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January 22, 2007

Comments

Look, we've been watching this rolling train wreck of a government for nigh on six years now. Let me cut to the chase:

Which is to say: as a way of solving any problem, from Iraq to global warming to port safety to food safety to pollution, this is not a serious plan.

Cut and paste at will. This phrase suffices to describe virtually everything the Bush administration has done from the beginning.

Hm, how to describe it?
You will get coverage only if you can proof that you never were ill in your life and never will be. If any relative of yours (living or dead) does not fulfill the same condition, we will charge extra. ;-)

> I can't really see any reason why people who
> are self-employed, ..., shouldn't be treated
> the same as those whose employers provide
> their health insurance ...

I think that self-employed are treated the same as businesses - at least I've been taking it as an adjustment to income (line 29 on 1040).

It unwisely encourages workers to choose overly expensive, gold-plated plans.

I have to agree with you in that I have no idea what this means. I’m clueless as to how me choosing the PPO plan makes the basic HMO plan more expensive for someone else. If anything I’m paying for benefit options that I don’t generally use, which should actually make coverage cheaper for someone else.

American insurance companies appear to have fought tooth and nail against "Canadian-style" single payer plans, because these plans would impinge on their right to do business. So having gained the right to do business, they appear to have chosen, in many cases, not to. Rather than obtain the right to insure people, they seem to have obtained the right to prevent people from getting insurance.

I have no objection to a free market in medicine and health insurance. By all means, have a free market: either let anyone hang up a shingle as a medical practitioner, as anyone today can hang up a shingle as a web designer or a programmer, or else regulate the business the way the government regulates aviation, shipping, and railways: allow any possible business model within a set of strict government-set safety of life guidelines. But let us not have a legislated professional monopoly and then defend it on "free market" grounds.

Gold Plated means non-Health Savings Account

Whether the issue is troop surges in Baghdad, replacing top attorneys, or deciding that some have too much health insurance, the Bush Administration takes Benjamin Franklin's words to heart:

"So convenient a thing it is to be a reasonable creature, since it enables one to find a Reason for everything one has a mind to do."

Maybe the American Enterprise Institute counseled Bush as follows:

Mr. President, now that we have successfully removed the disincentives for dying by killing the Death Tax, our next move should be to remove the incentives to see a doctor in a timely manner, thus moving the American public closer to a tax-free death.

Frankly, I wouldn't worry too much about GWB's toothless proposal. He is no position to offer up a serious plan for fixing our health care system - no political capital, nobody trusts them to even know what the problem is, any plan of his will never get through Congress, etc... This is just a distraction, just like previous "big ideas" trotted out at the SoTU. They aren't designed to be implemented, just arouse some interest.

I picture some speechwriters and policy wonks political hacks sitting around trying to figure out what the minor key of the SoTU might be.

"What're the kids talking about these days?"
"Mars!"
"We did that one already."
"Republican corruption!"
"Why, I oughta!"
"Healthcare?"
"Perfect! Gimme 200 words on healthcare and make it ZING!"

Well, let's take a look at those expensive, gold-plated insurance plans. Who is paying for them? Why, the employer, of course. Which is to say the stockholders, who are most likely members of the 5% of the population who own 90% of everything.

So those health benefits are being paid for with money that could be in a rich person's pocket.

I'm surprised Bush didn't gag on such a mild word as unwise.

FemDem: "Gold Plated means non-Health Savings Account."

Oh God, I hope you're wrong. If he does propose that, it will be time to reprise my last post on HSAs.

I think that self-employed are treated the same as businesses - at least I've been taking it as an adjustment to income (line 29 on 1040).

That works if you're self-employed. But if you're not, and just buy insurance yourself, maybe because your employer doesn't provide it, it doesn't. Instead it goes into medical deductions, which is not very helpful.

Switchgrass is high in fiber and improves the wind, don't you know.

The Secretary of Switchgrass picks up the phone. The White House is on the other end. This, two hours after the State of the Union address has proposed the new National Switchgrass Initiative.

"Congratulations, Mr. Secretary, we're cutting the switchgrass budget. Plus, we think there may be switchgrass growing on Mars, so we'd like you to shut down your operations and start looking there."

Secretary: Very clever, Mr. President. That'll divert their attention! When does the bombing begin?

President, heard in the background: "Heh,heh, heh heh, heh heh heh, hynu heh heh, why do you think we call it switchgrass, hyunh, hyunh ha?

It is very educational one can learn a lot

It is very educational one can learn a lot

I think the logic here is a little strange.

First we are told that the employer-based plans, more or less, are "gold-plated." I suppose he means that because insurance is tax-free income employer-paid plans are more elaborate than they would be otherwise, and the demand for health care thus rises, increasing prices.

But the proposed solution appears to be to extend the tax benefit to people buying individual plans. As someone who has an individual plan (expensive, but automatically available with rates based on zip code and age - thank you Massachusetts) I don't mind getting a tax break, but I fail to see how this proposal addresses the real problem. If Bush's statement of the problem is accurate, won't this make things worse?

I don't understand Bush's Gold Plated objection. I'm market friendly. If people want to pay for Gold Plated, go for it. The problem of health care is at an intersection of the following interests:

Basic normal health issues

End of life issues

Catastrophic surprises

Funding new health care products or techniques

Medical care is a scarce resource. If the demand is not restrained, prices go up. If we cap prices something has to give in the above. Almost all other countries have dealt with this by allowing the US to fund medical research. They additionaly restrict one of the other areas (which one is different from country to country).

We can reduce costs. The question is what part of the current balance do we otherwise change in order to do so.

(Note this is not a defense of the current balance, but a plea to be aware of it and to study carefully how plans are going to change it)

My initial preferences would be to have people very involved in the payment of their own basic care and end-of-life care, because these are the areas where incentives work the best. The area of catastrophic surprises makes most sense to me with respect to government involvement. I would pretty much avoid meddling with the innovation system which has worked better than it ever has in the history of the world.

Last year the average premium charged for employer-provided insurance for a family of four: $11,500.

Cite: http://www.nchc.org/facts/cost.shtml

For the moment let's assume that privately purchased policies are comparable in cost. In reality, unless purchased through a non-employment-related group, they're more expensive for comparable coverage.

The 15% tax bracket tops out at about $60K if you file married / joint. If you fall somewhere in that range, Bush will give you a $1725 discount on your $11,500 premium, leaving you with a bill for $9775.

