plan, not because it goes too far but because it doesn't go far enough -- even as a first step. The last thing most of them want is to nullify that first step and put us back to zero. If he pushes it, he might not even last out this turn.

--Pete

[kandrathe]

Washington state is one of the states noted above and I would tend to agree with Jester on this. The Washington AG, Rob McKenna, is one of the 13 AGs that are in on the original lawsuit. However, his joining in on that was against the wishes of the rest of the state government. Right now, the state lawmakers are looking for ways to force him to drop the issue so we shall see if he will be able to continue the grandstanding or whether he will be compelled to stop. In addition, given the liberal majority in the state I would expect that he will not have any power to advance legislation within the state, so he would be stymied in that avenue.

Contrary to Kandrathe's assertion earlier that the state AGs are out to make a name for themselves using public money, I would expect that McKenna's actions could end up being political suicide. McKenna has been able to be one of the lone conservatives elected in this liberal state due to the fact that, in the past, he has been pragmatic and effective without embracing conservative ideology. Now that he has shown a more partisan conservative nature I would expect to see him lose a lot of the liberal and moderate votes that put him in office.

Perhaps he's making a stand that will elevate himself above Washington state politics, and give him the bona fides to move to the other Washington. If Washington is as blue as you imply, then it would be an exercise in frustration to attempt to keep your soul there if you were at all conservative.

[kandrathe]

I think you're 100% correct. Most of the people I've talked to don't like the plan, not because it goes too far but because it doesn't go far enough -- even as a first step. The last thing most of them want is to nullify that first step and put us back to zero. If he pushes it, he might not even last out this turn.

I don't think the entire Act gets nullified if one provision is found unconstitutional. Congress just wouldn't be able to use the IRS to penalize citizens who refuse to buy health insurance. I heard today that the Ways and Means Committee has estimated the cost to add this enforcement arm to the IRS would cost an additional 5 billion dollars per year (unfunded), and result in hiring about 16,000 enforcement agents (added to their staff of 101,054). Yay! More government jobs!

[kandrathe]

... do I even have to repeat the argument again? Look at the experience in other countries. Look at it on the whole, not just at anecdotes that confirm your presuppositions. Look at costs. Look at outcomes. They work. They are not drowning in a sea of Munchausen's patients, demanding MRIs and heart surgery three times a day.

No, but, people who need care do need to wait on lists and they are denied services if the system deems they do not need it. People with the means to pay out of pocket get preferential treatment. Health care in the US is great, but due to inflationary pressure, it does cost more. This bill will end up rationing our care, and make our health care worse in hopes of driving down the costs.

Depending on how you parse the CBO numbers, and what you include as being part of the health care bill, the number is either slightly positive, or slightly negative. It is not "entirely fictitious [and] unbelievable," unless of course you've already concluded that this is going to cost a zillion dollars, and refuse to believe any number that says otherwise.

I don't know what the real numbers are. The CBO process has become a legislative game where they send in the right words for analysis to get the number they want with crazy assumptions that don't hold a drop of water. I still think the CBO tries to be accurate, but they are given illogical assumptions to begin with.

Try 50 odd million, thanks to the recession. And that's just those uninsured for a whole year - the number for the transitionally uninsured at any given time is much higher. Your 9.6 million figure is for all immigrants, including legal ones. Check here.

I would agree that the number of uninsured would increase with chronic unemployment, and as I've said I was one of them last year. But your numbers on immigrants, I don't agree with. According to the Center for Immigration Studies, the number of immigrants is 37.9 million, with nearly 1 in 3 being here illegally.

They're set to reduce the growth of future spending on Medicare by $500 billion over 10 years. Is that a "$500 billion cut"? Maybe. It depends on how they go about containing costs. If the system is as terrifyingly inefficient as it seems to be, I have no trouble believing that there is $50 billion a year in excess cost growth that can be prevented. But we'll see.

From the WSJ article, GovernmentCare’s Assault on Seniors, "The Congressional Budget Office estimates that only 1% of Medicare cuts will come from eliminating fraud, waste and abuse."

Regardless, leaving aside "kill grandma" imagery, the quantity being spent to keep seniors alive cannot increase indefinitely. The question is, how much can you afford to spend, and what level of care can you get for that sum? The scary CBO projections involve the idea that you will spend almost limitless amounts, and get whatever care that buys. That's not a realistic way to look at the problem.

Ok, so now the government (medicare) gets to decide who gets to live, and who is beyond care.

Great! 8 million more insured. Social costs go down, risk is dispersed more evenly.

