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June 19, 2007

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Unless someone truly amazing, like Gandhi, decides to run against her in the primary

Well this could be a fun game, what would the GOP say about Democratic Presidential Nominee Gandhi?

Mister Gandhi, he dead!

While I still don’t believe it’s workable (at realistic expense), for purely selfish reasons the idea of national healthcare or universal insurance becomes more appealing the older I get. If someone comes up with a plan I can at least fool myself into believing I won’t oppose it. Of course, they have to save social security at the same time.

As for Tinky-Winky – he (it?) can do Barney for all I care.

Well this could be a fun game, what would the GOP say about Democratic Presidential Nominee Gandhi?

You have to ask?

Personally, I'd vote for Gandhi for Congress but not for President.

Steve - I should have known.

Ghandi was a man who very lucky he was up against the British, who were by that point not ruthless enough to just shoot him the way almost any other colonial nation would have done.

He took non-violence to the point of basically making yourself a victim unless your opponents restrain themselves. He was lucky the British did.

Just to beat Gary to the punch: who is this "Ghandi" of whom you speak?

IIRC, Gandhi not only never ran for public office, but refused even to accept any position within his party - the Indian National Congress - despite being begged to becoming its chairman (?). Actual INC leadership thus devolved on Gandhi's close followers, such as Jawaharlal Nehru and Subhas Chandra Bose. Both were remarkable men, but neither was of the Mahatma's stature, perhaps because they had to make compromises with reality of a sort that Gandhi himself could simply evade.

(Another of his disciples is reported to have said something along the lines of "Gandhiji, you have no idea how much it costs for you to live in poverty!")

Now Joan of Arc - there's a candidate for Colorado!

OCSteve: While I still don’t believe it’s workable (at realistic expense)

Because there's something unique about the US that means it can't do what every other developed country in the world manages to do?

Or because you're so used to living with an expensive and unworkable health care system that you just assume making it better will mean making it more expensive?

Because there's something unique about the US that means it can't do what every other developed country in the world manages to do?

It's an ideological thing. We encourage entrepreneurs to come up with whatever new treatments they think will be extremely profitable. Then we make them do slow expensive testing to show that the new methods are somewhat useful and not particularly dangerous. Then we let them market the new methods to whichever doctors are willing to try them. We assert that extremely rich people should be able to have whatever medical care they can afford, and we also assert that everybody else should have whatever care they need, provided medical entrepreneurs can invent it.

With that ideology it's inevitable that health care would be more expensive than we can afford. Then we go further. We use an expensive byzantine system where insurance companies reject some claims and it isn't clear who to blame.

Medical care has to be rationed somehow. Otherwise we'll go from spending one out of every five dollars on medical care, to one out of every three, to one out of two, etc.

Without any outside intervention, the way it gets rationed is your doctor tells you you're going to die unless you get an expensive procedure, and you look at the choice -- you can spend your entire savings and go deeply in debt to have it done, or you can choose not to. Or maybe under the circumstances you aren't that good a credit risk. Ask your children to cosign the loan? Bad deal all round.

With single-payer government involved, your doctor tells you you'll die unless you get the work done, and you go on a waiting list, and you get to think about whether you'll die before they get around to helping you.

With private insurance, ideally your doctor checks and sees that your insurance won't cover the needed procedure. (Which is somewhat risky and undependable anyway.) He tells you that you're going to die. Much more comfortable for everybody. We're willing to spend a lot of money for this comfort.

Somebody has to choose which medical care we don't get. We don't want to do it ourselves and we don't want a government clerk to do it. Ideally we don't want to hear about it at all.

Why Gandhi is unsuitable as US president:

a) not born a US citizen
b) not a white Christian (though male)
c) a vegetarian (i.e. no red meat)
d) would be too obvious an outsourcing
e) not enough hair (therefore he would lose the debates).
f) looks too much like Ben Kingsley
g) a commie

That he is dead should be no problem (can't remember the constitution saying anything about "alive" as a prerequisite for running for office).