If you currently get health insurance through your employer, however, which is most professional or middle class families, your taxes are going up.

As noted above, this does nothing to help people who can't get insurance in the first place, or who are unable to afford it even at a 10 - 15% discount.

This bold plan makes coverage available to everyone who can qualify for health insurance, who doesn't get it through their employer, and who can't afford it now but would be able to if it were only 15% or so cheaper.

Everyone in that group please raise your hand.

For everyone else it's either neutral, or a step backward.

Thanks -

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If you currently get health insurance through your employer, however, which is most professional or middle class families, your taxes are going up.

Russell,

I had read something vague about this, but didn't see it in the radio address. Do you have more information? Thanks.

Looks like Bush took a page from the progressives’ playbook. This makes a lot more sense to me after reading this article. Somewhat long but worthwhile.

Sebastian claims: Medical care is a scarce resource. If the demand is not restrained, prices go up.

This is not true.

Sebastian also claims: Almost all other countries have dealt with this by allowing the US to fund medical research.

This is not true either.

Sebastian further claims: They additionaly restrict one of the other areas (which one is different from country to country).

This is such a vague statement that it could be true, but it's also so vague as to be worthless.

Bernard -

From the NYT article hilzoy cites:

"The basic concept is that employer-provided health insurance, now treated as a fringe benefit exempt from taxation, would no longer be entirely tax-free. Workers could be taxed if their coverage exceeded limits set by the government."

Thanks -

"Sebastian claims: Medical care is a scarce resource. If the demand is not restrained, prices go up.

This is not true."

Not to be too childish, but umm, yes it is.

For the purposes of conversation which part do you disagree with? Do you believe that doctors or their time represents an infinite resource? Or do you believe that scarce resources are not subject supply and demand?

"Sebastian also claims: Almost all other countries have dealt with this by allowing the US to fund medical research.

This is not true either."

That deserves nothing more than, 'heh'. But just so you don't nitpick I'll be super careful in the wording. The carefully worded claim ought to be "Almost all other countries have dealt with this by allowing the US market to fund medical research." And that one is about as obviously correct a claim as is possible in the discussion of something as complicated as health care.

Russell,

Thank you. I should have seen that myself.

I have to say that from an equity point of view this doesn't seem like a terrible idea. A $7500/yr allowance for individual coverage is pretty decent. I'd be very surprised if many people got a lot more than that in medical insurance benefits from their employers, so I don't see the tax as particularly burdensome.

At the same time I agree it doesn't really solve much of the problem. I'd describe it as an innocuous effort to be able to say something about medical insurance without actually doing much.

Not to be too childish, but umm, yes it is.

Hee. I suppose I could respond "Oh no it's not!" but I think I'll just ask you to show me an example of something you're claiming as a universal truth. Show me, for example, how health care in the UK or in Canada or in France or any other country where demand is not restrained, is so much more expensive than it is in the US, where demand is actively restrained.

For the purposes of conversation which part do you disagree with? Do you believe that doctors or their time represents an infinite resource? Or do you believe that scarce resources are not subject supply and demand?

I think that you are trying to pretend that health care is subject to market supply-and-demand: that people want expensive items like lung transplants just because they've been told they can, and not (as I think you will find in the real world) because they're going to die otherwise.

The carefully worded claim ought to be "Almost all other countries have dealt with this by allowing the US market to fund medical research."

Carefully worded, and still untrue. The claim that no national government, except the US, funds medical research, anywhere in the world, is about as untrue a statement as you will find with regard to health care.

Though I suppose you could claim that all government-funded medical research, in every nation in the world, is funded with an eye on the US market to make this research profitable: and I don't think I could prove this wasn't true, but I would ask you to find some evidence, somewhere, to show that all governments everywhere make their decisions on what medical research to fund with regard first and foremost on what Americans will buy.

"Carefully worded, and still untrue. The claim that no national government, except the US, funds medical research, anywhere in the world, is about as untrue a statement as you will find with regard to health care."

I'm sorry that you aren't understanding the context such as to interpret my statement as a silly claim of zero level of funding by other governments. I am talking about being able to restrain costs by lowering funding levels. A huge majority of medical research takes place either in the United States or is funded by profit which can be obtained in the United States. Even the 'European' drug companies make a vast amount of their money in the US market. This means that in order to maintain the current level of technological advance (which maybe you don't care about--a different issue) other countries don't have to pay as much as they otherwise would have to.

"I think that you are trying to pretend that health care is subject to market supply-and-demand: that people want expensive items like lung transplants just because they've been told they can, and not (as I think you will find in the real world) because they're going to die otherwise."

I'm sorry, what does that have to do with the fact that medical CARE is a scarce resource? And if you were reading carefully, you would note that I broke out a number of different things from the lump 'health care' only one of which was the catastrophic kind of care that you are talking about.

I, too, would be interested in knowing what Sebastian means by constraining demand for healthcare.

Constraining demand at least sounds like there's just too darned many people consuming too darned much healthcare when they don't have to.

I'll grant that's true when it comes to elective/cosmetic procedures, but those aren't covered by any insurance policy I know of, and therefore are not what people refer to when they're talking about the need for better healthcare in the US.

So what forms of medical care are left to be constrained? Which ones do you consider optional?

This means that in order to maintain the current level of technological advance (which maybe you don't care about--a different issue) other countries don't have to pay as much as they otherwise would have to.

Ah, now that's a more realistic claim than your claim that only the US funds medical research. Fair enough. You're still not presenting any evidence for it, I see, but it's less fantastic than your initial claim.

I'm sorry, what does that have to do with the fact that medical CARE is a scarce resource?

By the fact that most people only want medical care when they NEED it. Your assertion appears to be that unless demand is artificially restricted, as in the US (known worldwide as a bastion of cheap health care /Fe) costs will go up wildly. But if you consider that most people only make use of health care when they need it, and not when they can afford it, it's more sensible and less wasteful to provide health care when people need it, and only what they need, rather than the US ideal of only providing health care when people can afford it, and only what they can afford.

"Though I suppose you could claim that all government-funded medical research, in every nation in the world, is funded with an eye on the US market to make this research profitable"

Nope. Not ALL. Just a huge majority.

"But if you consider that most people only make use of health care when they need it, and not when they can afford it"

I don't consider that because demand for health care really does go up when prices go down.

"I, too, would be interested in knowing what Sebastian means by constraining demand for healthcare.

