by von
There are three essential components to health care reform -- or else it's not worth doing.
- Coverage. Obviously, the reform has to cover folks who are currently uninsured.
- Personal. Everyone should have access to good health care; good health care shouldn't depend on a person having a job. Health care is a personal good. Aside from this fact, the US's system of linking health care to employment puts US companies at a competitive disadvantage by subjecting them to the so-called "triple tax": companies pay once for their employee's health care, indirectly subsidize Medicare and Medicaid through those payments,* and pay higher premiums to help cover the cost of treating the uninsured. This triple tax is then passed along to employees in the form of a lower salary, and other negative effects.**
- Deficit. We pay an unprecedented amount for health care -- indeed, no other OECD country devotes as much of its economy to health care as we do -- and we face an enormous, and growing deficit. Health care reform should reduce both, and you should see the reduction in the budget projections. (See "bending the cost curve," below.)
Those should be the criteria for evaluating any health care reform package. Note what's left out:
- Claims that we will "bend" the cost curve. There are sensible things that we can do to try to moderate cost, and nearly every plan tries to do at least some of them. But no one has presented a test to determine whether any of them will work to the degree promised. Indeed, the CBO estimates that at least one of the reforms under debate -- HR 3200, presented by the Democratic leadership in the House -- will bend the cost curve in the wrong direction. Hope is not reform.
- An argument for, or against, a public option. I'm against most versions of a public option, but whether a plan has -- or doesn't have -- a public option shouldn't be part of the test. If a public option meets the three criteria, then the plan must be taken seriously. (What does it mean when I say I'm against "most versions of a public options"? Well, I can see the arguments for state-run cooperatives, particularly if multiple states are allowed to band together in the same cooperative.)
These three, related criteria -- the impact on coverage, personal care, and the deficit -- are the criteria that I propose that we use to measure any health care plan.
If you look beyond labels and rigorously apply those three criteria, I think that you'll find that the version of health care favored by the Democratic leadership in the House (HR 3200) is a bad idea. Yes, HR 3200 expands coverage to a certain extent. But, as a recent report by the CBO confirms, HR 3200 strengthens the link between employment and good health care. That's a step in the wrong direction. You should have access to health care because you're a person, not because you're employed. Linking health care to employment is also bad for business. Indeed, the legacy cost of health care is a key reason why we, the tax payers, have been forced to bail out American automakers.
HR 3200 also penalizes small businesses. Under HR 3200, a business with a payroll as low as $250,000 -- that could be a family-owned restaurant or a local bookstore -- either has to pay for its employees' health insurance or is subject to a penalty. Employees of small businesses should absolutely have access to good coverage. But it's a bad idea to mandate that small businesses pay for that coverage. It's not as though small business owners are currently refusing to provide health insurance to their employees because they're evil; health insurance is expensive.
Regarding the last element of the test -- the deficit -- HR 3200 has a disastrous impact. Even if Congress adopts the new penalties and surcharges imposed on small businesses, the surtax on the wealthy, and the numerous other complicated regulatory and tax changes hidden in HR 3200's one-thousand-plus pages, HR 3200 still adds $239 billion to the deficit over the next decade while having none of its purported "curve shifting" benefits.
HR 3200 is not a good bill. Its defects are fundamental. It should be killed, not reformed -- particularly since HR 3200 is not the sole Democratic option. There are many other Democratic bills in circulation, several of which don't have HR 3200's problems. But these alternate Democratic (and Republican) bills won't have a chance to breathe so long as HR 3200 is sucking the oxygen out of the room.
The Democratic leadership in the House needs to get out of the way.
*This is because, by law, Medicare and Medicaid usually pay doctors less for any given service than a private insurance plan. Thus, to continue to make acceptable profits, doctors tend to charge private insurers more than they otherwise would. These additional charges are passed along to employers (and, indirectly, employees) in the form of higher insurance premiums.
**That employer health care results in lower cash wages is also among the findings of the authors who studied Hawaii's mandatory employer-based health care system.
UPDATE: Some minor wordsmithing.
UPDATE 2: Good. There will be no healthcare vote in the House before the August recess. That gives opponents of HR 3200 an excellent chance to kill the bill, and, perhaps, give time for the bipartisan Senate group discussed by Publius (or, as I suspect Publius hopes, a different group) to consider other options.
The perfect is the enemy of the good.
