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June 17, 2009

Comments

Show me how we're going to pay for it, Eric.

If Peru can do it, so can the US.

Let's scale back military spending, repeal the Bush era tax cuts, create some higher tier tax brackets and then pursue cost control mechanisms.

"In the real world, that translates (frequently) into denying health insurance benefits under some technicality or another to those customers that are most in need and that have been paying premiums for years."

The 'that' you are talking about is the profit motive. But governments also work under economic constraints. So they tend to deny benefits based on the constraints of taxation. Since the US government already spends enough to get universal health care anywhere else in the world, but only covers 27% of people in the US, it seems possible that either the US government really sucks at providing healthcare, or that people in the US spend way more money than most people in the Western world for undetermined (or politically difficult to talk about)reasons. Either way, we are very likely to hit monetary limits well before health care desires are satisfied. We need to have an understanding about what we intend to do about that. Anecdotes about denial of coverage in insurance (blaming profits) aren't helpful unless you have some idea of how the government system will avoid denial of benefits without hitting its monetary constraints.

Or just stop fighting wars of choice. What did the price tag for the last two come to again?

Seb: costs are attributable to a few factors, some of which you listed but soft-pedaled. Drug costs are big. The particular pool of those covered now. But there are also extra costs due to overprescription that were in the new yorker article that was linked to in the comments thread in your post.

"If Peru can do it, so can the US."

I take it this is your answer to the question of why we don't have universal coverage in the US despite the fact that the government already spends more than the UK and about as much as Canada?

The government ALREADY spends that much. If it were so darn good with money and saving costs, we would ALREADY have universal coverage. Something else is going on, and unless you look at it, handwaving about Peru is just self-deception.

The government ALREADY spends that much. If it were so darn good with money and saving costs, we would ALREADY have universal coverage. Something else is going on, and unless you look at it, handwaving about Peru is just self-deception.

You do realize that the government provides health care mostly for the most expensive people to cover, right? Yes, there are other things going on that we need to fix, but there is not a linear relationship between the number of people covered and the cost of doing so.

Something else is going on. . .

Indeed it is. From where I sit, what is "going on" is that you have so internalized post-Reagan free market mantras that you sincerely believe the market would provide universal coverage if it were the most rational solution. Do you, Sebastian -- an educated man, a lawyer, a raconteur -- do you really believe that the current government expenditures on health care are indicative of expenditures under any universal plan? That seems . . . unlikely. Or willfully blind.

"...or that people in the US spend way more money than most people in the Western world for undetermined (or politically difficult to talk about) reasons."

"Undetermined"? Uhhhh, no, Sebastian; not necessarily. "Politically difficult to talk about"? No, not necessarily, either.
Especially as the two factors are basically the same thing: the profit motive: which you are so quick to cite. The excess costs Americans pay - across the board - for healthcare are mostly being siphoned off to provide fat bottom lines for the corporate entities who underwrite it. Simple.

When health care is seen - truly seen, not just talked about - as a "public good", rather than just another way to make big bucks for big companies, then these sort of abuses will become a thing of the past. Until then, it's only "difficult to talk about" because it might upset Big Business's lucrative applecart. But not hard to understand.

"So they tend to deny benefits based on the constraints of taxation."

But not based on the ability to deny benefits entirely to one specific person who happens to have a very serious illness. Public health care systems do not kick you out for the crime of being seriously ill. They may or may not cover all of the options available if you manage to keep your private insurance coverage after becoming seriously ill, but I think most sane people would agree that giving 90% of the treatment to 1,000 sick people is better than giving 100% of the treatment to 900 people and 0% of the treatment to 100 people. Of course, if they imagine that the 100 are all deadbeats maybe they could justify it in their own minds, but they should (and clearly do) realize that they could become one of the 100 with 0% treatment without having done anything wrong, simply by an arbitrary decision made by an insurance company cost-control bureaucrat with absolutely no duty of care for them - indeed with the reverse of a duty of care, they are tasked with avoiding providing care.

At least in a public system all those who are interested in controlling costs must consider that in terms of optimizing the outcomes for all comers; they simply do not have the option of kicking out people with expensive conditions. That disastrous outcome just does not happen in a public system.

"You do realize that the government provides health care mostly for the most expensive people to cover, right? Yes, there are other things going on that we need to fix, but there is not a linear relationship between the number of people covered and the cost of doing so."

Of course I realize that. Which is why I don't compare it to private outlays, but rather universal systems in other countries. They cover old people in the UK too. (They cover lots of heavier smokers as well). The point is that the US government already spends more than the UK and as much as Canada. But the US doesn't have universal coverage, and Canada and the UK do.

"From where I sit, what is "going on" is that you have so internalized post-Reagan free market mantras that you sincerely believe the market would provide universal coverage if it were the most rational solution."

You must be sitting pretty far away if you read my post as saying anything like that. I don't believe that a free market would provide universal care at a quality level that would be acceptable.

"Drug costs are big. The particular pool of those covered now. But there are also extra costs due to overprescription that were in the new yorker article that was linked to in the comments thread in your post."

Drug costs are about 10% of the total costs. If you reduced them to zero (and I suspect even you don't believe you could do that) the US government would still be spending about as much as the UK does for their entire universal health care system, and would still be covering about 27% of people. Drug costs aren't the issue. And I don't soft-pedal over-prescription, that is part of the approximately 10%. So unless you believe that the savings can go about 4 times past 100%, prescription drugs aren't the problem. They only feel like the problem because they are one of the few areas where people actually see the direct costs.

Furthermore, you don't analyze why the government hasn't fixed the over-prescription problem already. Overtreatment isn't a new issue in Medicare. It has been around since 1965.

Let's be realistic, health insurers have not operated in a free market for decades. Health insurance companies do not have to sell their services to me, they have to sell them to my employer. My employer has different priorities than I do. I need good coverage for me and my family (so I'll shop around for a company I can afford that does not have a reputation for denying claims), my employer needs to keep costs low.

In addition to the public option (which I think will cost too much, but whatever), Obama should be canceling the tax break for employer provided health care. My company pays $9K/yr for my coverage, and I don't need nearly that much. Pay me an extra $9K and let me go get my own insurance.

Paying for it:

The folks who were paying premiums and denied the product that they purchased from the health insurers were paying for their healthcare needs.

Their money was stolen. Refunds all around.

Why don't the health insurers take the next tiny step and order their award-winning employees (do they get home and take the families out to dinner with their performance award money -- hey, kids, a guy with lymphoma is going without medical care tonight because Daddy is devoted to the effing, American ethic of efficiency, productivity, profitablity, and shareholder (may their tumors grow unabated) value? You can have dessert tonight, my little predators in training) to serve a hit on these suffering people?

One bullet, maybe two, Mafia style. Expense and misery dispensed with, at little cost with more falling to the bottom line. The NRA could take the job on for target practice, the stupid gets.

Sebastian, I agree with you that something else is going on and it says something about the willful complication of our healthcare system that we can't figure it out. I don't think we're supposed to figure it out.

One item that is going on, I believe, is that Americans are thoroughly incompetent at governing themselves -- at any level. We're culturally brainwashed to become incompetent at governing.

We really don't like each other much, viewing each other, as we do, as profit-centers.

I'm already disgusted with healthcare reform this time around because by the time everyone gets their piece of the action, its going to become so complicated that the PIN number to access your healthcare account will be 73 characters long, making the guy with the lymphoma hope his disease hurries up.

Cripes. I feel better now.

73 characters long? At least it will still fit in an 80-byte record.

Show me how we're going to pay for it, Eric.

Funny how pro-lifers tend to be in favor of letting people die rather than cut into health-insurance profit margins.

Von, you're far from the only pro-lifer I know who takes that position: I guess you could call it Better Dead Than Red.

And I see Sebastian is still crying up that the US is just too inferior and awful a country to be able to provide what other developed countries manage to provide. How you hate your country, Sebastian, and how little you evidently care about making it better.

Pay me an extra $9K and let me go get my own insurance.

Do you know how much getting your own insurance will cost?

Esp. since you'd be shopping around as a "pool" of 1?

I'm unemployed, and about to begin a worker retraining program. What health insurance is out there for middle-aged students?

I looked around. Here in Washington State, I can get Group Health student insurance for $140 month - with a $10,000 deductible. $160 month premiums through another company (the name of which I can't remember) gets me a $5,000 deductible, with a $25,000 maximum benefit.

Fortunately, thanks to the stimulus package extension of COBRA benefits, I can keep my job-associated insurance for 6 months at a reduced rate of $132 per month, and another 6 months after that for the non-reduced rate of $427/month.