Maybe. Perhaps the parents will trim their health care insurance back, and let their kids spend the $695 in fines to the IRS. It's hard to predict. What I assume will happen is that a new low cost, low benefit, high deductible plan will emerge to be popular with kids who believe themselves to be invincible.

Well, them and anyone paying for drugs in the "donut hole," right?

What I'm saying is that the one area where you have described profits as profligate, is only getting more profitable without restrictions.

Not onto high income renters? Landlords are fomenting a class war? Or just really hate the poor?

This is an unintended consequence of taxing rental income. 64% of poor people in the US rent. If you raise costs to landlords by 15%, it will be transferred directly into the price of rent. The increase in rent price will be a larger impact to poor people, than to wealthier people with a higher ratio of income to housing costs.

Regardless, the tax structure can be dealt with separately. For all useful purposes, federal government revenue is one big pot, and you can consider any dollar collected as going to any source. In practice, it's not quite so simple, but if they had any sense, it would be.

Regardless, siphoning another 25 billion a year from the private economy for government us will help further stagnate our economy. I know you believe that spending is spending, but it will only direct a portion of the revenue (less administrative costs) toward health care, which is a market already over saturated with spending. In the private economy it would have been invested in growing all industry without bias.

Providing insurance through employers was always a stupid idea. If this gets people off their current, employer-based insurance, that's a win for future reform. They'll still have insurance, thanks to the new system, and it will be easier to fix later.

I agree that employers should be removed from the health insurance system, but as you know, I would rather it be made fully private and driven by individual choice rather than fully government controlled and rationed.

The issue of the size of fines is a problem. I suspect fines large enough to work are also fines large enough to make the issue moot - just charge people/employers for the health care directly. I see this as one of the largest issues with the system, and a major argument for single-payer or government run health care.

It shows how ludicrous system, and the fines are in the first place. If you make them too large then you will force companies to choose how to commit fiscal suicide, being forced to pay ridiculously large and ever growing health insurance premiums, or facing the wrath of the IRS.

We'll see about that. Insurance premiums should not respond to taxes on insurance - that makes no sense. Why would people pay more (retail) for something because they have to pay more tax on it? That should drive down prices, not up.

For the Cadillac health plans, most of which are bound by union contracts, the employees will get taxed on their benefit (starting in 2018, if the Act survives that long). The reason it was pushed off to 2018, was to allow the current incumbents to get clear of Washington before this time bomb explodes all over their political careers. I believe the impact will be that management and labor will need to renegotiate health care plans to bring them into price compliance, but the benefits will most likely remain forcing the remaining participants in the plans to carry the extra load for their unionized compatriots.

Regulation may have the effect of raising premiums. I haven't seen this in the predictions, but perhaps they are not considering it.

Cause and effect my dear Jester. Regulation of any commodity that increases its scarcity or demand will impact price.

I'm not sure what you mean by the "risk aspect of heath insurance disappears". Risk is the entire point of insurance. Are people no longer going to get sick at different times, to different extents?

Somehow, a functional insurance system has to have the currently healthy subsidize the currently sick, in exchange for protection against future illness. You get to breathe easy, but the costs are distributed evenly across time and across people. Overwhelmingly, people who have such a system appreciate it. However, the young and stupid have a short-run, selfish incentive to defect from the system while it is less likely they need it. Another great argument for just making the whole system single payer - you don't have to bother playing this game, and you don't suffer the consequences of playing it wrong.

Health insurance already mostly is not insurance. It is more like prepaid health care. With the new law, I can pay as little as is possible, and then when I actually do get sick opt into the premium plan and they have to let me in and pay for all of my care until I die.

Easy solution to that - legalize it.

Better solution -- legalize them all and get rid of 90% of the FDA.

The notion that the "bulk" of cost is consumed by people who do not need treatment is absolutely wrong. Show me one study that concludes anything even close to that. By my understanding, chronic conditions make up the bulk of expenditure.

Only a few people suffer acute death per year. Most of us suffer from something chronically, and eventually lethally. This is the nature of dying organisms.

Providing insurance through employers was always a stupid idea. If this gets people off their current, employer-based insurance, that's a win for future reform. They'll still have insurance, thanks to the new system, and it will be easier to fix later.

I agree that employers should be removed from the health insurance system, but as you know, I would rather it be made fully private and driven by individual choice rather than fully government controlled and rationed.

The issue of the size of fines is a problem. I suspect fines large enough to work are also fines large enough to make the issue moot - just charge people/employers for the health care directly. I see this as one of the largest issues with the system, and a major argument for single-payer or government run health care.