Decoupling health care insurance from employment is a fundamental change to our health care system. If you are holding out for this fundamental change then you are ignoring reality.
Incremental change is how our health care system will get better. The house bill is a step in the right direction. It isn't the final destination.
Posted by: Blue Neponset | July 28, 2009 at 11:44 AM
All the criteria conflict. This is especially apparent in the critique of the employer mandate presented in this blog entry. The employer mandate goes a great length to expand coverage. Note that you leave out your 3 criteria when bringing up points against the employer mandate and don't acknowledge that Hawaii also has one of the highest rates of coverage in America. Covering people costs money, so obviously someone has to foot the bill. The employer mandate puts part of this on businesses.
It's possible to forgo an employer mandate and retain the coverage criteria, but not without a public option or extremely heavy regulation of the insurance industry (forcing them to offer a minimal plan at an affordable price). Plus expansion in medicare coverage. You can also subsidize lower income people but i think that's certainly not something that's going to limit costs. And either way, this puts costs on government which goes against criteria 3.
Posted by: Derek | July 28, 2009 at 11:50 AM
Very little is said on the impact proper nutrition would have on the health of the currently under-insured (and everyone else for that matter). After having watched "Food, Inc"- and seeing the point made about how poor people are left with McDonalds being their only option to feed families (and the resulting health impact of that fact such as exploding diabetes cases among the poor) because the cost of fresh fruit and veggies are just a bit more than they can spend to feed everyone- I think food stamps which are limited to staples such as rice, pasta, veggies and fruit should be a part of any health reform plan.
You can't possibly bring the costs down without getting people on the margins to eat healthier. Just a thought.
Posted by: timjbd | July 28, 2009 at 11:55 AM
All the criteria conflict. This is especially apparent in the critique of the employer mandate presented in this blog entry. The employer mandate goes a great length to expand coverage.
That's false, as you implicitly concede in your second paragraph (below). You can can have greater coverage without an employer mandate.
It's possible to forgo an employer mandate and retain the coverage criteria, but not without a public option or extremely heavy regulation of the insurance industry (forcing them to offer a minimal plan at an affordable price).
And this is false as well. For example, there are plans -- Democratic plans, even -- that provide for a refundable tax credit that allows individuals to purchase their own insurance (either a public option or a private plan).
Posted by: von | July 28, 2009 at 11:56 AM
Incremental change is how our health care system will get better. The house bill is a step in the right direction. It isn't the final destination.
This is something that I've never understood, Blue Neponset. If your goal is to eventually decouple health insurance from employment, how is it a good first step to strengthen that link?
Posted by: von | July 28, 2009 at 11:57 AM
You can't possibly bring the costs down without getting people on the margins to eat healthier. Just a thought.
I agree with that. A rational solution would be to increase taxes on certain unhealthy foods -- something that I'd be willing to consider, but which it almost certainly DOA.
Posted by: von | July 28, 2009 at 11:58 AM
The only essential element I'm concerned with is a public option (which itself is already a compromise from single payer universal healhcare).
Without a "public option" where Citizens can get health insurance directly through the government, what the politicians appear to be doing is handing the corporate-medical-monopoly 50 million new customers.
If there isn't a public option, it's hard to see how anything Obama might sign isn't a complete sell-out.
(And "cooperatives" are a joke, unless it's NATIONAL it can't compete because it just won't have the scale needed or the broad national attention needed to keep it effective.)
Without a clear "public (entirely government run at the national level) option", anything else is just a half-measure with lipstick on it.
Posted by: News Reference | July 28, 2009 at 11:59 AM
Could you give us your thoughts on the Swiss system based on regulation of private insurers? They've done a number of things to bend the cost curve for their comprehensive basic plan. Among others: (1) insurance companies as a group and care providers as a group negotiate fees annually for the covered services; (2) no applicant can be turned down, (3) community rate setting, and (4) insurance companies must operate the comprehensive basic plan on a non-profit basis.
I picked these in particular because they address a number of the factors that critics point to when they assert that US insurance companies add significant costs to the system for things that are not health care: profits, expenses to avoid covering risky patients, and staff at both the insurance company and the care provider who often, in effect, negotiate whether a service is covered and what will be paid if it is covered after the service has been provided.
Posted by: Michael Cain | July 28, 2009 at 12:03 PM
Without a "public option" where Citizens can get health insurance directly through the government, what the politicians appear to be doing is handing the corporate-medical-monopoly 50 million new customers.