I don't have a family to ensure; just little ol' me. Without COBRA, it'd cost me about $5000 per year in order to get coverage like what I had under my employer (i.e., a $500 deductible and $2 million lifetime maximum benefit).

I'm willing to bet it'd cost more than $9000 per year for you to get decent coverage for your family.

You can shop around for a company that doesn't deny claims- good luck with that, by the way - but you also need to watch out for more than that. What deductible do the policies offer? Is there an annual maximum benefit; a lifetime maximum benefit? What are your second-opinion options? Can you self-refer or do you need a gatekeeper primary care physician to get such services as nutritional counseling, physical therapy, mental health counseling?

So, really; when you say you'd be happy to go find your own insurance for $9000, are you just assuming you can find something as good as what your employer offers, or have you actually gone out and priced some policies?

"And I see Sebastian is still crying up that the US is just too inferior and awful a country to be able to provide what other developed countries manage to provide. How you hate your country, Sebastian, and how little you evidently care about making it better."

I see that you are still up to your old games. But for the record, the first step to fixing a problem is acknowledging the problem. If you can't notice that our government already spends more than enough money to have the UK system, but somehow can only cover 27% of people in our country, you can't get very far. And once that is noticed, you have to explain why we already spend as much as Canada and don't have their universal system either.

Somewhere in the answer to those questions is the key to making a successful and universal US health care system. We aren't going to get there without dealing with those questions.

Anecdotes about denial of coverage in insurance (blaming profits) aren't helpful

Eric provided estimates of total numbers (20k people, $300M, 1k medical conditions), not just anecdotes. Were the totals helpful, or are you slyly pretending that all you saw were the anecdotes- and of course, it'd be silly for us to make policy based on anecdotes...

Since the US government already spends enough to get universal health care anywhere else in the world, but only covers 27% of people in the US, it seems possible that either the US government really sucks at providing healthcare, or that people in the US spend way more money than most people in the Western world for undetermined (or politically difficult to talk about)reasons.

It seems to me that these are two completely separate problems: 1)why the US spends so much on healthcare and 2)whether that healthcare should be provided by public or private means, or some mixture of the two.
You don't seem to be all that interested in the whys of point 1, just in raising it as a blocking issue to discussing point 2. If we assume (as you appear to have done) that the answer to point 2 doesn't have much effect on point 1, then I have no idea why you think it's relevant.
Also not sure why one of your choices is "the US government really sucks at providing healthcare" when the private sector seems to have as much or more trouble providing healthcare at the costs seen in the rest of the world. Other than ideology.

Why do we spend 25 times as much as Canada on defense when we're not any safer?

I don't buy that the problem with US health care stem from health insurers operating under the profit motive; non-profit health care providers (e.g. blue cross) frequently behave in very similar fashion, and other nations with UHC have providers that can operate for profit (e.g Netherlands).

That said, I also think (as I've said before) that HC hyperinflation stems from the private sector, and that von is wrong about his high spending in the public sector point.

Can we stop with the pretend ignorance? It doesn't really suit.

Medicare, like ordinary insurance, pays on a per-procedure basis. It just pays less than the private insurers. Medicaid is apparently worse. The problem with American health care is that it performs too many expensive procedures on too few people on an annual basis.

The public plan, if Ezra is a reliable source, will have to do two things. First, it will pay a "fair market" price for each procedure. So, as compared to current Medicaid/Medicare costs, the per-procedure cost will rise. (However, as many more healthier people will be in the public plan than are in M/M, the per-patient cost should drop dramatically.) Second, the public plan will have to force high-cost areas to adopt the Best Management Practices of the low-cost areas.

How much medicine is really "defensive" and how much is to increase profits? I dunno and as best I can tell not a lot of people do. But when you go to the doctor, do you insist on tests that he hasn't ordered or do you just get what he tells you?

The problem, Eric, is that public programs are under the exact same pressures, albeit in a different form. They, too, have to worry about balancing the books, and in a public system that means rationing care. I've lived in countries with public health systems and seen this firsthand. Currently, I reside in Japan. The grandfather of a Japanese friend of mine is sick with terminal cancer, and recently the hospital kicked him out because the national healthcare system judged his case financially unsustainable. He's going to die, whether it's in one month, three months, or six, and the remainder of his life is not going to be of all that high a quality no matter what, so the healthcare bureaucracy determined that it was better to spend the tax money elsewhere rather than pay for expensive cancer treatments that barring a miracle will not save his life. He's now at home receiving (inexpensive) palliative care. So, if you define "insurance" as "the right to receive any and all medical treatment for one's condition, irrespective of cost or projected medical outcome", which is what most public healthcare advocates seem to expect, he too has been "denied insurance".

Healthcare, particularly for people who are seriously ill or in the last stages of a terminal illness, is expensive, sometimes prohibitively so, and introducing a public option is not going to magically change that. There will still be cases where people are "denied care". Even raising more revenue through increased taxes, etc. is not going to fix this issue. I should say that I don't have a problem with it - if I was 85 years old and dying, I wouldn't want to be a drain on the system by insisting on expensive, futile treatments.

The U.S. healthcare system as it's currently constituted has some serious inefficiencies and structural flaws that are in need of reserve. Costs can be brought down through smart reforms (though not exclusively liberal-endorsed ones - stricter malpractice laws would also reduce them). But public healthcare is not a magic bullet, and I wish liberals would stop inhibiting productive debate by insisting it can be.


Sebastian: But for the record, the first step to fixing a problem is acknowledging the problem.

Yes indeed. When are you going to acknowledge the problem, Sebastian? Or are you going to continue to cry down the US as just way too inferior to be able to cope? Because that's a highly convenient way of avoiding the problem... pretend ignorance.

Francis: Can we stop with the pretend ignorance? It doesn't really suit.

It suits people who put profit for health insurance companies above human lives very well indeed.

Let's scale back military spending, repeal the Bush era tax cuts, create some higher tier tax brackets and then pursue cost control mechanisms.

Universal coverage will require that the better-off pay for care for the worse-off. In very round numbers, the US spends 15% of national income on health care, with an expected value of annual household spending (based on current premium rates) of about $12,000. That puts a break-even point at around $80,000: those with income above that level spend, on average, less than 15% of their income for their insurance/care, those below spend more. This is often concealed; a worker earning $30,000 in wages and receiving an $8,000 company contribution to a family policy is paying much more than 15%, there's just a sizable chunk of their income that they never see.

Assume a flat 15% tax on all income to pay for universal coverage. The poor receive a substantial subsidy and the wealthy get really socked. The household with a million-dollar income pays $150,000 per year for health care, while the value of annual care they actually consume is likely only to reach that level one or two years in a person's lifetime. The well-off, especially the rich, will fight universal coverage tooth and nail because they know that eventually they will be the ones paying for it. Despite people's hopes, I anticipate it will be several more years before the demands of the voters will outweigh the influence that the rich wield on Congress.

Xeynon: Costs can be brought down through smart reforms (though not exclusively liberal-endorsed ones - stricter malpractice laws would also reduce them).

Actually, a national health service free at point of use would tend to reduce a lot more than malpractice costs (which is not the magic bullet conservatives like to pretend). If the only means a person has of coping with the excessive costs of US healthcare is to identify someone who can be blamed and sue them for expenses, then fairly obviously, you see a lot of people taking suit.

But, if people have no particular need to raise money to pay for their healthcare, because that's all covered, then fairly obviously, you see fewer people suing... and the costs they are awarded can be lower because their healthcare costs are already covered.

But, that's too obvious and practical a benefit of a socialized health care system for lawyers to like it very much - especially as it seems to be a tenet of faith among conservatives that when the poor sue the rich for damages done to the poor, the poor are greedy and in the wrong and their presumption ought to be curbed.

But, if people have no particular need to raise money to pay for their healthcare, because that's all covered, then fairly obviously, you see fewer people suing... and the costs they are awarded can be lower because their healthcare costs are already covered.

Seems backwards to me. Unless you find a doctor willing to perform an expensive procedure on collateral-free credit, you can't sue him/her for bungling it before you pay for it. I've seen evidence that people sue in order to get money to pay outstanding medical bills, but not for future coverage. I'm willing to be convinced by evidence though.

I agree that malpractice reform is not a magic bullet, but it would help, and I just cited it as an example of a good idea for reform from the right side of the aisle on this issue.

Where I disagree, and rather sharply, is that people will have no need to "raise money to pay for their healthcare". Under a public system, people still pay for their healthcare in the form of higher taxes to fund it. That means less money in-hand to spend on other things, which means a need to tighten the belt elsewhere. Even with a tax code that's as progressive as it can possibly be without smothering economic growth, most people are going to have to pay higher taxes to fund a public system. That is, unless they're willing to accept a system that rations care, which they're not.