It shows how ludicrous system, and the fines are in the first place. If you make them too large then you will force companies to choose how to commit fiscal suicide, being forced to pay ridiculously large and ever growing health insurance premiums, or facing the wrath of the IRS.

We'll see about that. Insurance premiums should not respond to taxes on insurance - that makes no sense. Why would people pay more (retail) for something because they have to pay more tax on it? That should drive down prices, not up.

For the Cadillac health plans, most of which are bound by union contracts, the employees will get taxed on their benefit (starting in 2018, if the Act survives that long). The reason it was pushed off to 2018, was to allow the current incumbents to get clear of Washington before this time bomb explodes all over their political careers. I believe the impact will be that management and labor will need to renegotiate health care plans to bring them into price compliance, but the benefits will most likely remain forcing the remaining participants in the plans to carry the extra load for their unionized compatriots.

Regulation may have the effect of raising premiums. I haven't seen this in the predictions, but perhaps they are not considering it.

Cause and effect my dear Jester. Regulation of any commodity that increases its scarcity or demand will impact price.

(Continued due to too many quotes! -- Epic!)

[kandrathe]

The notion that the "bulk" of cost is consumed by people who do not need treatment is absolutely wrong. Show me one study that concludes anything even close to that. By my understanding, chronic conditions make up the bulk of expenditure.

Only a few people suffer acute death per year. Most of us suffer from something chronically, and eventually lethally. This is the nature of dying organisms.

The changing social nature of diagnosis has raised costs substantially, although it has also improved outcomes. That diagnosis cannot continue to increase forever and ever is one of the things that makes me skeptical of the projections for perpetually increasing medical costs. However, curbing this problem will be difficult if not impossible if doctors are selected for "customer service" in a free market system, rather than for medical competence in a system driven by professional ethics. People don't want to hear that treatment really wouldn't be worth it. They want to hear that there is a magic cure. Doctors make money off of providing that cure, whether it really works or not. The actual medical logic behind it is quite secondary, and this drives up costs.

And yet... that is a persons choice. If they have excess income that they want to devote to yearly MRI's, then that should be their choice. The problem is that the costs of the excesses (as described in the Cato paper) are not bourne by the consumer.

Replacement of the market with a single-payer system absolutely strikes me as the correct first step. This goes halfway, and it is still unclear what the results will be. I predict moderate gains in outcomes, and small reductions in costs. Further reform should focus on costs much more heavily.

Or, it might be that there is a back lash, and repeal. Neither actually go in the direction which I favor, which is to return health care to a state run program, where it can be sized to the local needs and economy.

Classic Cato, ignoring any sense in which (all together now) HEALTH CARE IS NOT LIKE OTHER COMMODITIES!

I agree. But, if we'd stop paying for it for people, except for the truly needy, the price of the commodity would come down.

I have personally been the beneficiary of two different single-payer health care systems. I use them almost never. Were I more rational, I would probably go to the doctor slightly more often than I do, for checkup and preventative things. But I don't like doctors. Very few people do. My family does not overuse health care. My friends do not overuse health care. It's just not what people do. We do not think of it in that way.

I am like you, I don't use it unless I really, really have to and I despise going to even a routine checkup. But, I know people who are over consumers too. In other anecdotes, I've heard good and bad from the Canadian, and British systems. In other places, like France, it doesn't seem to work very well at all. But, for me, that is secondary to the notion that I should be reliant on government for anything. I oppose all the social programs, except those for the extreme poor to help lift them out of their poverty.

But, if Cato is to be believed, I should be consuming as much health care as I can get my hands on. This is not how people act, it's not how I act, and it's a stupid assumption that drives conclusions contradicted by the evidence from the entire OECD for the last fifty years. Taking one's ideology over empirical reality is living in a fantasy land, not that this has ever stopped the Cato Institute.

What about their cited studies, the RAND Health Insurance Experiment, and Amy Finklestein at MIT?

Surely it is possible that something offered for a low price would be consumed more readily than if there were more significant costs associated with the goods or services. Even if health care, as you say, is not like other commodities, when price is not a deterrent you may consume it and more of it when you might not have otherwise done so. Look at knee and hip replacement surgery for the elderly, if they had to pay for a significant portion of this procedure I would bet heavily the consumption would be affected. The question is; is this improvement in their quality of life, worth the costs for tax payers? We now separate the utilitarian from the egalitarian. From the WSJ article I cited earlier, seniors who have mobility are also generally more heathly, and consume fewer services. In the long run, even something somewhat expensive might be worth the investment to reduce longer term nursing home care.