Constraining demand at least sounds like there's just too darned many people consuming too darned much healthcare when they don't have to."

In reality the government is likely to attempt to control demand and supply. And there is a really tricky problem do be negotiated as well. Let's look at the narrow and relatively easy area of 'basic health care'. For purposes of discussion we'll talk about it as dealing with routine (though sometimes chronic) health care issues. This specifically excludes low frequency catastrophic diseases (flesh-eating bacteria, most cancers, etc.) and specifically excludes end-of-life issues.

Even in this much simpler area, there is a problem with the idea that a national system will save costs such as to avoid the problem I outline above. The reality is that for basic health care issues, the middle class gets pretty darn good service (if they have insurance) and the uninsured have much more trouble. Making insurance universally available (or nationalizing health care or any other such scheme) isn't at all likely to make things cheaper without cutting some of the benefits available to the people who already have health care. You are adding lots of uncovered people. That costs lots of money. In order to maintain a certain level of funding, that means that you have to cut benefits on those who already have them. There are some savings on emergency room visits for instance--but most infections don't actually land someone in the hospital. Most will go away by themselves. Many medical conditions that can and are relieved by modern medicine, resolve themselves if given time. That doesn't mean we should want uninsured people to go untreated. What it means is that the idea that transitioning a huge population into routine medical care will be self-funded by money saved in the emergency room is much like the idea that tax cuts are self-funding because they increase growth. The theory is fine in precisely the right circumstances, but not in most circumstances.

Does this mean we shouldn't do it? No. It means we shouldn't delude ourselves about the cost. And this is in the easy area.

Any bets on what the "Wha????" moment from the SoTU will be? "Manimals" will be tough to top, but in all seriousness, the only reason I plan on paying any attention is for what idea comes from nowhere and returns just as quickly.

By the fact that most people only want medical care when they NEED it.

They may just go to the doctor's office only when they are sick, but after they get there is when Sebastian's point rings true. I have an HSA, and so far I've had to pay all my bills out of pocket. I make sure my doctors know this. It's interesting to see how my bills are different for those with insurance. Fewer/cheaper tests, delayed (but not dangerously so) intervention, cheaper drugs, etc.

Plus there's the 30% or so of the total spending that occurs in a person's last year alive. I've often watched doctors do all sorts of unnatural things, in a desperate attempt to fix things that can't be fixed, in part because someone else is paying the bill.

I make sure my doctors know this. It's interesting to see how my bills are different for those with insurance. Fewer/cheaper tests, delayed (but not dangerously so) intervention, cheaper drugs, etc.

Perhaps less preventive care as well...

In response to CW: People on private health insurance schemes often don't get health care they need because their insurer doesn't want to have to pay for it - someone recently offered an example on this blog, I think, of how an MRI they needed was delayed for a year because their insurance provider kept trying to fob them off with a cheaper option.

My point is, CW, that while health care is rationed on ability to pay, yes, people who can pay more will get more, and people who can pay less will get less. This won't mean that either group will be getting the best or most effective health care options possible.

Sebastian: Making insurance universally available (or nationalizing health care or any other such scheme) isn't at all likely to make things cheaper without cutting some of the benefits available to the people who already have health care.

Given that the US currently pays double what any other equivalently advanced country pays for its national health care system, while US citizens on average actually get less health care than other equivalent countries, this kind of statement - unsourced, uncited - is remarkably unconvincing.

The VA, which operates on a smaller scale than the NHS but deals proportionally with more patients with extreme medical needs, operates more cheaply and more effectively than any private health care system. Fred at Slacktivist says that it's inappropriate to call the ability to believe things that you know are not true "faith", but if not for Fred, I'd call this an article of faith on your part - since you have got to know that you are believing what the evidence available tells you is not true.

"The VA, which operates on a smaller scale than the NHS but deals proportionally with more patients with extreme medical needs, operates more cheaply and more effectively than any private health care system. Fred at Slacktivist says that it's inappropriate to call the ability to believe things that you know are not true "faith", but if not for Fred, I'd call this an article of faith on your part - since you have got to know that you are believing what the evidence available tells you is not true."

You can opt out of the VA, and a huge percentage of people do. Why?

I don't really think it's reasonable to disagree with what I take to be Sebastian's underlying point: that health care resources are not free and that greater usage will put upward pressure on costs.

These resources are finite - X doctors, Y hospital beds, Z MRI machines, etc. Adding more will cost. Similarly, usage of health care does have a discretionary component. cw points this out, and I can provide a personal example or two myself. Not everything is a matter of life and death.

That is not to say that the current US system makes anything like efficient use of its resources. I think we can get much better outcomes for the money we spend, so there are substantial savings available to offset some of the extra cost of universal coverage. In addition, there will be benefits, social and financial, that aren't measured in the health care numbers.

I find the discussions of health care a bit frustrating, because my feeling is that we talk past each other. Pretending that supply and demand don't matter is as useless as pretending the US system is just hunky-dory, and needs only a tweak or two.

You can opt out of the VA, and a huge percentage of people do. Why?

Cite, please.

Last I checked, the number of people enrolled in the VHA system has doubled since 2000. This is not to say people don't avail themselves of the VHA; they do, but the reasons are largely geographical as opposed to any perceived quality of care issue.

You can opt out of the VA, and a huge percentage of people do. Why?

Cite, please.

Last I checked, the number of people enrolled in the VHA system has doubled since 2000. This is not to say people don't avail themselves of the VHA; they do, but the reasons are largely geographical as opposed to any perceived quality of care issue.

I cannot find the right resources to cite at this moment but, there is an argument that if you increase availability to primary care and preventative screening (let's say everyone had health insurance and went in for check ups) you can decrease spending on catastrophic medical problems. Think of an example being, we can manage high blood pressure for someone without insurance (a pretty cheap medicine most of the time) for a ton less than that same patient who never knew they had high blood pressure and wound up with kidney failure, heart conditions, etc. where prices for medicine and technology skyrocket, and costs are deferred perhaps to Medicare or Medicaid. Just one example. If memory serves me right, dialysis accounts for some astronomical amount of money in the billions of dollars (and for the most part a lot of these cases could be prevented).

Oh, my post was after thinking about Sebastian's 2:19 post.

Pooh - Perhaps less preventive care as well...