I also don't buy the argument that because other countries do it, the U.S. can. In the case of a poor country like Peru (cited upthread), the government can afford to offer universal care only because it is subsidized by rich countries in the form of aid and cheap drugs. In the case of wealthy countries like those in Europe or Canada, governments are able to massively reduce costs by strongarming pharma and medical technology companies into selling them drugs and equipment at artificially low prices. And those countries' systems, despite cutting costs by imposing waiting periods on optional procedures, rationing care, etc. STILL hemorrhage money - the NHS, for example, is billions of pounds in debt.

I'm not particularly sympathetic to insurance companies, or to other parties with a vested interest in the current U.S. system. But I've seen nothing to convince me that a public system is going to be more effective or cheaper than a reformed market-based one.

unless they're willing to accept a system that rations care, which they're not.

We already have a system that rations care, and does so completely irrationally.

I've seen nothing to convince me that a public system is going to be more effective or cheaper than a reformed market-based one.

So in your world, the Veterans Administration does not exist?

Several points:

1. A single payor system would be much easier to fund then a blended system with a public option. There would be increased taxes, but most people would end up paying less through taxes than they currently are for coverage (taking into account the hidden pay loss from employers' contributions.)

2. One of the reasons for the huge chunk of expenditures for Medicare as a percent of GDP is that a large portion of this population did not have great health care earlier in their lives, particularly preventive care because insurance companies seldom pushed preventive care and frequently refused to pay for doctor visits that did not result in a diagnosis of something wrong. Thus people avoided basic checkups which could have uncovered conditions early enough for basic treatment to take place.

3. Rationing should take place. We (meaning most Americans) are spoiled brats and think we should get whatever we want and have it paid for. This includes the elderly. Although private insurance frequently does deny important care, some of the denials are perfectly legitimate.
Medicare, OTOH, seldom denies coverage base on lack of medical necessity, which it should IMO.

4. The reality is that the public option is a weak cousin of the single payor system, but it is still better than the way things are right now. And the fact is, we don't know how much public option is going to cost (throw the CBO's estimate out the window as even they admit it is based on lack of details and only refers to one plan anyway.)

5. For those who talk about how Canadians are flocking across the border for care here (mostly anecdotal but I am sure it happens) why do you think thousands of Americans are flocking to places like India, Romania and other countries for health care? Not anecdotal, btw.

6. Regarding a reformed market based system, I have hyet to hear any actual reforms that would a) work and that b) the market will voluntarily accept.

7. Finally regarding non-profit companies such as some of the BCBS plans. What is interesting is that, although technically non-profit in the sense they don't have to pay off stockholders, they have built up tremendous cash reserves (at least some of them0. This allows them to go to companies and undercut the competition, take the business and then raise rates later.

8. Really finally, health insurance companies thrive in countries with single payor systems. Hell, they thrive in this country offering supplemental insurance to Medicare recipients. So don't give me any sob stories about insurance companies. They will do just fine.

We already have a system that rations care, and does so completely irrationally.

Agreed. But any public system is also going to have to ration care. If you poll people about their support for "universal healthcare" as an airy fairy, detail-free notion, a clear majority support it. Once you start discussing unpleasant specific details that any remotely fiscally solvent universal healthcare system would entail - rationing, waiting periods for non-critical procedures, restrictions on patient choice, etc. - support plummets. That's my point.

So in your world, the Veterans Administration does not exist?

You can't take data about a relatively small program that covers a limited, unrepresentative slice of the population and extrapolate it to a universal system. You need an apples-to-apples comparison.

The point is that the US government already spends more than the UK and as much as Canada. But the US doesn't have universal coverage, and Canada and the UK do.

and the US, per capita, spends more than double what the UK spends, and just under double what Canada spends. almost 3x what Japan spends. the only country that even comes close is Luxembourg (though only 5/6 of what we spend) - and it has the highest standard of living in the world.

they all beat us handily in life expectancy - which kinda sucks for those of you pinning your hopes on the "reduced quality and rationing!" canard.

why do you think thousands of Americans are flocking to places like India, Romania and other countries for health care? Not anecdotal, btw.

It's not because those countries offer superior care to that available in the U.S. It's because they offer care of comparable or slightly lower quality at massively lower costs, and without all the red tape involved in the U.S. This is due to the fact that doctors and other medical personnel make orders of magnitude less in said countries and that there is less competition bidding for high-end healthcare. My brother worked as an English teacher in Bangkok. He made $500/month doing this. One of his students was a cardiologist, working at one of the best hospitals in Thailand, who made LESS than what he did (and, unsurprisingly, wanted to move to the U.S. so that he could practice medicine where he'd actually make a significant amount of money doing so).

Even if a universal healthcare system would pay for, say, knee replacement surgery (which it wouldn't), significant numbers of people would still be flying to Romania, Thailand, or India to have it done rather than deal with red tape and waiting periods at home. Significant numbers of Germans, English, Canadians, etc. do, which you will immediately realize if you visit an elite hospital in a developing country.

Xeynon -- "Once you start discussing unpleasant specific details that any remotely fiscally solvent universal healthcare system would entail - rationing, waiting periods for non-critical procedures, restrictions on patient choice, etc. - support plummets. That's my point."

Yes, but all those things exist in the current setup as well, which means that the opposition is largely a result of rhetorical manipulation. Anyone who does not face one or more of these specific details is already in a position to find a market solution that will supplement any public plan to the point where these specific details cease to effect him. And in the mean time all of those people who are tied to their jobs because of the threat of losing coverage and those who have no coverage at all are at the very least no worse off than they were before.

Even with a tax code that's as progressive as it can possibly be without smothering economic growth, most people are going to have to pay higher taxes to fund a public system.

We're not even close to a tax code that's as progressive as it can possibly be without smothering economic growth.

they all beat us handily in life expectancy - which kinda sucks for those of you pinning your hopes on the "reduced quality and rationing!" canard.

Except that, you know, life expectancy is dependent on a number of factors other than quality of medical care, something that has been exhaustively documented. For one, people in Europe and Japan have lower rates of obesity and its assortment of life-shortening complications. Furthermore, they have lower death rates due to artificial causes - accidents, drug ODs, homicide, etc. Lastly, every country calculates statistics differently, and the U.S. has one of the most stringent standards in the world (e.g., babies who live for 12 hours or less post partum are considered stillbirths in Europe, whereas they are counted as infant mortality events in the U.S.). This doesn't prove that U.S. healthcare is just as good as that in other countries (though there are some other measures, such as cancer survival rates, that suggest just that), but it does cast doubt on the legitimacy of life expectancy figures as a reliable proxy for health care quality.

And in the mean time all of those people who are tied to their jobs because of the threat of losing coverage and those who have no coverage at all are at the very least no worse off than they were before.

This is a very good point, and something I think those approaching the question of health care reform from both the perspectives of both the right and the left I think can agree on - healthcare that's not portable between places of employment is one of the worst aspects of the current system, and one that any reform should address.

For one, people in Europe and Japan have lower rates of obesity and its assortment of life-shortening complications.

health care doesn't start and stop at the doctor's door. in my book, "health care" includes things like reducing obesity.

"Even if a universal healthcare system would pay for, say, knee replacement surgery (which it wouldn't),"

And why would you say that?

Of course it would if a knee replacement was necessary.

And you are right about the reasons Americans leave the country for care. Because the insurance companies work hard to make sure they don't have to pay for the care here.

Regarding portability, that does exist to some degree right now in that if you have group insurance at your current job and leave to go to another employer, and you take the new employer's insurance, they cannot use pre-existing condition to deny a claim.

However, it does not apply if you leave a job and take out your own individual policy. So, if, for example, you wanted to start your own business, and if you had a pre-existing condition, particularly one that required continued treatment, evcen if you had insurance you wouldn't be covered for that treatment. I have no doubt that stops many people from going out on their own.

Additionally, tfhe cost of individual covergae, particularly for a family, unless you want super high deductibles and limits can be extremely high.

stricter malpractice laws would also reduce them

Though Jesurgislac's argument in favor of an NHS still applies, there's an even more important point to consider about all those out-of-control malpractice suits that demand tort reform. According to the CBO (whose numbers are gospel when we wish to panic about Obama's 2019 budget):

But even large savings in premiums can have only a small direct impact on health care spending--private or governmental--because malpractice costs account for less than 2 percent of that spending.
and
According to the General Accounting Office (GAO), annual investment returns for the nation's 15 largest malpractice insurers dropped by an average of 1.6 percentage points from 2000 to 2002--enough to account for a 7.2 percent increase in premium rates. That figure corresponds to almost half of the 15 percent increase in rates estimated by the Centers for Medicare and Medicaid Services.