[Jester]

Epic indeed - you've even got duplicates of quotes/responses in there. :lol:

I think this has grown beyond my ability to make a sensible reply to all of it. So just a few points.

There may be 37.9 million immigrants in the US, but most of them have health insurance, so they are not counted. the 9.6 million figure is for all non-insured immigrants, not just illegal immigrants.

The RAND experiment is fascinating, but it seems to show two things that I think are important, and one that I think is obvious. The obvious one is that making people pay directly for their health care decreases use. No kidding. I definitely want my money, no matter what, and I'm sad to lose it.

What is different is that the commodity itself is not an *incentive*. I only want heart surgery if I have a heart problem. If I don't have that, you can promise me the a thousand of the best-quality heart surgeries in the world, and I won't take any of them. Equally, I don't want insulin, I don't want antidepressants, I don't want a hip replacement, I don't want an MRI, and I definitely don't want a hospital bed. Anyone who does want these things without medical need should be strongly discouraged from "purchasing" them, no matter what the system.

The non-obvious things are: when the price incentive was included, both non-necessary *and necessary* treatment went down. That is to say, people were opting out of important treatment to save money. While in superlibertarianland this is an unmitigated good (people get to choose - their money or their life!), for the rest of us, that means crappier health care. People aren't good judges of their medical needs, and delay costly examinations and treatment when they shouldn't, resulting in worse, and often less economically efficient, outcomes. What could have been treated with a bottle of pills or a minor surgery today, takes expensive medical firepower tomorrow. As the report says:

On the other hand, the HIE showed that cost sharing can be a blunt tool. It reduced both needed and unneeded health services. Indeed, subsequent RAND work on appropriateness of care found that economic incentives by themselves do not improve appropriateness of care or lead to clinically sensible reductions in service use.

Second, once a patient entered into the system for treatment, their costs were about the same. That means that people are not weighing whether or not to get procedures. They're weighing whether or not to see a doctor at all. In addition to the serious problems with self-diagnosis, this does not get at the fundamental cause of health care cost increases. To quote the report again:

In addition, cost sharing may not address the principal causes of cost growth. Cost sharing cuts expenditures by reducing visits but has little effect on the cost of treatment once care is sought. If, as is widely believed, cost increases are driven by treatment expense and new technologies, cost sharing can contribute to reducing costs at each point in time but may have little effect on the overall rate of cost growth.

Amen. The problem is that health care is getting more and more expensive, per person, per treatment, per anything. THAT is what needs solving.

-Jester

[Roland]

Interesting choice of state. My states congressional representatives were more unanimous than Massachusetts in opposition to the war, including both our Senators (Wellstone and Dayton). They are one of the states who are generally opposed to Obama-care, as it will probably mess up their own version of universal health coverage.

Our own version of universal health care is in no great shape, either. In fact, the consequences of its enactment have forced the current Governor to begin working on legislation to limit insurance companies ability to raise health care costs - particularly for businesses.

Case in point: the health care provider my company uses (6 employees) has a rate increase of 28.9% as of April 1st (when the policy renews). Before you suggest "shopping around", the company already looked into it: ALL health insurance providers in the state cost approximately the same (post rate increase). The only person who stood a chance at receiving our tax- and business-funded universal health care was me. I missed the quota (300% Federal poverty level) by about a grand. As a consolation prize, I can apply for "catastrophic" health care coverage with a annual deductible of about $4500, after which the insurance kicks in. Oh, it also has a caveat that should I in any way receive other health insurance in the future, I will have to pay back the costs provided to me by MassHealth (as my understanding of it went; I don't have the paperwork available at the moment, but there was some clause about being required to pay back what the provider spent if certain conditions were met).

So, yeah... Massachusetts was and is NOT a model for Federal-level health care. Then again, Massachusetts is not a model for ANYTHING - unless doing everything wrong is the goal. It only took two years to see the problems start to show, and that's just on the funding side of the coin. That's not even touching upon the fact that more and more medical treatment places are turning down MassHealth. So, even if you manage to receive MassHealth, you're limited in where you can exercise it. Same complaints as so many other insurance companies - hospitals, dentists, you name it refuse to do business with certain insurance companies, citing complaints of fraud (on the provider's part), strong-arming, late or failed payment, etc.

It's one thing to provide health care for everyone. It's another to mandate it as a legal requirement. Without fixing the underlying problems, however, it does far more harm than good.