J Thomas: Without any outside intervention, the way it gets rationed is your doctor tells you you're going to die unless you get an expensive procedure, and you look at the choice -- you can spend your entire savings and go deeply in debt to have it done, or you can choose not to. Or maybe under the circumstances you aren't that good a credit risk. Ask your children to cosign the loan? Bad deal all round.

And of course, the definition of "expensive" depends on your income. For Deamonte Driver's mom, $560 was too expensive for her to afford - especially as she didn't know her children could die from untreated tooth decay.

It makes good business sense to refuse to treat people who can't afford to pay. It makes excellent business sense to deny people cheap preventive health care: that's a bulk cost with no profit in it. As a direct result, the American taxpayer ends up paying twice as much for less, because the taxpayer finally takes the burden at the point when it's going to be hideously expensive and the patient may die anyway.

Pharmaceutical companies and health insurance companies would rather whistle nonchalantly and blame expensive, expensive research (the bulk of which is actually done at the taxpayer's expense in publicly funded institutions, but they don't want you to look at that) or malpractice insurance, or anything, in fact, but the basic economic facts: health care in the US is expensive because the total costs include the health insurance companies' profit margins; the administration costs of establishing who's paying and how they're paying; and the huge medical costs of business-savvy decisions like denying a tooth extraction until the tooth decay gets bad enough to kill.

Still, I'm not convinced that any US government has the political backbone to say they don't care that establishing a national health care system will cut savagely into health insurance company profits, and to ignore the media storm that conservatives will instigate.

Jes: Neither. Because I believe that our government can’t run a lemonade stand without reams of paperwork, 42 people to squeeze one lemon, the ice melting before the first customer appears, and a 12 oz. glass costing $142.50.

OCSteve: Because I believe that our government can’t run a lemonade stand without reams of paperwork, 42 people to squeeze one lemon, the ice melting before the first customer appears, and a 12 oz. glass costing $142.50.

Just saying "Door number one" - there's something unique about the US - would have been adequate, though not as funny.

OCSteve - One of the reasons the USG has problems with efficiency is that one of the two major parties is absolutely dedicated to the proposition that government can't do anything right and they actively work to prove their point by undermining effective government programs. I do not believe it's an accident that GOP appointees tend to be lousy at their jobs - if you're appointed to do something you don't believe should be done in the first place, there's no incentive to figure out how to do it well.

Hilzoy: Can this humble lurker as for a favor? I would love to read a defense for patriotism from you, or at least a clarification of what it means to you. I favor something that I have come to identify as cosmopolitanism, though my ignorance about political theory may be part of why I do this. The reason, for example, that I do more for my local community than for others is that I have more local know-how, and can maximize my impact. But there is no privileging of nationality there at all.

Just saying "Door number one" - there's something unique about the US - would have been adequate, though not as funny.

There's a reason the U.S. had to go through a civil war before abolishing slavery.

OCSteve: Party of the reason for our gov't's inability to function properly is that the GOP actively works to make it so it can't.

togolosh pwn3d

pedro: basically, what I mean by it is: loving my country, which I take to be analogous to loving my family. Neither automatially translates into the view that you have to take care of family members/compatriots first in all situations: in the case of family members, there are situations in which you clearly shouldn't. (E.g., hiring for jobs that are supposed to be given on merit.)

Because I believe that our government can’t run a lemonade stand without reams of paperwork, 42 people to squeeze one lemon, the ice melting before the first customer appears, and a 12 oz. glass costing $142.50.

Most evidence suggests that Medicare is more efficient than private insurers. Certainly it's not a stereotypical operation where a toilet seat costs $5000.

It's hard to overstate the amount of expense and paperwork we could eliminate if we had a true single-payer system. Ask anyone who works in a doctor's office.

I said that if someone comes up with a plan I can believe in I won’t oppose it. Bring it… I ain’t getting any younger. ;)

"Because there's something unique about the US that means it can't do what every other developed country in the world manages to do?"

Yes. Just because other people can free ride doesn't mean that EVERYONE can free ride. The costs of researching medical discovery has to be paid or it won't get done. Right now the vast majority of the cost of research (wherever it is actually done) is paid for by profits earned in the US market.