So, you know, I'm not really seeing this having much of an effect on total health care costs, and not really seeing "tort reform" as the definitive fix for it. On the other hand, trial lawyers do unfortunately tend to favor donating to Democrats, so "tort reform" remains a conservative talking point.

"Even if a universal healthcare system would pay for, say, knee replacement surgery (which it wouldn't),"

And why would you say that?

Of course it would if a knee replacement was necessary.

Germany's does, for instance. Hip replacement too. My great-aunt had all three done over the course of ten years. And even offer various types of physical therapy, which was good for her because she ended up needing water therapy -- too many failing joints to do the standard stuff.

Universal coverage is, in fact, MORE likely to offer things like joint replacement than private care. In private care, two years down the line you're likely to be insured by someone else. It's cheaper to give you steroid shots and anti-inflammatories than replace your knee.

On the other hand, if you're in a health plan that's going to have you as a consumer of health care for life -- they'll see knee replacement NOW is cheaper than "10 years of shots, doctors visits, therapies, drug regimines, then knee replacement when you're older, frailer, and more damage has been done".

Cost effectiveness changes rather widely when your time frame zooms out from 24 months to decades.

@Xeynon:

So in your world, the Veterans Administration does not exist?

You can't take data about a relatively small program that covers a limited, unrepresentative slice of the population and extrapolate it to a universal system.

Indeed? Then why, pray tell, do you insist on doing so in order to mournfully conclude the US government couldn't possibly efficiently fund medical care?

"You don't seem to be all that interested in the whys of point 1, just in raising it as a blocking issue to discussing point 2. If we assume (as you appear to have done) that the answer to point 2 doesn't have much effect on point 1, then I have no idea why you think it's relevant."

You aren't reading carefully. I'm objecting to the idea that the government is going to be saving much money by taking over. Notice what I'm responding to.

I'm completely for universal care under various possibilities which you can find by reading various threads or if I have time to reiterate tomorrow.

I'm saying that we have to deal with serious issues to get to a functioning point 2. Unlike people who think saying "the government doesn't have to make a profit" fixes anything.

Cleek, yes the US as a whole spends a lot more money. But the US GOVERNMENT spends almost exactly as much as Canada.

I think there should be universal housing, free meals, clothing, transportation, and entertainment for everyone. In a rich country like this it is shameful that some go without these things. I'm sure the majority will vote for it. And the rich should pay for it: they have more than they should have anyway.

I mean, how fair is it that some have things and others don't?

Everyone should be exactly 5'11" tall and weigh 165 lbs and have brown skin and black hair. Every piece of clothing should be the same color. There can be no varieties of anything. All must be exactly equal. Not just equal starting points. Not just equal opportunities. But equality at every step of every process all the time.

Fair and equal - justice.

But diversity too. Yes, diversity too.

Making sure people don't die is hardly an attack on individuality, d'd'd'dave.

I think there should be universal housing, free meals, clothing, transportation, and entertainment for everyone.

Among ObWi commenters, that probably makes you the only one. Would you like to discuss the actual issue at hand, or engage in petulant, childish irrelevancies?

If you envy Gary for the respect he gets, ddddave, you are certainly not going in the right direction to get any yourself.

Cleek, yes the US as a whole spends a lot more money. But the US GOVERNMENT spends almost exactly as much as Canada.

sure. and the US govt is spending its dollars in an inflated market, and is covering the most-expensive group of patients.

cost reduction is an important issue. but it's not the primary one. we can have a public option with addressing cost (it will just... cost more - maybe we could fight one less war next year?). or, we can address cost without having a public option. both need to happen, but neither is a prerequisite for the other.

and i gotta say... seeing conservatives clutching their pearls and wailing that America just can't make it work ("No We Can't" sounds like a great campaign slogan) is pretty amusing.

America can do anything, except have a rational and affordable healthcare system! No We Can't!

"On the other hand, trial lawyers do unfortunately tend to favor donating to Democrats, so "tort reform" remains a conservative talking point."

LOL. And opposition to it remains a liberal sticking point.

Actually, I think tort reform could contribute somewhat to lowering medical costs, a fair amount of which are due to "defensive medicine", which costs quite a bit more than the actual malpractice litigation.

Xeynon: babies who live for 12 hours or less post partum are considered stillbirths in Europe

*raises eyebrow* This particular assertion is certainly not true of the UK. The NHS definition of a stillbirth is:

A stillborn baby is a baby born after the 24th week of pregnancy who does not show any signs of life.

If the baby dies in the womb, is it known as an intra-uterine stillbirth. If the baby dies during labour, it is called an intra-partum stillbirth.

If the baby dies before 24 weeks, it is known as miscarriage.

This EU research page mentions the difference between number of stillbirths in European countries and in America, but doesn't reference any difference in logging as extreme as you suggest.

I have no idea where you got this from, Xeynon, but I can find no evidence from European-wide or UK websites on stillbirth that it's actually true. (My guess is it may be one of the plot points the pro-life movement makes up to affirm American moral superiority.)

Good pre-natal care is regarded as a strong factor in avoiding stillbirths. Given the high proportion of women without insurance who presumably receive no pre-natal care, I'd guess this would be enough to account for a considerable difference in the number of stillbirths in countries with good health care systems and the number in the US.

Xeynon: Seems backwards to me. Unless you find a doctor willing to perform an expensive procedure on collateral-free credit, you can't sue him/her for bungling it before you pay for it. I've seen evidence that people sue in order to get money to pay outstanding medical bills, but not for future coverage.

Really? So: Doctor A is supposed to treat patient B, and makes a mistake. The mistake means patient B will require a whole lot more treatment for the next few years - maybe lifelong.

Whether someone in the UK will sue Doctor A for making that mistake depends on a number of factors, including: How culpable is Doctor A? How ready was Doctor A to apologize for the mistake? How much damage did Doctor A's mistake cause? How many additional costs is Doctor A's mistake going to cost patient B and their family - ie, costs not directly health-care related?

But the one factor that won't influence whether or not patient B will sue Doctor A: How much the future health care made inevitable by Doctor A's mistake is going to cost the NHS. That factor will be for Doctor A's employer - the NHS - to consider. It may affect Doctor A's future career in all sorts of ways, whether or not patient B sues.

But you're saying that in the US, you've never heard of someone getting damages to cover the inevitable costs for the future healthcare made necessary by a doctor's error?

and not only do "conservatives" insist we can't control costs, they want to make it illegal to try.

now that's conservatism!

America can do anything, except have a rational and affordable healthcare system! No We Can't!

You got me thinking about American Exceptionalism, cleek. It doesn't necessarily have to mean that we're better than everyone else in a given endeavor. We could also be exceptionally bad at things, just so long as we're exceptional. It all makes sense now. Palin 2012!

Actually, I think tort reform could contribute somewhat to lowering medical costs, a fair amount of which are due to "defensive medicine", which costs quite a bit more than the actual malpractice litigation.

I know that it's somehow got to be the fault of people daring to take their betters to court, but the CBO considered that, too:

Proponents of limiting malpractice liability have argued that much greater savings in health care costs would be possible through reductions in the practice of defensive medicine. However, some so-called defensive medicine may be motivated less by liability concerns than by the income it generates for physicians or by the positive (albeit small) benefits to patients. On the basis of existing studies and its own research, CBO believes that savings from reducing defensive medicine would be very small.

And since it's Whac-A-Mole(TM) time again, there's an 2004 NBER study on these issues and the whole "Doctors are being driven out of providing health care by the high cost of accountability for their mistakes!" canard, which is often next on the checklist.

Wow. Even by dddave's standards, that was ridiculous.

" Would you like to discuss the actual issue at hand, or engage in petulant, childish irrelevancies?"

The issue at hand is how best to spend this NEW money that the many will take out of the pockets of the few. (We're not even talking about the vast debts and deficit producing programs we already have). There is such a blithe presumption that whatever the majority wants they have a right to take.

Michael Cain, yesterday at 7:58p wrote:

"Assume a flat 15% tax* on all income to pay for universal coverage. The poor receive a substantial subsidy and the wealthy get really socked. The household with a million-dollar income pays $150,000 per year for health care, while the value of annual care they actually consume is likely only to reach that level one or two years in a person's lifetime. The well-off, especially the rich, will fight universal coverage tooth and nail because they know that eventually they will be the ones paying for it. Despite people's hopes, I anticipate it will be several more years before the demands of the voters will outweigh the influence that the rich wield on Congress."*

Demands of voters vs influence of rich? Both of those are about influence rather than rights. What about property rights and taking without due process and fair compensation?