To summarize MY current position:
- My employer's provider is jacking up the rates almost 30% (which the company cannot afford, thus I will have to absorb the increase).
- I don't qualify for MassHealth, at least until I become unemployed (missed it by about $1,000 over the limit)
- If I do not have health insurance that fits the states requirements for 60 or more days, I get penalized at the end of the year (on my tax returns - I am unsure what the penalties are, but denial of refunds and/or additional penalties are likely).
- Even if I did qualify for MassHealth, a sizable portion of the medical service industry would refuse to accept my insurance - thus leading to out-of-pocket expenses.

Yep, it's a great system. I truly love my state.

[Jester]

It's one thing to provide health care for everyone. It's another to mandate it as a legal requirement. Without fixing the underlying problems, however, it does far more harm than good.

Ouch. Those problems certainly sound painful to deal with. Why is RomneyCare reasonably popular is Massachusetts, then? Is it just that people haven't run into the problems yet? Or not considering the costs enough?

Sounds to me like there are all sorts of fun holes with the system. Makes me glad I live in single-payer land - don't have to sweat any of it, personally.

-Jester

Edit: Make that very popular.

[Roland]

Massachusetts likes their health care, and I suspect the rest of the US is going to come to like their very similar care quite soon.

Those who were smart (cynical) hated it from day one. Those were were naive (ignorant) loved it... for the first two years. Now the dirt pile has grown into a mountain under the rug - can't sweep it under there anymore.

1) Insurance companies are jacking up rates in the league of 15% - 45% for businesses to cover the "costs" of MassHealth.

2) Medical providers are refusing to accept MassHealth due to a multitude of issues - most notably late / absent payment by the provider.

3) Only those who fall below their wage caps qualify for MassHealth (under 300% of Federal Poverty level - that's approximately $32,400 for a single person, and I think a cap of $66,000 for a family). Essentially, if you make enough to live in this state, you don't qualify for MassHealth. Buy your own health insurance or be fortunate enough to get it through your employer.

The state put the cart before the horse when they came out with MassHealth. They screwed up, on many fronts, but the most basic was not drafting legislation to control the insurance companies when they came out with the package. Personally, I'm not a fan of Obama-care, but then I'm cynical, and I'm coming from an enlightened position. I've seen what can go wrong first-hand when things are handled improperly, and in the rush to get this thing out the door I worry the same mistakes will be made. That's not to say I'm not in favor of change - I am. It just has to be the RIGHT change. Demanding health care for everyone is great, but if you don't fix the underlying issues, you're dooming everyone. From what little I've managed to glean off the net (mind you, I've put virtually no effort into this) it seems they've thought of some of this in advance, and are taking steps to ensure things go off more smoothly than they did here in Massachusetts. I hope that pragmatism continues. It will certainly be needed if this bill is going to do what those in favor of it hope it will do.

For myself, I'm not overly concerned about the federal level. The bill has passed, the stage is set. Whatever comes, comes. I have enough to worry about on a state level to not concern myself overly with the federal level.

[Roland]

Ouch. Those problems certainly sound painful to deal with. Why is RomneyCare reasonably popular is Massachusetts, then? Is it just that people haven't run into the problems yet?

Sounds to me like there are all sorts of fun holes with the system. Makes me glad I live in single-payer land - don't have to sweat any of it, personally.

-Jester

Where are people espousing the joys of MassHealth? Certainly no one I know of is - at least not anymore. When it first came out, yes. Lots of people sung praises. Finally they could have affordable health care! Mind you, it was mostly for those who were either unemployed, or only had part-time work (and thus absolutely needed MassHealth to qualify for the insurance requirement in the tax code), but still there were positive words about the whole ordeal (at least by some). These days, though, I don't hear too many people jumping with joy about it. I hear about how medical service places are refusing to accept it. I hear about how the insurance companies are jacking up rates to businesses to cover the "costs" of the plan. I hear about how those who fall within the wide gap of the income caps can't afford to get their own health insurance. Maybe I'm not hearing the full spectrum - entirely possible. Mostly I'm hearing about its problems, but perhaps that's from a biased point of view.

I will say, at the very least, it's worrisome when you start hearing about medical providers not accepting MassHealth. Its bad enough when they won't accept some of the private health insurance companies, but to not accept the government-offered insurance (and for the same reasons!)? That is not a good sign. Besides, as I said businesses in Massachusetts are the ones footing the bill for MassHealth. The private insurance companies are forcing large rate increases onto businesses to pay for the deficit MassHealth has cost them, to the extent that the Governor has decided to step in and start working on legislation to prevent it. I have little faith in our Governor to do anything except wring every possible dollar out of the state for his own gains, but that's another issue entirely. Needless to say, something has to be done, and it's a good thing that someone in power is starting to address the issue. I only hope something constructive and meaningful comes out of it all, and soon, or the problems may become far-reaching.