You'd think so, but in my experience I seem to be subject to a "pay me now or pay me later" mindset. I find myself willing to pay $400 for a physical, hoping it lessens the chance of a $10000 bill later on. But I'll also admit that I have the $400 to spend, so my experience is limited to those with good health and assets. Perhaps Bush hasn't ever met anyone else...

I seem to be subject to a "pay me now or pay me later" mindset. I find myself willing to pay $400 for a physical, hoping it lessens the chance of a $10000 bill later on.

This captures one of the problems of our current system. An insurer's incentive to pay now are less than yours, because there is a fair chance that someone else - a different insurer or Medicare - will pay later.

I am impressed at people's ability to survey a situation that includes (among many others) Gary Farber and conclude that the problem is that there's too much cheap care lying about.

I honestly don't see much problem with Bush's suggestion so long as it is not the end of the talk about healthcare. I've spent a lot of time b*tching myself about the fact that I'm excluded from private insurance due to my own preexisting condition, but I don't see this plan as particularly dangerous or harmful. It doesn't do much, but as long as it's not meant to be a comprehensive solution, there doesn't seem to be anything wrong with it.

Let Bush think he's solving world hunger and bringing about world peace, but the rest of us can keep talking about what's going wrong and how to address it. There are multiple universal healthcare plans out there now (I favor Wyden's, but mostly I'm just incredibly excited that it's being addressed in an honest and real way). It looks like there is a good chance of this being solved, soon, which has left me much more optimistic about politics today (and politicians' being in touch with real-life concerns) than I have been in a long time.

While I agree Bush's "gold-plated" reference is pretty muddled, I assume it's the same thing I've heard over and over the past few years: Employer-based healthcare covers so much of the cost of using medical treatment, people don't have any incentive to be cost-effective when demanding medicine, diagnostic tests, etc., so that means insurers are spending on lots of unnecessary tests, which is what drives up health-care spending.

Which some free-market fans claim proves the reason the free market isn't producing fabulously cost-effective medical care is that we consumers are mucking everything up, whereas if we had to bear more of the cost, we wouldn't squander so much of the insurer's money.

For the record, I believe there was a study that showed this holds true for people who have really, really good upper-executive class health plans, but not for the rest of us.

Certainly as someone who went without health insurance for the first two decades of my working life, I was a lot more cautious about buying care. That's why I wound up with pneumonia, because I kept thinking my cough would go away.

Conversely, when I had this nightmarish feeling in my chest late in 2005, I went and spent the day in the local emergency room without hesitation. As it turned out, it was just a massive case of acid reflux (alcohol plus chocolate--Christmas, what can I say?), but it seems to me it was exactly the kind of situation health insurance is made for.

I can't see any harm in providing a tax deduction for non-employer health insurance (other than, of course, a further loss in revenue--and I don't consider that a dealbreaker) but the fact people have been calling for eliminating the tax deduction on employer-provided health insurance makes no sense whatsoever, even for Republicans and libertarians: It's an increase in taxes (at least they'd count ending any other deductions as an increase), it's not a government-provided benefit, I can't see it helps any of their special interest groups ... But i suppose it does preserve their faith that the free market can raise the dead, heal the sick and turn night into day.

As far as "unnecessary" diagnostic tests go, I wonder how many are aware that many conditions are exclusionary diagnoses: they require (some set of) other conditions to be ruled out before they can be diagnosed.

You might have a risk factor in the hundredths of one percent for some specific condition on the list, but you still need to rule it out before you can be sure that what's really going on is (x condition).

Health care is a complicated thing -- you can't simplify it down to "if people just stopped spending so much on all this unnecessary stuff, costs would go down." Not all care rec'd is strictly necessary in 20/20 hindsight, but a lot of care does significantly improve the quality of life of those receiving it -- which is why people get that care.

This business of patients taking more charge of things is pernicious folly, by the way, for a simple reason: very, very few of us are qualified, or can get qualified.

This may be more obvious to those of us who live with chronic illness or disability, but, well, take a few cases.

You are the parent of a basically healthy five-year-old child who's developed persistent earaches. They seem to clear up in response to topical antibiotics, but despite a high standard of hygeine and a good diet for the kid, they keep coming back. Are you all that sure you want to have to play an important part in deciding on treatment?

You are a middle-aged adult, somewhat overweight and under-exercised, who eats an adequate but not great diet but takes a good regimen of nutritional supplements. There is a history of heart disease in your family. You find yourself progressively winded during the day and have difficulty sleeping at night. Your intermittent migraine headaches have become more intense, and your thyrhoid glands in the neck are persistently enlarged and sensitive. I have, as it happens, three relatives or friends who had that set of symptoms in their mid-40s. One is an adult-onset diabetic, one had thyroid cancer, one had sleep apnea and a secondary infection. Wouldn't you feel silly if you failed tot ake one of those options seriously and overrode your doctor, only to die of it a few years later?

An elderly relative is losing their memory and mobility, prone to uncontrollable spasms, disorientation, and all the rest. You read up on Alzheimer's and find it a strong match, your doctor agrees, and you proceed. After a sudden heart attack, the autopsy shows that it was Parkinson's. Good thing you were frugal with your diagnostic money, right?

The fact is that many of us are less competent to direct our diagnosis and treatment than we are to be CEO of a Fortune 500 company. Both chronic and acute complications can at any time call for knowledge and, yes, speculative hunches and "just in case" probing and a lot else that essentially none of us are in a position to judge fairly. We don't let people go into drug stores and pick any drugs they want, in any quantity, at any time, and we have professional standards for those who issue and fill prescriptions because of the knowledge problem. It is the same damn problem all through medicine.

Of course, at heart it's the class war again. No Bush or Kennedy is going to have to pinch pennies when someone in the family has a hard-to-diagnose ailment. Nor is there any rhetoric suggesting that the rich need to rein in their use of health care. This is once again about those evil poor people who haven't managed to become master physicians while holding down multiple jobs and all. And it is, as always, nonsense.

Seb: "Making insurance universally available (or nationalizing health care or any other such scheme) isn't at all likely to make things cheaper without cutting some of the benefits available to the people who already have health care."

Actually, no. A decent-sized chunk of health care costs go to things like administration, which could be drastically curtailed under a single-insurer/single-payer system, allowing for considerable savings without cutting care.