Someone will answer that health care is about the right to life; and the right to life trumps the right to property. I agree that the right to life is paramount.

If that is paramount then we need to regulate diet, daily exercise, daily rest, mandatory vacations, stress levels, dangerous transport, everyone must be sheathed in latex, etc. Someone will say, 'we can't do that. It is trampling on rights'.

Seriously. There is no discussion. Why do we abrogate property rights and not these other rights?

You don't start from 'here's what I have, how can I spend it best'. You start from 'here's what I'll take from that guy over there, how can I spend it best'.

* As if the 'takers' would ever settle on a proportional sharing as adequate. No, they would hold out for progressivity.

Also, in my opinion, no one has been able to give a satisfactory answer to Sebastian's point. ie how efficient can the gov't be if they already spend the same as canada per capita yet care for only about 30% with that money?

Eric: Wow. Even by dddave's standards, that was ridiculous.

I think he was trying to be funny: but with d'd'd'dave, it's difficult because so much of what he says is beyond satire.

Also, in my opinion, no one has been able to give a satisfactory answer to Sebastian's point.

Fortunately, your opinion isn't determinative, since the rest of us can actually read the threads in question.

And come on,

"What about X?"

"Well, [points about X]"

"What about X?"

"[reiteration of points about X]"

"I see no one has seriously addressed X."

is actually a flowchart on page 27 of the Trolling Manual. Could you at least bring your "A" game here, d'd'd'dave?

"America can do anything, except have a rational and affordable healthcare system!"

No. I believe that we can have a rational and affordable healthcare system. Just not without addressing the important issues. From my perspective they are: universal coverage at fairly high level, looking seriously at end-of-life-care where we spend the most money, moving away from procedure-based payments when possible because they incentivize the use of procedures even if not necessary.

Not-as-crucial is drug costs (they are a small percentage of the whole, the profit from them goes to create more drugs which is a good thing, and even if profit were removed entirely from them, you aren't saving very much and not nearly as much as the rhetorical time spent on the issue). It is like Republicans harping on earmarks. They look bad, but anyone who understands the place they actually hold in the budget realizes that fixing them does almost nothing to fix the budget as a whole.

Almost-completely-irrelevant: that companies make a profit and the government doesn't have to. Cost constraints work in both the public and private sphere. Making something 'governmental' doesn't change that at all.

And that is a huge part of the point about the US Government already paying enough for a universal system. It doesn't have the profit motive now. It doesn't have as much overhead already. Every advantage you assert the government has, is already held by the government.

My argument isn't that it sucks therefore nothing can be done (which is what many on this thread and others seem to want to interpret).

My argument is that it sucks therefore you should figure out why it sucks and what to do about it before you have it take over.

mds, re: "Well, [points about X]"

Debate proposition: The government can lower costs of healthcare.

Sebastian, arguing for con: But they haven't lowered costs even though they already spend more than other nations (per capita) and serve only 30%.

Eric Martin, 6/17/09 6:16p arguing pro: Drug costs are big...there are also extra costs due to overprescription that were in the new yorker article that was linked to in the comments thread in your post.

Me: yes, drug costs are high and overprescribed. the gov't has not solved that in re: their 30% of patients.

Michael Neal, 6/17/09 6:27p, arguing for pro: 'You do realize that the government provides health care mostly for the most expensive people to cover, right? Yes, there are other things going on that we need to fix, but there is not a linear relationship between the number of people covered and the cost of doing so.'

Me: yes, the government provides healthcare for the most expensive people. However, the government would have to cover the remaining 70% of persons for zero additional cost in order to not exceed Canadas cost per capita. That is not what the gov't is proposing to do. They are proposing to aggregate what they pay now plus what all privately insured persons pay now plus $1 to $1.6 trillion more over the next 10 years.

CS 6/17/09 6:29p argues for pro: Do you, Sebastian -- an educated man, a lawyer, a raconteur -- do you really believe that the current government expenditures on health care are indicative of expenditures under any universal plan? That seems . . . unlikely. Or willfully blind.

Me: Makes no point. Just smears Sebastian.

I'd go further but there are already a number of comments where Sebastian refutes each argument. Why bother again?

Demands of voters vs influence of rich? Both of those are about influence rather than rights. What about property rights and taking without due process and fair compensation?

I really hope that you understand that the Takings Clause does not protect citizens against taxation, nor was it intended to do so. No reasonable reading of the Constitution gives that interpretation.

Seriously. There is no discussion. Why do we abrogate property rights and not these other rights?

You either genuinely believe that all taxation is theft or you don't. If you do, there isn't a lot of room for discussion (although you ought to have the exact same issue with all spending if that's the case). If you don't, then stop using the position as a shield to avoid discussion, or stop discussing.

Even if a universal healthcare system would pay for, say, knee replacement surgery (which it wouldn't)

Not sure why it wouldn't. It does in other countries, although there can be a wait depending on the system (eg the underfunded UK system's wait list is apparently months long- but, the underfunded UK system does provide the proceedure).

This doesn't prove that U.S. healthcare is just as good as that in other countries (though there are some other measures, such as cancer survival rates, that suggest just that)

You should note that cancer survival rates are much more subject to fluctuations based on health care regime than infant mortality measurements- eg prostate cancer in older men is often not the cause of death if untreated- so detecting such a slow cancer and having the patient die of heart failure three years later is a "survival" in the US, but possibly unrecorded in other countries.

Moral: don't use up all of your skepticism on stuff that doesn't support your argument.

You can't take data about a relatively small program that covers a limited, unrepresentative slice of the population and extrapolate it to a universal system.

Well, we've got to extrapolate from something if we want to estimate costs. The government run systems, both here and abroad, appear to deliver cheaper care. And they lack some of the very bad aspects of our system: non-portability, arbitrary denial of coverage, lack of preventative care.
The US system won't be exactly like France's, or Sweden's. It won't have exactly the same per-capita cost, either. But there appear to be numerous opportunities for savings, and improving health care in other ways (again eg preventative care). The lack of a perfect analogue someplace else shouldn't obscure that.

You aren't reading carefully. I'm objecting to the idea that the government is going to be saving much money by taking over. Notice what I'm responding to.

I don't see it; Eric's original post only said one thing about costs, and that was specifically pointing out that we should be having a discussion about things other than costs (ie The health care reform discussion should not only be about the comparative costs.).
So having the conversation derailed into a debate about costs seems like an unnecessary distraction. Eric didn't make any claims here about cost savings (although I think he has elsewhere, and others certainly have).

Not that it's unimportant, but there have already been threads on that subject. So Im not sure why we needed to have this one as well when Eric had seemingly wanted to discuss the impact of delivery of healthcare rather than costs.

Okay, cherry-picking and specious use of the word "refute." Seriously, this is much better.

yes, the government provides healthcare for the most expensive people. However, the government would have to cover the remaining 70% of persons for zero additional cost in order to not exceed Canadas cost per capita.

Truly, yours is a dizzying intellect. "Costs will remain the same for the original 30%" is the unsupported assertion in dispute.

CS:[...]do you really believe that the current government expenditures on health care are indicative of expenditures under any universal plan?
Me: Makes no point.

Oddly enough, there's actually a summary of that particular main point in there again. But perhaps it's too tricky to translate from the original "Taker."

Anyway, this approach was certainly better than demanding that Gary Farber dance for you in return for you paying your taxes. Keep it up.

" "Costs will remain the same for the original 30%" is the unsupported assertion in dispute."


"Costs will radically shrink for the original 30% if we add people who don't need as much medical care." is also an unsupported assertion, and rather less plausible. Sounds like the old "We'll make it up on volume!" joke.

Sounds like the old "We'll make it up on volume!" joke.

Or that old saw about not being able to distinguish between "qualitative" and "quantitative." I think Jack Benny started it.

If we add people who don't need as much medical care, costs per person WILL shrink. That's basic division.

I apologize for seeming to stalk Sebastian, but since he keeps making the same point over and over, I don't feel too bad about arguing with him over and over.

His latest formulation is that the US government doesn't have to make a profit and it STILL spends more than, say, the Canadian government while covering a much smaller fraction of the population.

Now let's get something straight: the US government doesn't provide health care for the most part. It buys health care. It drives a hard bargain with the sellers of health care, except where prohibited by law. (Republican-inspired law, mainly.) Even with all its purchasing power, the US government is buying from a "health care system" which Seb himself acknowledges is twice as expensive as, say, Canada's.

So the problem is NOT the inefficiency of the government. The problem is the inefficiency of the private-enterprise system that sells health care (to individuals as well as to the government) for about double what it costs next door.