Edit:
Wikipedia was a decent, unbiased write-up on MassHealth. It touches upon some of the inherent problems with the system, but doesn't hit completely home on all of them. On the other hand, it does push the positive aspects of MassHealth, though some of them are rather paper-thin in comparison.

Some of my favorite tidbits:
"In February 2008 the Boston Globe reported that Commonwealth Care covered 169,000 people and had a projected cost of $618 million for the fiscal year. By June 2011 enrollment is projected to grow to 342,000 people at an annual expense of $1.35 billion. The original projections were for the program to ultimately cover approximately 215,000 people at a cost of $725 million."

"Massachusetts' problem of overcrowded waiting rooms and overworked primary-care physicians (who were already in short supply) has been exacerbated by the influx of patients now covered. One criticism of the program is that it has done nothing to realign incentives for MDs to provide primary care."

"Initial bids received by the Connector showed a likely cost for the minimum insurance plan of about $380 per month. The Connector rejected those bids, and asked insurers to propose less expensive plans. New bids were announced on March 3, 2007. The Governor announced that "the average uninsured Massachusetts resident will be able to purchase health insurance for $175 per month."[37] But plan costs will vary greatly depending on the plan selected, age and geographic location, ranging from just over $100 per month for plans for young adults with high copayments and deductibles to nearly $900 per month for comprehensive plans for older adults with low deductibles and copayments."

[Jester]

Where are people espousing the joys of MassHealth?

Well, I linked to an article giving the results of polling. It looks like, as of Sept. 2009, that it still commanded a large majority of support - 59% support, 28% oppose. If that were an election, it'd be a landslide. Support has been eroding, but it certainly hasn't shifted to net negative, or even 50-50.

Maybe I'm not hearing the full spectrum - entirely possible. Mostly I'm hearing about its problems, but perhaps that's from a biased point of view.

Unlike the weather, people don't randomly talk about how nice their health care is. You hear the problems much louder than the benefits, and everyone likes to kvetch. Which is not to say that, simply because it is still popular, Massachusetts health care is a great way to go. I don't think we know enough to really judge yet, but I certainly hope the Federal version deals with some of the problems you've outlined.

As I said, it sure ain't the bill I would have passed, if the US Senate gave a hoot what I think.

-Jester

[Occhidiangela]

Dear morons:

This (morons) means eppie, and maybe a few others.

The House passed a spending bill, one among others, but not a commensurate revenue generating bill that pays for it. What matters is scope and scale here.

THis is sorta like GW Bush and his majority funding a war on a credit card: unfunded mandate, to be paid for by some nebulous future revenue.

Sorry, I am not impressed with this change and hope, version 2.0. On top of the largess of Bush's not paying for that war, but deferring that payment to a future revenue stream, we have now added something else, a certain special something that becomes an entitlement, also unfunded in the out years.

Jester, that last sentence I ask you to pay particular attention to, as you proclaim to be a student of economics.

What Freakin' Free Lunch are these people counting on?

My grandkids are broke, and not even born yet. Thanks, W and O, ya both deserve my contempt and spittle. Be in the same room as I, and you'll both get it, in the flesh.

Baby Boomer presidents: zero for three. Do NOT vote for a Baby Boom president EVER again.

Ever.

"Talking 'bout My Generation," aka the generation of abysmal failures in the White House.

And as for brains, F*** me, Gerald Ford looks like Einstein compared to Clinton, Bush II, and Obama.

Occhi

[eppie]

My grandkids are broke, and not even born yet. Thanks, W and O, ya both deserve my contempt and spittle. Be in the same room as I, and you'll both get it, in the flesh.

No thanks to you and your fellow citizens. That think tax paying is unconstitutional. And we are not only talking about your grandchildren. Grandchildren of people in other countries pay the consequences of your and my fellow countrymen.

Don't blame Obama and Bush for the fact that you are not able to vote for the right people that can make a country run smoothly. You get what you deserve. Most people with a good income just find having 6 cars more important than a good health care system for people that are less lucky. I'm sure Obama wanted to make the system better and cheaper, but that wouldn't get him the votes he needed.

The thing is; you actually have a point ranting about huge spendings that will have to be paid by future generations, but using that to complain about health care for everyone is just out of place.
I can't remember you complaining so much when we told you right here that it would have been better for everyone if Bush didn't decide to spend so much money to go to war in Iraq.
(but you seemed less grumpy in those days:D)

[Jester]

The House passed a spending bill, one among others, but not a commensurate revenue generating bill that pays for it. What matters is scope and scale here.