You can pay the salaries of the tens of thousands of high-level scientists who will work their entire careers without every getting a product out into the health care system either by prices on the drugs which do get to the health care system, or by some other mechanism. But going to some other mechanism doesn't make those costs vanish. If you don't pay them, they won't do the work. And since we don't know in advance which ones are the ones who will discover useful stuff and which ones won't, we can't just not pay them AND expect the fast pace of discovery to continue.

You can choose to pay for discovery and continue having it, or not, but not paying and continuing to have it is a choice available to free riders, not the main payer of the system.

"Most evidence suggests that Medicare is more efficient than private insurers. Certainly it's not a stereotypical operation where a toilet seat costs $5000.

It's hard to overstate the amount of expense and paperwork we could eliminate if we had a true single-payer system. Ask anyone who works in a doctor's office."

Yet MANY doctors accept insurance who do not accept Medicare. That suggests that the government is paying below cost--which indeed makes it look more efficient than insurance companies. But that doesn't actually make it more efficient. Also many costs are outsourced to other parts of the government without showing up in the Medicare budget--see for example auditing which is done by Treasury.

Yes. Just because other people can free ride doesn't mean that EVERYONE can free ride. The costs of researching medical discovery has to be paid or it won't get done.

Even accepting the premises of your comment (that nationalized health care in the US would inevitably result in a significant slowdown of medical discovery), that's not by itself an argument against nationalizing health care. There's nothing intrinsically good about a fast pace of medical discovery -- it's a means to the end of provision of health care in whatever way you think is just and desirable. If your goal is (as mine is) health care provided in such a way as to maximize the number of healthy person-years for everyone in the US, then there's a strong argument to be made that devoting all resources currently devoted to medical research to the adequate provision of health care that has already been discovered to more people would be a net gain.

I don't think that's necessary -- I think that great improvements in the provision of health care are compatible with continued medical research and advancement -- but if a tradeoff had to be made, I'd be perfectly happy trading, say, the research necessary to develop a new heart surgery technique likely to add six months of lifespan for the few patients wealthy enough to afford it, for preventative dental care for thousands of children now not getting it.

Most evidence suggests that Medicare is more efficient than private insurers. Certainly it's not a stereotypical operation where a toilet seat costs $5000... It's hard to overstate the amount of expense and paperwork we could eliminate if we had a true single-payer system. Ask anyone who works in a doctor's office.
==========
Yet MANY doctors accept insurance who do not accept Medicare. That suggests that the government is paying below cost--which indeed makes it look more efficient than insurance companies.

I have a friend whose company operates dental clinics for low-income children, in states where such care is covered by the government. No other types of patients. He regularly states to legislators around the country that if he had to staff the clinics to the level needed to handle dozens or hundreds of insurance plans, he would lose money at the typical government payment rate. He asserts that because he staffs to the level needed to handle only a single plan, he and his staff can make a living at those government rates.

Only anecdotal, but suggests that the government rates cover the costs of service, but not the costs associated with providing payment through a fragmented private insurance system.

"I'd be perfectly happy trading, say, the research necessary to develop a new heart surgery technique likely to add six months of lifespan for the few patients wealthy enough to afford it, for preventative dental care for thousands of children now not getting it."

Who needs universal health care for that?

And aren't you choosing the easy case trade off? Are you willing to push the cure for Alzheimer's (which will effect maybe 1/3 of the population, which will cost trillions in care, and which causes enormous heartbreak for the last 5-10 years of life) off 30 years?

It seems to me that we could have the best of both worlds by having an explictly two-tiered system. Define a baseline of care. This baseline NEVER includes the most recent technology unless the new technology is cheaper than the (say 5 or 7 year) older technology--this neatly tracks the fact that most medical patents don't have an effective life of more than 5 or so years after going through the clinical process anyway. Most people who can afford insurance will still opt for it--this will spur technology. People who can't, will be regularly covered (so we won't have kids dying to stupid things like molar abcess)but won't have access to cutting edge technology unless it is cheaper. (This probably happens sometimes, but not very often).