Consider the experience of Taiwan:

"This paper examines the performance of Taiwan’s National Health Insurance (NHI), a universal health insurance program, implemented in 1995, that covers comprehensive services. The authors address two key questions: Did the NHI cause Taiwanese health spending to escalate to an "unaffordable" level? What are the benefits of the NHI? They find that Taiwan’s single-payer NHI system enabled Taiwan to manage health spending inflation and that the resulting savings largely offset the incremental cost of covering the previously uninsured. Under the NHI, the Taiwanese have more equal access to health care, greater financial risk protection, and equity in health care financing. The NHI consistently receives a 70 percent public satisfaction rate."

On the VA, a quick google ("Veterans Administration" + quality + satisfaction) turned up this story, from about six weeks ago:

"Eighty-eight-year-old George Sack can go anywhere he wants for health care, but he chooses to go to the VA, CBS News correspondent Wyatt Andrews reports. That's right, the Veterans Administration.

If his choice surprises you, it doesn't surprise health care experts. In studies, including one by Harvard, and in six straight years of patient satisfaction surveys, the VA earned the highest health care quality rating in the country. It's also the least expensive. (...)

The VA is also a bargain for taxpayers, and not just because of the computers. Doctors are salaried employees, which saves on labor. Drugs are cheaper because of negotiated discounts. Even with its older population, VA care overall costs 30 percent less than the national average."

There's an enormous amount of waste in our system that's due to the fact that it's fragmented and irrational, with perverse incentives strewn all over the place. We could save a lot of money by changing it.

The essence of the conservative position here appears to be that the reason the cost of health care is going up is because people don't have to bear the full burden of the cost, and so they consume health related services frivolously.

What I want to say is that, IMVHO, this argument doesn't pass the smell test.

People who get insurance through their employer do not get a free ride. In general, they pay a significant percentage of the premium. That percentage rises every year, as does the base premium.

If you opt for name-brand pharma, you pay a much higher co-pay. You cannot consult with a specialist without getting prior approval from both your primary care physician and your insurance company. Many if not most elective procedures are not covered. Prostheses like glasses and hearing aids are not normally covered.

The only people who have "gold plated" policies are very highly compensated executive management, and people in highly sought after technical specialties. There may be some fat coverage policies left over from the glory days of labor in, for example, the automotive industry, but you can look forward to those going away in short order. The trend is, and has been for years, for consumers to bear an increasing amount of the cost of care. So much so that it puts lots of folks into financial hardship.

ObWi has a generous number of lawyers, academics, and other relatively well compensated folks on board. Show of hands -- how many have indulged in unnecessary medical procedures over the last year?

The US pays, by far, the highest per capita cost of any OECD nation, and has the worst outcomes. There are, no doubt, many causes for this, but the "unwise" consumption of medical services by folks with "gold plated" policies provided through their employers *is not* at the top of the list.

Thanks -

And Fraser: if you ever want to counter the argument that what's driving up health care costs is people being too willing to get the odd test or checkup, see the graph in the post. The amount that those of us without serious medical problems contribute to health care spending is peanuts.

"As far as "unnecessary" diagnostic tests go, I wonder how many are aware that many conditions are exclusionary diagnoses: they require (some set of) other conditions to be ruled out before they can be diagnosed."

Well the fact is that in many other countries, certain types of diagnostic tests (especially MRIs) are not used at nearly the same frequency as they are used in the United States. (Canada 1/3 UK 1/2 for instance). So whenever I hear about defects in the US system when it comes to using diagnostic tools, I'm skeptical that going toward more government control will help that.

A huge majority of medical research takes place either in the United States or is funded by profit which can be obtained in the United States.

I am pretty sure that a large portion of nonpharmaceutical medical research in this country is in fact funded by things like NIH grants.

"If you opt for name-brand pharma, you pay a much higher co-pay. You cannot consult with a specialist without getting prior approval from both your primary care physician and your insurance company."

But that won't change for the better under a more nationalized systems. Do you think the government isn't going to have a formulary? Do you think you will be able to just drop in on a cardiologist without an appointment or referral and then expect the government to pay?

I'm amenable to the idea that we can get more bang for our buck by serving the whole population. But pretending that there aren't tradeoffs is a quick way to convince me that people shouldn't be allowed to meddle much with the system. If you don't look at the tradeoffs it doesn't mean they don't exist. It just means that we are trading off stuff that we aren't thinking about--and therefore that we don't know how much we value.

Well the fact is that in many other countries, certain types of diagnostic tests (especially MRIs) are not used at nearly the same frequency as they are used in the United States. (Canada 1/3 UK 1/2 for instance). So whenever I hear about defects in the US system when it comes to using diagnostic tools, I'm skeptical that going toward more government control will help that.

Uh, Sebastian, what does your point have to do with hilzoy's???? Could your parse out your thinking here, because I'm not getting it.

"And it is, as always, nonsense"

Pernicious nonsense. But I would call Bush's morning drink:"pernicious orange juice".

Bush's Health Plan ...Ezra Klein decided to look on BHP somewhat favourable. His commenters do excellent work in the attempt to correct him, including some interesting implications for California and community rating. I could not match them. The health care debate is approaching the SS debate n blogosphere excellence. Present company included.

But twice Ezra, well to quote the 2nd:"I don't know how we expect to get critical mass for comprehensive changes if we keep subsidizing the folks getting the most from the current system. I'm not saying we burn the village to save it, but at some point, you can't keep putting out the fires yourself"

Am I seeing just traces of a "heighten-the-contradiction" Leninism here? Ezra, stick with health care, and leave the bearded bomb-throwing crazed Socialism to the experts.

"I am pretty sure that a large portion of nonpharmaceutical medical research in this country is in fact funded by things like NIH grants."

Argh. Angell has been so destructive to the debate with that assertion.

A) Getting from targets to the drug is in fact one of the hardest and most expensive parts, so the statement isn't analytically useful so far as cost goes.

B) Most medical devices don't fall under that either. And a huge percentage of the interesting growth is in new devices.

C) Most actual non-pharma therapies (techniques) have to go through huge validation protocols that are largely absorbed by private practices and hospitals.

The taxanes (for cancer) are the major counterexample, and are a notable counterexample because they represent a really rare path of discovery (going largely through NIH funding).

If NIH funding for actual therapies was really so good, why doesn't some government (say France or Germany) invest that way, use the discoveries for free in their countries and then make a killing in the US market. They could do an AirBus style joint venture and do great! They don't do it because government research and therapy creation aren't nearly as closely linked as it sounds like you think.