Yes, it does. Specifically, this bill, gigantic though it may be to mere mortals, is small change compared with existing health care obligations, with the defense budget (both ongoing and exceptional for the Iraq and Afghanistan wars), social security, or any one of the other extremely expensive things the government is involved in.

So, while this bill increases the scope of health care quite substantially, it is only a moderate increase in scale.

THis is sorta like GW Bush and his majority funding a war on a credit card: unfunded mandate, to be paid for by some nebulous future revenue.

Well, not entirely. The bill does contain some measures for increasing revenue, such as the excise tax on "cadillac" health care plans. I sincerely doubt that is a wise way to generate revenue, but it's in there.

Plus, on the cost of going to war "on a credit card" (twice!), this bill could have been funded from here until your grandchildren's grandchildren have grandchildren. Scale and scope, as you say.

On top of the largess of Bush's not paying for that war, but deferring that payment to a future revenue stream, we have now added something else, a certain special something that becomes an entitlement, also unfunded in the out years.

Jester, that last sentence I ask you to pay particular attention to, as you proclaim to be a student of economics.

Duly noted. I hope I have been consistent: I believe in higher taxes to fund the programs I advocate. If those taxes are not forthcoming, and no other cuts can be made to make up the shortfall, then there's only one answer left, which is the answer to your next question...

What Freakin' Free Lunch are these people counting on?

Inflation. If they don't have the wisdom to keep growing health care costs down, nor the testicles to raise taxes to balance the budget, then inflation is the last remaining option.

(Afterthought: Economic growth, as well, of course. Today's economy is small compared with tomorrow's, in all likelihood, and revenue should increase accordingly. But, that's not a "free" lunch in any sense, and the economy is unlikely to grow so large that these costs become trivial.)

My grandkids are broke, and not even born yet.

Probably a touch dramatic, no? The US is not in a pretty situation, but it is still an enviably rich country. Moderate cuts combined with moderate tax increases could set the fiscal balance straight again, without moving the US tax rate outside of the normal OECD range.

However, in defence of Mr. Obama, and against Mr. Bush, if Bush had pursued a policy of fiscal responsibility during the good times, he would have left the country in much better shape. If Obama started cutting programs and raising taxes today, with unemployment barely below 10%, he'd trigger another economic crisis. The correct time to attack these problems has passed, and will come again soon, but it's not right now.

-Jester

[kandrathe]

The RAND experiment is fascinating, but it seems to show two things that I think are important, and one that I think is obvious. The obvious one is that making people pay directly for their health care decreases use. No kidding. I definitely want my money, no matter what, and I'm sad to lose it.

That is all I'm asking for. Some personal investment in every health care decision, even if it is just a fraction of every cost with some significant deductible (even as low as $3000 per person per year).

What is different is that the commodity itself is not an *incentive*. I only want heart surgery if I have a heart problem. If I don't have that, you can promise me the a thousand of the best-quality heart surgeries in the world, and I won't take any of them. Equally, I don't want insulin, I don't want antidepressants, I don't want a hip replacement, I don't want an MRI, and I definitely don't want a hospital bed. Anyone who does want these things without medical need should be strongly discouraged from "purchasing" them, no matter what the system.

I agree with you. However, for those that do consume, if you are offered option A for $1000 per month, versus option B for $100 per month for a chronic condition you might not care which one if your cost for the more expensive option is $120 per year, as opposed to hitting the deductible cap of $3000. Currently, our insurance system drives the costs of all goods and services down to a small fraction of the true price, where the consumer behavior is skewed. If I'm offered a Cadillac for the price of a Yugo, I'll take the Cadillac every time.

The non-obvious things are: when the price incentive was included, both non-necessary *and necessary* treatment went down. That is to say, people were opting out of important treatment to save money. While in superlibertarianland this is an unmitigated good (people get to choose - their money or their life!), for the rest of us, that means crappier health care.

In superlibertarianland it's this thing I like to call personal responsibility. If you want to drive a motor cycle without a helmet, then I will have less sympathy when your brains are being scooped up off the interstate. No matter how hard you try, you will not be able to legislate away stupidity. Even if we were to all be locked up in rubber padded cells with restraints, some adrenaline junky would figure out how to hurt themselves. Are we going to ban 3 wheelers, big macs, salt, sky diving, speed boats, hockey, snowmobiles, ski racing, surfing, shark diving, para-sailing, hang gliders, rock climbing, spelunking, hunting, mountain climbing, trans fats, ladders, icy sidewalks, sports cars, sun tanning, and listening to radios while bathing? One of the thrills of living is getting very close to dying, and unfortunately some of these dare devils end up permanently damaged, but not dead. Also, until we perfect immortality (which will have other social consequences), we are all chronically doomed to die, and usually our waning years are expensive. Should we trade our freedom of choice for the security of health care on demand?