In reality you aren't trading much, because if you were going to slow down medical research, everyone would be quite a few years behind anyway. This way you get universal coverage in the real sense of the phrase (everyone is covered for basic medical care) without killing off the goose that got us here.

Sure, that's not insane on its face -- obviously a single-payer system is going to have to replace the wildly irrational rationing of care by employment status and income we have now with some other more sensible mode of rationing.

I don't know that your plan the best way to do it, but it seems reasonably worth considering.

Not insane on the face? Oh dear, a potential area for agreement! I had better reconsider my proposition. ;)

Via an aside, you hit a key issue. One of the political problems with creating a good health care system is that lots of people want to think of it as replacing a rationing system with a non-rationing system, instead of replacing a nonsensical rationing system with a rationing system that better fits our overall needs.

Oh dear, a potential area for agreement! I had better reconsider my proposition. ;)

No, it's all good -- we're maintaining the necessary quota of disagreement in the union thread. Seriously, if universal health care were offered on those terms, I'd take it in a heartbeat. My guess is that it could be improved upon, but it's night and day better than what we've got now.

That system might even be fair, because the poor track would involve only tested treatments and the rich track would involve a lot bleeding-edge tech. The explicit class distinction would be awful for our society though.

(I seem to recall something along these lines in Frederick Pohl's _Gateway_).

"The explicit class distinction would be awful for our society though."

More awful than the current class distinction in which the uninsured only get care in emergency rooms?

Yet MANY doctors accept insurance who do not accept Medicare. That suggests that the government is paying below cost--which indeed makes it look more efficient than insurance companies. But that doesn't actually make it more efficient.

My understanding is that efficiency is measured in terms of administrative costs, not in terms of the overall balance sheet. So it really doesn't matter how many claims they pay or how much they pay for them.

But that's only a marginal point; private-sector insurers aren't woefully inefficient, we can safely assume, because efficiency is a point they compete on. If one insurer is more efficient than another, in terms of their internal administration, they can charge the same rates and make more of a profit, thus winning the competitive battle. So you can assume that successful insurers are running a relatively tight ship.

Instead, the salient point is that most of the inefficiency in our present system is inflicted on others. Doctor's offices waste countless man-hours dealing with the multiplicity of insurance companies out there, filling out different forms and adhering to different standards, resubmitting claims to one insurer after another in hopes of securing coverage. A single-payer system, by its nature, gets rid of all that.

"The explicit class distinction would be awful for our society though."

'More awful than the current class distinction in which the uninsured only get care in emergency rooms?'

Note "explicit". Now one has great, or good, or ok, or sucky, or no insurance: a spectrum. Then one will be in the live-healthy-to-age-120 class or the that-tech's-for-your-betters class.

"Instead, the salient point is that most of the inefficiency in our present system is inflicted on others."

Every bill we get for the baby leads to several phone calls to get mistakes fixed. I think we're still waiting to hear about $900 of the cost of his birth one year ago Monday.

"Note "explicit". Now one has great, or good, or ok, or sucky, or no insurance: a spectrum. Then one will be in the live-healthy-to-age-120 class or the that-tech's-for-your-betters class."

No, we would have fantastic, great, good, and government mandated-floor insurance with no one uninsured. Just like we have Mansions, nice detached homes, townhomes, apartments, and government-mandated minimum standards for apartments. But without homeless people.

The question is really what you see the point of government intervention as being. If you see it as mandating and providing the same level of health care for all people--with no one getting anything better, I suspect you are seriously risking the end of competitive-driven innovation, and I'm unaware of anything that comes close to providing such a high level of innovation.

If you see the government's role as providing the floor beyond which health care is not permitted to fall, that is a totally different story.

Rationing is going to happen under either system.

Seb: I actually don't know of anyone who is now proposing that everyone get the same level of health care in the sense of fixing a cap on the system, so that no one could pay for anything better. It's one way I can tell time has passed: in the 1970s, there were -- well, not lots, but some -- earnest articles about whether it would be OK to let people buy better health insurance than the government provided, in that mythical world in which it does provide it for everyone. Nowadays, the overwhelming consensus is: duh, of course it is.