Sebastian: A reduced rate of use doesn't, by itself, tell us the circumstances under which diagnostic tests and gear are used. Just as two bullets in the person actually trying to kill you are better than five in random bystanders, it seems at least possible that half the number of MRIs used with twice the consideration might very well be a net gain. But that's just me looking at the principle of the thing; I'd be happy to look at data about diagnostic times and such.

I'm amenable to the idea that we can get more bang for our buck by serving the whole population. But pretending that there aren't tradeoffs is a quick way to convince me that people shouldn't be allowed to meddle much with the system.

You mean like pretending that there's no tradeoff between more and better basic care beginning with prenatal and continuing into adulthood, and less catastrophic care later? That kind of pretending?

There was an article on Yahoo! News today noting that state prison inmates are, on average, living longer than people on the outside, with the most pronounced difference being among black men. Care to guess why that is?

"Uh, Sebastian, what does your point have to do with hilzoy's???? Could your parse out your thinking here, because I'm not getting it."

That was a response to russel (which is why I quoted him ;) ) Hilzoy commented while I was posting it, so I hadn't seen her comment when I wrote it.

I'm not particularly convinced by the argument that cutting administrative costs will save enough money to add tens of millions of people to the system without additional cost. If you talk to doctors with Medicare patients (or talk to them about why they don't accept Medicare patients) you will hear about a crushing burden of paperwork with a pittance in pay that makes the patients not very worth it compared to privately insured patients. It sounds to me like the paperwork burden is still very high when the government is involved. (This also jibes with other experiences of government involvement. Government contracts are routinely much more complicated than private contracts for similar projects).

As far as Medicare payments go, it is possible to take the position that doctors in the US are grossly overpaid, so they shouldn't get more than what Medicare gives them, but I wonder about the incentive problems of convincing someone to spend 8 or so years of their life in training for a job that doesn't pay well. They might do it if they were already wealthy or if they were unusually good-hearted, but I suspect that would still limit the number of doctors in a noticeable way.

"There was an article on Yahoo! News today noting that state prison inmates are, on average, living longer than people on the outside, with the most pronounced difference being among black men. Care to guess why that is?"

Sure. They are on average younger and on average better exercised than the 18-64 population that they are being compared to.

What was your guess going to be?

The U.S. ranks highest in utilization of high-tech imaging compared to other countries worldwide, while Germany and Singapore rank high in utilization of both high and low tech imaging, a new study shows.

The study compared utilization of radiography (low-tech imaging) to CT and MR (high tech imaging) in 15 countries (U.S., Canada, Netherlands, United Kingdom, Germany, France, Italy, Spain, South Korea, China, India, Singapore, Indonesia, Brazil and Mexico) to determine how the world's radiology resources were being used.

Germany, Singapore and South Korea had the highest per capita utilization for X-ray, with the lowest utilization in India, China and Indonesia, said Mark Schweitzer, MD, of the Hospital for Joint Diseases for Orthopedic Institute in New York, and one of the authors of the study.

On the other hand, the U.S. had the highest per capita use of MR and CT, almost 10 times more than Singapore and Germany, which each ranked second in per capita utilization of high-tech imaging. The lowest MR usage was in India, China and Indonesia.

cite

If anyone can get a hold of the actual study instead of the synopsis, I'd love to read it.

Just to be clear, this is complete ad hoc speculation. If anything in it is right, I'll be pleasantly surprised.

Sebastian: I wonder if it's possible whether relatively predictable and limited access to expensive gear leads to smarter use of other diagnostic tools. This would pipe into my earlier wondering about the prudence of the expensive stuff's use.

I'm still sailing without data, though, and expect to get the respect due me for it.

I just want to point out that the study is quoting CT and MRI (hi tech) vs. X-ray imaging (low tech). It isn't CT (low tech) vs. MRI (hi tech).

"I wonder if it's possible whether relatively predictable and limited access to expensive gear leads to smarter use of other diagnostic tools."

It is possible, but I think it is at least equally possible that having 1/10th access to CT and MRI means that you don't use it in boderline cases where it would be appropriate in the US. I fully suspect that MRI is OVERUSED in the US, the only reason I bring up the point at all is because of the strange perception that a more nationalized system would lead to increased access to MRIs. If you have a case boderline enough that an insurance company can deny you access to an MRI without a big fear of getting sued, I seriously doubt you would have had easy access to an MRI under a more state-controlled system.

And yet, anecdotally, none of the friends I have in Canada, the UK, or Australia had to wait longer for MRI tests in circumstances when they were diagnostically useful than family members of mine here, and most less. This is what has me wondering about the whole thing.

(With, of course, the possibility that my sample's unusual. I know for sure it is in other ways, so I'm not using it as anything but a starting point here.)

That was a response to russel

Ahem. ;)

"And yet, anecdotally, none of the friends I have in Canada, the UK, or Australia had to wait longer for MRI tests in circumstances when they were diagnostically useful than family members of mine here, and most less."

The question I would ask about that was "diagnostically useful" in what sense? With the US 10 times the usage rate per capita, there are lots more people in the US getting the exams. I presume that in the more nationalized systems, there is a threshold of clear cases which get quickly served. At ten times the rate, you have to get quite a way from that clear case in order to start denying people. That seems especially true for people WITH insurance because that represents a medium sized subsection of the per capita number being compared to the whole population of the more nationalized systems. It seems unlikely to me that there could be some sort of unstated diagnostic efficiency with X-rays vs. CT or MRI which could make up the 15-20 times that insured Americans must be using the services without quickly spreading to the US (at least in some places)once it was identified. With that kind of statistical reality one of the following must be happening:

A) The Nationalized systems are dramatically underusing CT and MRI;

B) The US system is dramatically overusing CT and MRI;

C) The US system is overusing CT and MRI while the more nationalized systems are underusing them.

I suspect the answer is C. But in none of those cases are the anecdotes about insured people in the US having trouble getting MRIs likely to have improved stories under a more nationalized system.

Sebastian:

or D) nationalized system uses them when necessary and the US system is overusing CT and MRI because it is a way for practices to a) have their own machine, b)pay it off, and c) make up for lost profits elsewhere after 'c' is completed.

It is theoretically possible that the nationalized systems are using diagnostics perfectly. I just think the chances are low. And even if you are correct, that doesn't make it likely that insured people who can't get access to MRIs now will get them under a more nationalized system.

Seb -- I wonder about the incentive problems of convincing someone to spend 8 or so years of their life in training for a job that doesn't pay well.