--TP

You know, even if if the reasons for keeping the various uniquely expensive features of the American health network (doctor pay/R&D/marketing/jobs program for paper shufflers/high cost of malpractice/pull-out-all-the-stops end-of-life care/insurer payola) prove either indispensible or nondisposable, there's still plenty of compelling argument for universal coverage, even if the per capita expenditure averages out more or less the same.

It would still sure be great to cover everyone (even from a public health perspective), which the current system obviously fails to do, and it would be wonderful if insurance was removed from the indirect costs of hiring U.S. workers. (It would shift those costs up to the owners and the high-salaried, of course, but away from smaller businesses and individuals.) Seems to have a benefit for the purposes of entrepreneurship, and for making unemployment more temporary.

"I don't see it; Eric's original post only said one thing about costs, and that was specifically pointing out that we should be having a discussion about things other than costs "

I quoted this: "In the real world, that translates (frequently) into denying health insurance benefits under some technicality or another to those customers that are most in need and that have been paying premiums for years."

His "frequently" is unsupported (and likely incorrect) in a way that you would certainly not normally just let go, but whatever.

I wrote: "The 'that' you are talking about is the profit motive. But governments also work under economic constraints."

He is claiming that the profit motive is causing a large scale problem in denial of care providing. I pointed out that the profit motive is merely a cost constraint, and that governments suffer from very similar cost constraints.

Cost contraints lead to denial-of-service. These can come from seeking profit, or refusing to raise taxes. See New York and California...

You don't just deny treatment for fun. That is true in both public and private systems.

Sebastian: I reject the claim that profits and cost constraints are similar. Profits create many more perverse incentives, for then each individual involved in the decisions, especially management, is impacting their personal income and bonuses by trying to raise profits at any cost, by say oh, denying service to people. When it's not for profit, then there are constraints of cost, but they create different incentives.

Also, that's what makes the whole "rationing" scare tactic so repugnant, because there already IS rationing, it's just based on what makes the execs the most cash.

Also, the #1 reason health care should be universal is the same that Social Security is. Because otherwise the rich try and turn the middle class against it by demonizing it as something for lazy poor people, and try and destroy it that way.

Sebastian: You don't just deny treatment for fun. That is true in both public and private systems.

Private systems will deny treatment if providing treatment will cut into profits. I suppose if you think profits is serious business, you could say that's not denying treatment "for fun".

It's a mystery to me why you think it would be preferable to a socialized health care system, though.

I'm willing to bet it'd cost more than $9000 per year for you to get decent coverage for your family.

Actually, right now it's about $7K to insure my family, with a $5K deductable. Of course, if health insurers had to sell insurance products in the market that Auto, Home, and Life insurers do, I bet you'd find those prices coming down.

"If we add people who don't need as much medical care, costs per person WILL shrink. That's basic division."

Total dollars the government spends now: X
Total citizens covered by govt now: 0.3N
Total of all US citizens: N
Current total government expenditures per capita: X/N.
I have accepted Sebastians assertion that X/N approximates Canada's cost per capita.
Total dollars spent on healthcare privately: Y (a non-negative number)
Total proposed extra gov't expenditures over the next 10 years to prime the pump: 1 trillion

Equation: (X + Y + 1 trillion)/N > X/N

Where have I gone wrong?

My opposition seems to be wanting to say that X/0.3N + Y/0.7N + 1 trillion < X/N

It seems that the opposition must think that X/0.3N rather than X/N equals canada's per capita expenditure.

"Private systems will deny treatment if providing treatment will cut into profits. I suppose if you think profits is serious business, you could say that's not denying treatment "for fun"."

Any system must deny treatment in order to decrease overall costs significantly. There is not enough profit in the system to make a significant difference without doing so. Eventually, when the dust settles, it will be government who is denying treatment. > Limiting prescriptions, cutting back on end of life care, increasing the drive time to expensive diagnostic equipment, whatever.

This will not be evident at the start because there will be a period when actual profits (which are not significant) are drained from the system. Further, it will be made to appear that there are overall cost savings because costs will merely be shifted to the rich. Shifting costs is different than reducing costs.

X1= however much it costs for the government to cover people currently covered my Medicaid and Medicare under a new system

Z= however much it costs for the government to cover everybody else under the new system.

Equation: (X1+Z+Transition Costs)/N < X+Y/N

The assumption in this equation is that Z at least, and possibly X1, will both be lower than the original X and Y. Not to mention that X and Y don't cover all of N, they cover about 0.85N (source) So really it should be:

Equation: (X1+Z+Transition Costs)/N < (X+Y)/0.85N

The assumption here is that a good program, perhaps like those found in every other industrialized nation, could make Z < Y, like it has in every other industrialized nation. Which hardly seems a terrible leap.

Nate

First, it wasn't simple division was it? It was changing values: X became X1 and Y became Z where X > X1 and Y > Z.

Second, I understand that 'The assumption here is that a good program, perhaps like those found in every other industrialized nation, could make Z < Y, like it has in every other industrialized nation. Which hardly seems a terrible leap.'

That assumption is what I (and i think Sebastian) have challenged. It is incredible to imagine that X1 + Z + transition costs < X yet that is what must happen for X1 + Z + transition costs < than Canada's cost per capita. (Where per capita means every person not just those in a subset of everyone).

"Executives of three of the nation's largest health insurers told federal lawmakers in Washington on Tuesday that they would continue canceling medical coverage for some sick policyholders"

I try to see both sides of these things, but as far as I can tell these guys should be publicly beaten, then placed in stocks in a public place so they can be pelted with rotten vegetables.

After a few weeks of that they can be sold into slavery so they can spend their days waiting on, and begging the forgiveness of, the families of the people they've consigned to death.

When they grow old and die we'll bury them in a potter's field and their names will be forgotten, forever. Their hungry ghosts will wander the earth, eating whatever random coins and paper money they find lying around in a vain attempt to quench their damnable greed.

That seems fair and reasonable to me.

"Show me how we're going to pay for it, Eric."

As mentioned above, we're going to sell insurance company executives into a lifetime of slavery. If that doesn't raise enough, we'll sell their kids, too, or maybe hold them for ransom.

I'm all about relocating the Overton window, y'all.

"If Peru can do it, so can the US."

Never mind Peru. If crappy little underpopulated hardscrabble Vermont can do it, the rest of us can, too.

Thanks -

Carleton

'You either genuinely believe that all taxation is theft or you don't. If you do, there isn't a lot of room for discussion (although you ought to have the exact same issue with all spending if that's the case). If you don't, then stop using the position as a shield to avoid discussion, or stop discussing.'

I do not believe that all taxation is theft. We are talking about added taxation for added spending. Saying I am against that is not the same as rejecting all existing taxation.

I am happy to discuss with you how you and I can each buy half of X and have X for the lowest overall price. We'd be in it together, as equals. But that is not what is happening. You're talking about having me buy X for you. Excuse me, but that's not a bus I want to get on. If we're in this thing together, you're going to have to explain to me how you're in this with me.

I'm not even talking about all existing programs, deficits and debts. I haven't said I won't continue to pay a disproportionate share of what programs already exist. I'm just saying, at some point, when new programs keep coming one has to at least look in the direction of the word theft.

' If crappy little underpopulated hardscrabble Vermont can do it, the rest of us can, too.'

Vermont doesn't have it. They have proposed legislation for it. There is a long distance between a hope and a reality and then a huge chasm before you get to reality that survives over time.

thanks

But Dave, Peru does have it!

Remarkably, all those nations that have it haven't encountered the radical rationing problem you propose as inevitable. Weird.

I don't know where else in a free market system companies (or other groups) are expected to not use significant market position to drive bulk discounts on the grounds that they stifle profits that *might* be used for R&D.
Also, bear in mind that insurance profits do not drive medical R&D- they drive R&D into actuarial research and lobbying to let them keep denying care to people once they get sick.

You don't just deny treatment for fun. That is true in both public and private systems.

But a public system isn't really cost-driven in a micromanaging sense; we may choose to limit certain classes of care (eg very expensive care that merely prolongs life for a few weeks) but we're not likely to institutionalize some system where people are randomly denied normal, needed care. If we're going to be rationing care, Id much rather have the former than the latter.

At least, I know of no evidence that the VA or Medicare behave in this manner. Nor do I see a rationale for it, as the bureaucrats who manage the care there aren't given bonuses or kudos for denying care on technicalities. The closest thing like that I've ever heard of was a proposal that the VA not advertise their care so much to reduce usage, but I think that was shot down (don't recall the details).

So your general point (that we ought to consider how to pay for it and how to make it as inexpensive and successful as possible) is fine, but not on the topic of how health care delivery is different from public and private systems. The specific point, that government health care is likely to engage in similar behavior, I don't think is supported.