I should say: consensus among people who write about this stuff. What, say, the tattered remnants of the Socialist Workers' Party think, I have no idea.

Yeah, I'm not arguing against a two-tiered system on the abstract merits - just that an explicitly inferior system is very classist, the sort of thing one dislikes seeing associated with govt.

rilkefan: yeah, I was arguing less in favor of Seb's system -- which I think would actually be worse for innovation, but that's another issue -- than for, say, a system in which you had to pay extra to have access to experimental treatments, or for the inclusion of certain sorts of care (e.g., Viagra has to be purchased out of pocket.)

But that's only a marginal point; private-sector insurers aren't woefully inefficient, we can safely assume, because efficiency is a point they compete on. If one insurer is more efficient than another, in terms of their internal administration, they can charge the same rates and make more of a profit, thus winning the competitive battle. So you can assume that successful insurers are running a relatively tight ship.

Two comments on this.

First, it disregards the costs incurred by the care provider. The incremental cost to add the staff needed to handle the 701st insurance plan may be small, but multiplied by 700 it turns into a significant cost. If every doctor's office must incur a cost for dealing with 700 different plans, that cost may be greater than the savings of having insurers compete.

Second, it disregards at least somewhat the way that insurance companies make money; as my father, who worked for a large insurance firm used to say, premiums are due on the first and claims are paid on the 31st, we get to hold the money in the meantime, and if we can't make 15% annually on it, we need a new money manager. It is highly profitable for an insurance company to delay payments for a month or two. So long as it is profitable to pay employees to do things that simply delay payment (Krugman's infamous statement that 15% of all employees at health insurance companies have a job best described as "deny coverage"), the system contains inefficiencies that I would prefer to see eliminated.

Again, many of the 'efficiencies' of Medicare are artifacts of pushing the costs of things into other parts of the government budget. Just because Treasury takes care of auditing doesn't mean that the costs aren't incurred by Medicare.

Afaik the efficiencies of the VA system are easy to understand and robust under study.

Sebastian: The costs of researching medical discovery has to be paid or it won't get done. Right now the vast majority of the cost of research (wherever it is actually done) is paid for by profits earned in the US market.

In the sense that those profits are taxed and the taxpayer pays, yes. But not all medical research is done/paid for in the US: the notion that the rest of the world has a "free ride" on the US in medical terms is a right-wing American fantasy, truly. One can be impressed and appreciative of medical advances made by Americans, without denigrating the global scientific community as you so frequently do, Sebastian, whenever this comes up. And the notion that American medical research just wouldn't happen any more if health insurance companies stopped raking off the profits, is to denigrate the American scientific community, too.

What I mean is: the US pays double what the rest of the world pays for health care.

This double payment does not represent extra investment going into research and testing: it represents the profits made by insurance companies and the inefficiencies caused by having to employ large numbers of people just to deal with the paperwork involved. Claims made by pharmaceutical companies that their large profits are absolutely essential to fund R&D should be taken with a grain of sodium chloride. Shareholders are not interested in pure research: that's inevitably something paid for by governments because only governments can afford to fund anything so unprofitable.

"In the sense that those profits are taxed and the taxpayer pays, yes. But not all medical research is done/paid for in the US: the notion that the rest of the world has a "free ride" on the US in medical terms is a right-wing American fantasy, truly. One can be impressed and appreciative of medical advances made by Americans, without denigrating the global scientific community as you so frequently do, Sebastian, whenever this comes up."

I'm denigrating research done elsewhere. I'm saying that a vast percentage of that is paid for because of access to profits in the American market. That isn't a bad thing about Swiss researchers. But that is where their pay comes from--profits in the US market.

No one here is British?

I read a fair amount of British fiction, and at one time (between the '50s and '70s, I think) "NHS teeth" and "NHS eyeglasses" were class-coded sneers by the "U" at the "non-U."

Britain was still poor at that time, recovering from WWII, and the quality of National Health Service care, especially for non-vital items like orthodontics and eyeglasse, was low compared with private care.

Things may have improved.

I agree that we need single-payer health care, but we don't need to import aspects of the British class system.

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