So good of you to think of all the poor adjunct faculty at colleges like this ;)

Another point, Bush is going to index the amount that triggers the 'gold-plated' taxable amount of your health to inflation, but specifically not to rates of medical inflation. That means that shortly more and more of your health insurance costs will be taxed. If it doesn't 'bring down costs' you will be taxed more and more for less and less, as the years go on. Shades of the AMT.
I heard two young conservatives on the radio a few years ago touting HSA's. They indicated that people could make their own decisions as to whether to go to the ER for example. The woman interviewing them was a new mother, and pointed out that even if you were willing to take a chance on your own health, you might not be willing to do so if it involved your child. Especially if you were a new mother, and not yet familiar with symptoms of infant diseases, etc. The two young conservatives confidently told her that mothers knew these things by instinct, and wouldn't make mistakes. It's faith-based medicine.

Jes, from your 2:58, This won't mean that either group will be getting the best or most effective health care options possible.

I'd agree totally with this sentiment. The poor don't get the best, and the rich don't get the most effective. And even if I agree with Sebastian's main point about elasticity, the problem is I don't see any way the market will fix this. As mentioned upstream, for the vast bulk of expenditures, the patient usually isn't in a position (or isn't motivated or is too desperate) to make judgments about the relative cost/benefit of any procedure, so that judgement is left to other people with their own financial interests. The most obvious way to "fix" that problem is to take money out of the equation, which I think forces government intervention.

BTW, "best" being a loaded term, would you settle for "adequate"? I think we all understand that someone with enough money will usually have a better chance of finding better care than a poor person.

Sebastian: Sure. They are on average younger and on average better exercised than the 18-64 population that they are being compared to.

I'm willing to concede the argument about exercise, but how can they be living longer than the "population that they are being compared to" and still be younger? My mind boggles (well it does that anyway, but this pushed it even further)

"I'm willing to concede the argument about exercise, but how can they be living longer than the "population that they are being compared to" and still be younger? My mind boggles (well it does that anyway, but this pushed it even further)"

Because they are being compared to the general life expectancy of the 18-64 population as a whole. For simplicity lets assume a general population of 100 people even distributed across the 18-64 band (Imagine 2 people at each year to be pretty darn close). Then consider a prison population of 10 people with an age distribution of 18, 19, 20, 21, 22, 28, 28, 30, 45, 60. This population skews younger than the general population. So even though you determine the life expectancy of an 18 year old inside vs. outside, when you do the averages of the whole population you are still skewing much younger in the prison population.

But that won't change for the better under a more nationalized systems. Do you think the government isn't going to have a formulary?

No doubt. Actually, I'm not sure I'd say "for the better", and I'd actually hope any system of care would have a formulary.

My point isn't that a nationalized health care system will make all of our problems go away.

My point *is* that the reason we have high health care costs is not, or at least not, by far, primarily, due to the fact that people have health insurance and therefore help themselves to unnecessary health care services. "Gold plated" coverage plans notwithstanding.

It's actually not that easy to get a health care provider to sign off on high-ticket procedures or medications. I don't necessarily have a problem with that. Nor do I ignore that it is a fact.

As an aside, two "l"s in russell. I don't know a single Russell who uses one "l".

Thanks -

Sorry, no insult intended in the mispelling. :)

the

Concerning the use of simple X-ray, CT, MRI in Germany:
There is a tendency over here to do too many X-rays because the results are not shared, i.e. each doctor will do new ones. CT and especially MRI have to be justified (many doctors have an X-ray machine but the high-tech methods are "outsourced"). Given the state of technology the radiation dose of CT (new) and X-ray (often not) is similar, so the latter could be used instead (but for the given reasons rarely is). MRI is, I think, in most cases used, when other diagnostic methods don't yield the results wished-for, i.e. as a last measure. That way MRIs are kept low.
A "we have the device, now we have to use it as often as possible" mindset exists but regulations try to put a stopper on it.
I think for a complete picture sonography must be included because that is especially "popular" here.

Thank you, Hartmut! That sounds immediately plausible based on my experiences with medicine here. :)

Sebastian: For the purposes of conversation which part do you disagree with? Do you believe that doctors or their time represents an infinite resource?

Bernard Yomtov: These resources are finite - X doctors, Y hospital beds, Z MRI machines, etc.

I don't usually bother with such pedantry but, as Obsidian Wings' official logician/set-theorist let me just note that any resource on the Earth is necessarily finite. [Arguably, any resource anywhere in the universe is finite.] What you actually mean is something closer to "meaningfully limited" or something like that.

Bruce Baugh: The fact is that many of us are less competent to direct our diagnosis and treatment than we are to be CEO of a Fortune 500 company.

Given what I know of both professions, I'd say most people are less competent to be a janitor than they would be the CEO of a Fortune 500 company. And I'm completely serious.

I think the MRI-comparison isn't really an indication of the quality of health care.
First of all, it is an incomplete comparison, since you don't know how good the MRI scanners are - nor can you compare how effective they are used. The US has more cars per capita, but that doesn't mean your cars are better and definately doesn't mean your cars are more efficiently used...

Your study says "On the other hand, the U.S. had the highest per capita use of MR and CT, almost 10 times more than Singapore and Germany, which each ranked second in per capita utilization of high-tech imaging.". But Germany for instance doesn't have a waiting time for MRI's.

We *do* have a waiting time (5 days in the specialized centers, 2-6 weeks in hospitals), but if you're in a hurry you can go to Germany or Belgium and have a scan the next day (treatment in other European countries is covered in health insurance).

Personnally I wouldn't be suprized if the MRI scans were over-used in the States to cover for claims against negligence. It also reminds me of the studies that found that the number of appendix operations in a region had more correlation with the number of doctors than with the number of people living in the region. The same seems to true of MRI scanners.

If we forget about MRI scans and look at other factors, the US do not have access to a greater supply of health care resources than people in most other OECD countries:

despite the lack of waiting lists, Americans do not have access to a greater supply of health care resources than people in most other OECD countries. In fact, the U.S. has fewer per capita hospital beds, physicians, nurses, and CT scanners than the OECD median. One area where the United States exceeded the OECD median was the nurse staffing level in acute care hospitals. In 2002, there were 1.4 nurses per U.S. hospital bed, compared with the OECD median of 1.0 nurses per bed.