People aren't good judges of their medical needs, and delay costly examinations and treatment when they shouldn't, resulting in worse, and often less economically efficient, outcomes. What could have been treated with a bottle of pills or a minor surgery today, takes expensive medical firepower tomorrow.

Nothing says "nanny state" more than this last statement. You are offering a world where the government will ensure (by force of law and penalty) that I will be healthy. I agree that many (perhaps most) people do not have much common sense. Perhaps you might be correct that many (some) people will not make the best decisions regarding their health maintenance(but, I can't see how it could get worse). I don't believe that enforcing common sense is a role for our government. This is supposedly done under the guise of compassion for others, which I fear is really a selfish concern for limiting the costs of stupidity incurred by the society as a whole.

I do see a role for government in preventing us from harming others, but if we harm ourselves due to our own lack of common sense, then it should be our own burden. It is the grim reality of Darwin's survival of the fittest expressed into our modern society. Actions have consequences, and to remove them will be to actually encourage the unhealthy behaviors.

As the report says: <blockquote>"On the other hand, the HIE showed that cost sharing can be a blunt tool. It reduced both needed and unneeded health services. Indeed, subsequent RAND work on appropriateness of care found that economic incentives by themselves do not improve appropriateness of care or lead to clinically sensible reductions in service use."</blockquote>

I agree with this as well. I would separate our plans for illness from our plans for health maintenance. Illness can be insured, and works well with actuarial risk. Everyone needs health maintenance, and it should be in your own self interest to become as healthy as is possible. Thus, encouraging the consumer behaviors that will lead to health, such as eating correctly, exercising, and seeing your doctor and dentist for preventive maintenance. So, the product for health maintenance should be a prepaid health plan, where you buy limited access for illness prevention.

Second, once a patient entered into the system for treatment, their costs were about the same. That means that people are not weighing whether or not to get procedures. They're weighing whether or not to see a doctor at all. In addition to the serious problems with self-diagnosis, this does not get at the fundamental cause of health care cost increases. To quote the report again: <blockquote>"In addition, cost sharing may not address the principal causes of cost growth. Cost sharing cuts expenditures by reducing visits but has little effect on the cost of treatment once care is sought. If, as is widely believed, cost increases are driven by treatment expense and new technologies, cost sharing can contribute to reducing costs at each point in time but may have little effect on the overall rate of cost growth."</blockquote>Amen. The problem is that health care is getting more and more expensive, per person, per treatment, per anything. THAT is what needs solving.

Again, I agree. But again, moving to simple economics we know that this is a supply and demand problem, and that the price of a good or service is set by the amount of money that the consumer is willing to pay. Employers typically pay around 60% of the direct costs for the insurance plan, and the employee has the 40% taken from payroll deductions. This is the first way in which costs are masked. I only see the $200 per month missing from my paycheck (whether I consume health care or not).

Second, it's a group plan, so most of us are paying for the consumption of a few chronically, critically ill people. When I end up getting cancer or heart disease, (the leading causes of death), it will be my turn to consume more resources than I (plus my employer) ever contributed into the plan. That is again if... I don't first qualify for Medicare, where the over consumption of resources by a growing number of boomers will be financed by taxing the shrinking pool of income earners. I would direct you to look at the history of cost in the US health care market before and after government intervention in 1965. (source: wpri.org) (source: CBO) From these sources I glean two import important facts; 1) personal contribution to your own health care has steadily decreased since 1970, and 2) from the CBO, innovation and technology have contributed up to 65% of the increase in health care costs.

One answer, which I reject, is the collectivist answer which is to have government take over all health care and remove it from the private economy. They can then determine who needs it and who does not, who will live and who will die. They can set the prices, wages, and set up the limited number of queues for a limited number of services.

I think we are smart enough to determine how a private sector, free market version of health care, health insurance, and health maintenance can be structured which will allow the market to set price.

[Bolty]

Dear morons:

This (morons) means eppie, and maybe a few others.

Time to step back, Occhi. I thought better of you. Debate the issue, not the person. This thread could go to total crap very quickly and I don't want to see that happen.