I do not believe that all taxation is theft. We are talking about added taxation for added spending. Saying I am against that is not the same as rejecting all existing taxation.

When you reject taxation for a specific program by invoking private property rights and the Takings Clause, you are indeed making a blanket argument against taxation. You may only choose to invoke it against spending that you don't like, but there isn't anything in the Takings Clause or the concept of private property that allows for certain kinds of spending but not other kinds.

Taxation is about taking property and spending it on common causes. You may disagree on what constitutes a common cause. You may disagree about methods. etc. But either this is a legitimate action of government, or it is not. There is, as I see it, no middle ground here.

Honestly, it's an inexpensive way to avoid making a real argument about whether this is a legitimate common good, or about how costs should be distributed, using an argument that you would likely not accept from eg a pacifist who rejected using their money for weapons, or a white supremacist who rejected using their money on anything for minorities (ie black soldiers, loans to hispanic college students, etc), or a bike commuter who rejects spending on highways.

I am happy to discuss with you how you and I can each buy half of X and have X for the lowest overall price. We'd be in it together, as equals. But that is not what is happening. You're talking about having me buy X for you. Excuse me, but that's not a bus I want to get on.

Excuse me, Im on the paying-in side of the scale as well. I just feel that this is a hell of a country, and don't mind pulling my weight. It's helped me be successful in a way I almost certainly would not have been if I had been born in eg the Congo. I think a public health care system will improve the country, and hey, I like the country enough to put my money where my mouth is without complaining.

I'm just saying, at some point, when new programs keep coming one has to at least look in the direction of the word theft.

Either taxes are theft or they aren't. They may be unwise at certain levels. But I just don't see a rational argument that taxation at one level is morally acceptable, but at another level it is a moral crime. Where does the magic number come from? Does it change if we're in a war, or the face of a huge natural disaster? By how much?

"Either taxes are theft or they aren't. They may be unwise at certain levels. But I just don't see a rational argument that taxation at one level is morally acceptable, but at another level it is a moral crime."

I don't think taxation is generally theft but I also don't think your argument is sound. When kings levied taxes which starved serfs, that was taxation as theft.

You're sort of appealing to the Sorites Paradox: "Would you describe a man with one hair on his head as bald? Yes. Would you describe a man with two hairs on his head as bald? Yes. … You must refrain from describing a man with ten thousand hairs on his head as bald, so where do you draw the line?"

"Vermont doesn't have it."

The topic on the table is a public option.

Vermont offers no- or low-cost public programs for anyone who is not insured, or who has a plan with an insane deductible ($10K for individuals, $20K for families), and who makes below a certain income level. This is for folks who DO NOT qualify for Medicaid, Medicare, or Vermont's own similar Health Access Plan.

I believe the income cutoffs are 150% of the poverty level for adults, and 200% for pregnant women. I think the program for kids is for families with household income up to 300%.

So, strictly speaking, you are correct, the public option is only for folks who are not insured through their employer, don't qualify for federal programs, and can't afford to purchase coverage privately. It's not available to folks who have, or who can afford, private insurance.

But were what is available in Vermont available nationwide, I doubt we'd be having this debate.

They also have a guaranteed issue law, which means you pay the same premium regardless of prior conditions.

About 95% of all kids under 18 are covered. About 90% of the population overall is covered. By almost any measure of public health you care to name, Vermont is one of the healthiest states in the nation.

They're not rich, and they run a reasonably tight financial ship. They're just committed to making it happen for their people.

'Honestly, it's an inexpensive way to avoid making a real argument about whether this is a legitimate common good, or about how costs should be distributed, using an argument that you would likely not accept from eg a pacifist '

CW: Have some cake.
DDD: No thank you, I prefer pie.
CW: But cake is what we're doing today.
DDD: Okay, i'll just skip the cake and watch you eat.
CW: Do you want a chocolate cake or a white cake?
DDD: None for me thank you.
CW: At least tell me what frosting you want.
DDD: I like my pie without frosting.
CW: Grrr. Why won't you engage?!
DDD: Uh...I have...you're just not accepting my answers.

have no idea where you got this from, Xeynon, but I can find no evidence from European-wide or UK websites on stillbirth that it's actually true.

Sorry for the sloppy wording - I should not have suggested that Europe's standards are universally more lenient than those of the U.S., or that there is a single standard used throughout Europe. However, I know for a fact that some European countries (e.g. the Netherlands) use a looser definition of infant mortality.

Moral: don't use up all of your skepticism on stuff that doesn't support your argument.

I'm not, as I tried to suggest by using formulations such as "X doesn't necessarily prove Y, but Z suggests it", etc.

I'm agnostic as to what system of healthcare produces the best outcomes, and I'm open to being convinced that it's a European-style single payer system. But I have yet to see any evidence that firmly convinces me of that, and that was my point.

CW: Have some cake.
DDD: No thank you, I prefer pie.
CW: But cake is what we're doing today.

What you want is for others to recognize in you the sole right to decide which government programs are legitimate and which are "theft". Of course, if everyone has that right, then virtually every government program will be funded by "theft". And that's obviously morally wrong, so no more government. Funded by taxation, anyway. If you keep that right to yourself, then the programs you like are legit, and the ones you dislike are obviously not so. No strenuous, difficult argumentation required.
Using "theft" is much easier on the brain's resources than actually making a case- is this wise spending? Is this a wise way to fund the program? Is this tax regime fair?

Instead, you give us a little screenplay. Weirdly, your little dialogue has me not discussing what you want to discuss- I have no idea why, since I have been and am engaging with you on the matter. You just can't seem to come up with a better reply than to pretend Im not talking to you.
In your play, am I just supposed to give you whatever you want as soon as you want it? If Gary is supposed to be dancing for you, have I been nominated as your waiter?

When kings levied taxes which starved serfs, that was taxation as theft.

I disagree. We might describe a dictator's government as unjust in nature, but I don't think that a levy by a dictator is theft. It's bad, but not all bad things are theft; theft has a very specific meaning. Either 'taxation' falls under that meaning, or it does not.

This sort of Orwellian wordplay doesn't seem to have much purpose- like calling the defensive military actions of a dictator "aggressive", because they preserve his odious regime. We may not like him. We may want him to lose.

You're sort of appealing to the Sorites Paradox

This is one of those things that can be used against any argument- you argued upthread that the US gov spends as much per capita as Canada but only covers 27% of the population, and that this is troubling. Would 28% be troubling? How about 35%? Does the lack of a single specific threshold mean that you aren't actually troubled?
Besides, you were the one to invoke degrees of justness in taxation with your dictator example, which I don't agree with- I think the paradox hurts your counterargument, not the original argument ie I think governments either have the right to tax their populations, or they don't. Governments can be bad. Taxation can be unjust. But, as I said, not all bad, unjust things are theft.

d'd'dave's thesis is just untenable to me- virtually every taxpayer has some program they would prefer not to fund. Ergo, every single taypayer is being robbed, and every single government program is funded by theft.
Which is fine, that's a coherent viewpoint for an anarchist or radical libertarian. But he doesn't get to invoke this to dispute taxes or programs he doesn't like without eating the whole meal.
Or, he can, but I think it's a pretty poor attempt at an argument.

However, I know for a fact that some European countries (e.g. the Netherlands) use a looser definition of infant mortality.

Really? So, where do you get this "fact" from? I don't read Dutch, but with the handy use of google-translate, I've found a couple of websites in the Netherlands about stillbirth, and it looks like they have about the same definition of stillbirth as in the UK - this one and this one both explain that a stillbirth (a "doodgeboorte") is one where the baby is either dead in the uterus or dies during childbirth. There is absolutely no reference on either of these sites to a "stillbirth" being when the baby was born alive and died up to 12 hours later, so, again: where did you get this information from?

In fact (according to this">http://www.deverdwaaldeooievaar.be/miskraam/&ei=eeE6Svj6D9ONjAeHsryeDQ&sa=X&oi=translate&resnum=10&ct=result&prev=/search%3Fq%3Ddoodgeboorte%26hl%3Den%26sa%3DG">this website) the legal distinction being made is whether the stillborn baby can be recorded formally in a couple's "marriage book" (a book traditionally presented to a couple by the civil authorities on their marriage to allow them to record the names of their children) and a birth declaration made.

If the fetus is 26 weeks developed; "The declaration is required when the pregnancy is already 180 days or 26 weeks had. It is the doctor who decides whether the child is already 26 weeks old. Date of birth must be equal to time of death on the death certificate!"

If the fetus is not 26 weeks developed, then for there to be a birth declaration, "The doctor decides whether the child lived from birth (although this was very short). There must be a birth declaration (which is often a proxy) and a declaration of death to happen."