If you look at this comparison between Canada and the US for people with diabetes for instance:

CONCLUSIONS—Significant disparities exist in health service utilization for adult Caucasian individuals with diabetes in Canada versus the U.S. after controlling for various confounders. From what is known regarding optimal treatment of diabetes, those with diabetes in the U.S. have a greater chance of not receiving recommended care.

Ah, and I agree with Hartmut: the MRI is not the first thing recommended here either, but used if other tests don't find anything.

Preventive MRI is possible, but privetized (= not covered). It's currently not proven to be usefull (as even the FDA says, according to wikipedia).

Prices on the centre I looked up were 300 euro for simple scan, 1300 euro for full bodyscan, which seems not more expensive than the prices I found for American centre's.

Another point:
In Germany there are at the moment actually too many people with a medical degree and at least where I live there are regulations against too many doctors of one specialty within a district. I think there is a certain correlation of doctor-density and costs too.
From this point of view the limited resource seems to be the number of sick people ;-)
On the other hand there are regions with a lack of basic physicians because too few want to work there (and those present are tempted to leave).

"CT and especially MRI have to be justified (many doctors have an X-ray machine but the high-tech methods are "outsourced"). Given the state of technology the radiation dose of CT (new) and X-ray (often not) is similar, so the latter could be used instead (but for the given reasons rarely is). MRI is, I think, in most cases used, when other diagnostic methods don't yield the results wished-for, i.e. as a last measure. That way MRIs are kept low.
A "we have the device, now we have to use it as often as possible" mindset exists but regulations try to put a stopper on it."

Sure, but this comment isn't in distinction with the US system. Insurance companies aren't any more thrilled about paying for unneccessary MRIs and CTs (remember it is both) than the German government (which is in second place with 1/10th the number, so that isn't even talking about 3rd, 4th, or 5th place).

"Personnally I wouldn't be suprized if the MRI scans were over-used in the States to cover for claims against negligence."

I doubt they are ten times overused for that reason, but I agree with the comment in principle. But remember why we are talking about this in the first place: the suggestion was made (I believe in support of more a more nationalized system but I suppose Jesurgislac could have had other intentions) upthread that a lack of access to MRIs (by insured people) was a problem. If it is, there is no evidence that the problem would be improved by having a more nationalized system. The second most frequent usage is 1/10th that of the US.

My point is that if your complaint is about lack of access to MRIs by people who are currently insured, your complaint is likely to get worse and certainly no better under a more nationalized system.

That fits precisely with my argument that either the care of currently insured people will decline, or the cost of bringing a huge number of people into the system will be very large (and certainly not a neutral wash).

"From this point of view the limited resource seems to be the number of sick people ;)"

Well, it occurred to me this morning that if I had a gold-plated health plan and I knew my tax deductions would be cut by George Bush's plan, I and my family would run to the doctor immediately and demand some painful, expensive procedures like catherterizations fore and aft, some extensive colonic probing, and a spinal tap each, incentives being what they are.

On the other hand, if I had no medical insurance at all and expected to be able to deduct new policy costs next year under the Bush plan, I would postpone the rigorous chemotherapy I've yearned for until then, medical services being a commodity like any other.

Anarch:What you actually mean is something closer to "meaningfully limited" or something like that.

What I actually mean is "scarce" in the sense that it is costly to increase the supply, whether it is physically finite or not. This is the same as your "meaningfully limited." The trouble is that the more common meaning of "scarce," which implies that the resource is physically rare, confuses the issue. Iron, for example, is a scarce resource, even though there's plenty of it around.

Bruce:A reduced rate of use doesn't, by itself, tell us the circumstances under which diagnostic tests and gear are used. Just as two bullets in the person actually trying to kill you are better than five in random bystanders, it seems at least possible that half the number of MRIs used with twice the consideration might very well be a net gain.

It is certain that we are not using MRI's at anything close to maximum efficiency. How many MRI's do the 15% of the population that is uninsured get? Isn't it likely that shifting some away from current users to that group would improve outcomes?

fraser:the fact people have been calling for eliminating the tax deduction on employer-provided health insurance makes no sense whatsoever,

I'm surprised by the negative reaction to what seems to be the actual proposal. The tax will only hit those whose plans are about 30% above the average, and will only apply to the excess above that. If your employer provides you family coverage worth $23,000, double the average premium, you'll pay tax on $8000. Why is this an outrage? As a number of commenters have pointed out, this will affect only pretty high earners. Suppose, instead, Bush were proposing a small increase in taxes on high earners' salaries. Would there be massive objections?

I understand that this isn't going to accomplish much. But I don't see the great harm either.

Well, our friend Thomas at Red State doesn't like the plan either.

But, he at least comes up with some alternatives:

One, tongue in cheek, kill all the baby boomers (though I'd like a doctor's opinion on the location of the tongue);

and two, not so tongue in cheek, raise premiums so much on the baby boomers and everyone else who gets old, that they kill themselves.

Of course, there are those pesky anti-euthanasia laws that Red State and Thomas insist on, but we baby boomers are a clever lot. It'll just look like we did it by our own hand.

kill all the baby boomers ... raise premiums so much on the baby boomers and everyone else who gets old, that they kill themselves.

Ladies and gentlemen, your "pro-life" party!

Via Drum, Ezra Klein at American Prospect learns more about the Bush health plan (it's a tax cut for those least likely to get sick)
and pulls the plug.

Would it kill me to link? Possibly, and it's not covered under my health insurance.

The link. I was going to say that I want to be Boswell to Thullen's Johnson, but it doesn't sound quite right...

Call me cynical, but Bush's "gold-plated coverage" remark makes perfect sense to me.

It has nothing to do with any actual theory of how one person's insurance usage affects another's premiums.

It just means: "Your problems are caused by someone else who's getting a better deal than you. My plan will put those people in their place; then you will somehow benefit."

Bush has heard about this "class war" thing and figured what the hell, it's worth a try. But he had to do it in a vague and confusing way that didn't really implicate the system, just a few wayward individuals with their gold plate. PPO welfare queens.

If Klein's description is correct I apologize for saying nice things about Bush's plan. It does not even do a decent job of fixing the inequity I complained of. If your deduction is the same regardless of the plan you buy, or whether you buy one, the tax code will do nothing to encourage anyone to buy insurance.

This is really not a tax deduction for health insurance at all. It is just a complicated way of cutting taxes on most people with a small increase on some.

Hey, you're not the boswell of my samuel!

public spokesman, maybe. ;)

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