I suspect that what happened was that some pro-life site garbled the Netherland's rule about whether or not an infant can have a birth certificate and a legal name if born under 26 weeks with some fantasy about this 12-hour rule.

But I have yet to see any evidence that firmly convinces me of that, and that was my point.

My point about my looking up all this is that your judgement about what constitutes evidence is plainly not very reliable. It took me about 20 minutes with Google and Google Translate to find out that the item you said you "knew for a fact" was actually not factual at all - 20 minutes that it had evidently never occurred to you to spend checking what you "knew". So when you say you've never seen evidence that would firmly convince you, you merely convince me that you've always been careful never to look for it.

Jesurgislac, I misremembered - it was Switzerland, not the Netherlands, to which I meant to refer. For the record, they count babies shorter than 30 cm as stillbirths rather than live births, whereas in the U.S. any baby that has any sign of life when it's born - a muscle twitch, a breath, anything - is counted as a live birth. My mistake.

In any case, this is tangential to the larger argument, which is that using medical statistics like life expectancy as a proxy for quality of healthcare is very methodologically suspect - it hides a HUGE number of distinctions and confounding variables. It is possible that U.S. healthcare is markedly inferior to that found in Britain or Germany or other developed countries - but pointing to context-free medical statistics is not the way to prove it.

When kings levied taxes which starved serfs, that was taxation as theft.

Went for a walk, and had a thought expanding on this: I think we can agree that a dictatorship is an unjust form of government. Does it follow that a dictator's taxes- even if fairly raised, and spent defending against an aggressive neighbor and improving infrastructure- are theft? Are his courts- no matter how good the laws or fair the judges- by definition unjust? Are his military actions- no matter if they defend against a genuinely bad enemy- wrong?
I would say no- that we judge the courts, the taxes, the military actions, etc on their own merits, not on their actor. Just as we judge the courts, taxes, etc of a just system of government.
Shorter: there are no court decisions that I think I would describe as fair coming from a democratic system, but unfair when coming from a dictatorship. No tax regime that could be called fair for a democracy but unfair (or "theft") for a dictatorship.

If that's the case, then we can ignore the actor, and concentrate on the action- does it make sense to say that some taxes are legitimate and that others are theft? As opposed to merely saying that some taxes are wise and fair, and others unwise and unfair?

Theft suggests an action that cannot be legitimate under any circumstances, yet this analysis (where some taxes are fair and others are "theft") suggests that the line will constantly be shifting. For example, spending X on infrastructure might be "theft" one year, but the next year it isn't because we're rebuilding after a disaster.

It seems to me similar to calling wasting someone's time "murder". You are, after all, wasting some of their lifespan. Does this label add anything to a discussion on the issues of wasting people's time- how much is legitimate in everyday transactions, etc? Or is it a pretext for aborting the discussion in favor of claiming some illusionary moral high ground?

It is possible that U.S. healthcare is markedly inferior to that found in Britain or Germany or other developed countries - but pointing to context-free medical statistics is not the way to prove it.

Seems like a little bit too much skepticism- now, we can't *prove* that the US has a better healthcare system than Ghana, or Jupiter.

Seems like a little bit too much skepticism- now, we can't *prove* that the US has a better healthcare system than Ghana, or Jupiter.

Fair enough. I'd counter that at a certain point common sense kicks in - it would take an ad absurdum skepticism of stastical analysis to argue that the U.S. healthcare system is no better than Ghana's, because the differences in outcomes are vast and occur across every possible meaningful metric. That's not the case with the U.S. and other developed countries, however - in that case, the statistics provoke thought, but don't prove anything conclusively, as there are quite plausible alternative explanations for the differences in healthcare outcomes.

Show me that a group of Europeans and a group of Americans who have identical lifestyle habits, socioeconomic status, etc. and markedly different healthcare outcomes, and I'll be convinced.

Carleton 10:37p

Theft was your word not mine. I rejected it as descriptive of my position in my first response after you used it (2:44p). So, if you're saying i'm using it as 'a pretext for aborting the discussion in favor of claiming some illusionary moral high ground?' then you've lost me.

Perhaps you were addressing Sebastian at 2:44p.

"Shorter: there are no court decisions that I think I would describe as fair coming from a democratic system, but unfair when coming from a dictatorship. No tax regime that could be called fair for a democracy but unfair (or "theft") for a dictatorship."

I'm fine with that. Taxation at 90% is theft in either case.

Xeynon: I misremembered - it was Switzerland, not the Netherlands, to which I meant to refer. For the record, they count babies shorter than 30 cm as stillbirths rather than live births, whereas in the U.S. any baby that has any sign of life when it's born - a muscle twitch, a breath, anything - is counted as a live birth. My mistake.

Oh, and no doubt when I go look up Swiss websites to confirm that in Switzerland they use the same standard definition of stillbirth as everywhere else in Europe, and once again you got it completely wrong, you'll come back to me with "oh, my mistake, it was actually Bulgaria I meant"... and so it goes.

*swift Google*

Well, actually - since it appears you just don't know how to Google - I can provide you with a study (PDF) that explains where your lousy pro-life site got this muddled piece of information: Switzerland is divided into cantons, the cantons use different methods of reporting stillbirths/perinatal deaths (some by birth weight, some by length, some by gestational age at birth, and the study (from Swiss Medical Weekly, 2005) notes a significant under-reporting to the national register which the authors think could be corrected by having a general national standard agreed to and understood by all hospitals.

So, again, you got it wrong, Xeynon. And you haven't yet been able to cite a single authoritative website to prove your original or any other claim.

And in terms of this affecting overall European infant mortality statistics, Switzerland's population is roughly 1.57% of the population of the whole European Union (of which Switzerland is not a member).

In any case, this is tangential to the larger argument, which is that using medical statistics like life expectancy as a proxy for quality of healthcare is very methodologically suspect - it hides a HUGE number of distinctions and confounding variables.

Yes, but what would you know about that, given that you don't seem to know how to do some really fairly basic research into what you "know as a fact"?

It is possible that U.S. healthcare is markedly inferior to that found in Britain or Germany or other developed countries - but pointing to context-free medical statistics is not the way to prove it.

Coming from someone who has yet to point to any medical statistics whatsoever, that's ...ironic.

Switzerland they use the same standard definition of stillbirth as everywhere else in Europe

Which is to say "Infant died in uterus or in childbirth". The authors of the report I cited from Swiss Medical Weekly clearly accept this definition: their concern for the accuracy of the national register in Switzerland is because they accept this definition.

European countries with lower infant mortality rates than the US: European Union as a whole, Italy, Isle of Man, Greece, Ireland, Monaco, United Kingdom, Gibraltar, Portugal, Jersey, Netherlands, Luxembourg, Guernsey, Belgium, Austria, Denmark, Liechtenstein, Slovenia, Spain, Germany, Czech Republic, Andorra, Malta, Norway, Finland, France, Iceland, and Sweden, all report lower infant mortality rates than the US. (I left off Switzerland, since we already discussed that.)

European countries with higher life expectancy at birth than the US: Andorra, France, Sweden, Switzerland, Guernsey, Iceland, Italy, Gibraltar, Monaco, Liechtenstein, Spain, Norway, Jersey, Greece, Austria, Malta, Netherlands, Luxembourg, Germany, Belgium, United Kingdom, Finland, Isle of Man, European Union as a whole, Bosnia and Herzegovina, Denmark, Ireland, and Portugal.

One interesting piece of data: Scotland, a state within the United Kingdom that maintains separate statistics, is unhealthy by comparison to the rest of the UK: Life expectancy at birth for Scotland (2006 figures) is 74.2 years for males and 79.2 years for females; in the US as a whole, it's 75.65 years for males and 80.69 years for females. In 1996, life expectancy at birth for Scotland was 71.9 years to 74.2 years for males and 77.5 years to 79.2 years for females: in the most-deprived urban area of Scotland, in 2006, life-expectancy was still 71.9 years for males and 77.8 years for females.

Life expectancy at birth for a black man in the US (2004 figures) is 69.5 years: for a white woman it's 80.8. I wasn't able to find a breakdown by state, but: "Racial and ethnic minority groups are much more likely than non-Latino whites to be uninsured, and are less likely to have job-based health insurance coverage. Over one-third of Latinos (37%) are uninsured, the highest rate among all the groups studied and two and a half times the rate for whites (14%). Nearly a quarter of African Americans and about one-fifth of Asian Americans and Pacific Islanders have no health coverage." News release; New Report Provides Critical Information About Health Insurance Coverage and Access for Racial and Ethnic Minority Group That "new report" is from August 2000: have things changed much in the past decade?

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