I probably won't be able to convince you that there are ways to handle this concern other than through a public option: your mind seems made up. Nonetheless, here's a go: If your concern is that insurance companies have sustantial intrastate monopoly power -- that is, many states have one insurance company as a primary insurer -- wouldn't you solve that problem by allowing interstate competition among insurers .... just as we do with car insurance?
Posted by: von | July 28, 2009 at 12:06 PM
This is something that I've never understood, Blue Neponset. If your goal is to eventually decouple health insurance from employment, how is it a good first step to strengthen that link?
The first step IMHO, is to get some sort of public option for small business. Once that is in place we can add the self-employed to that plan. Once the self-employed are covered then we can work in some kind of tax credit so people can buy in to the public plan on an individual basis. Once that happens employers will encourage their employees to buy into the public plan. After a period of time, viola! health insurance is decoupled from employment. At that point, we can get rid of the tax credit and fund the plan via normal income taxes.
Right now the market doesn't do a good job of offering individual health care polices. They are very expensive and very limited. I don't think that is going to change.
Also, thanks for offering a reasonable opinion about this. I don't agree with you but I appreciate your honest argument on this topic.
Posted by: Blue Neponset | July 28, 2009 at 12:15 PM
Except Von, in my experience, Car and House insurance (two frequent items I've seen brought up as counter examples) suffer from many of the same problems as health insurance, it is just not life or death, so people don't scream as much.
For house insurance, I can remember a couple years ago reading about how home owners had to be very careful about deciding whether or not to file a claim with their agency cause it could result in dropped coverage or drastically increased fees. Very similar to what we are discussing here.
Car insurance is a separate matter, a bit more liquid; however, how long do you think car insurance would last if the car insurers KNEW you had a bad brake system, KNEW that it would be very expensive to fix, and that it was going to be an inevitable expense? My guess is that the car insurance company would be looking for the first exit possible, same as the health insurance companies do now in comparable situations.
Posted by: DecidedFenceSitter | July 28, 2009 at 12:16 PM
If your concern is that insurance companies have sustantial intrastate monopoly power -- that is, many states have one insurance company as a primary insurer -- wouldn't you solve that problem by allowing interstate competition among insurers.... just as we do with car insurance?
In a word . . . no. Because allowing competition is not the same thing as having competition. There's a reason why one element of antitrust analysis is the cost barriers to entry into the market. You can allow competition all you want, but until those barriers come down, you're not going to have competition that benefits the consumer. Which is reason # I-forget-how-many why the public option is a important.
Posted by: C.S. | July 28, 2009 at 12:23 PM
Yes!
I don't post much, but I felt moved to respond and applaud Von for starting this post by laying out GOALS of health care reform...Oddly (or probably not), this has been completely lacking in the public debate the last few weeks. There has been a lot of discussion of details of the plans without any articulation of what the goals are.
In fact someone (maybe here at ObWi) recently made the claim that Obama is failing to win the health care reform discussion because he hasn't convinced the American public of what health care reform really means for them.
Now, I agree mostly with Von's points - especially the first two. I think the major goals of health care reform should be to ensure coverage of everyone and end the employer based health care system. The first is just common morality/decency - it is/should be unacceptable to allow people to suffer from entirely curable diseases in a society as wealthy as ours. The second is common sense (especially in the current economic climate) - not only does the employer based system place US companies at a competitive disadvantage, it also disadvantages the US economy by limiting the liquidity of labor due to fear of losing health care.
Von and I diverge a little bit on the last point. Since I don't share Von's libertarianism and skepticism of govt endeavors, I think that there is nothing wrong with the federal government taking on a greater share of the health care costs. I'd like to see reform lead to lowering the overall health care expenditure in the US ("bend the cost curve"), but if the federal government assumes a greater percentage of the total cost in order to achieve the goals stated above, then that seems like a completely acceptable outcome...with the caveat that it is paid for. I agree with Von that this shouldn't increase our already outrageous deficits. However, political realities aside, this is where some hard choices would have to be made, and I would argue that if someone puts forth a plan that achieves the primary goals stated above, then it's worth prioritizing in the budget above a lot of other things we currently spend money on.
For my own personal feelings, I would start by changing our structure of agriculture subsidies for corn and soybeans. At the outset, you save money which can be used to pay for new/additional health care expenditures. Further down the road, I think you also see huge savings in terms of impact on nutrition and health. A study out yesterday shows that obesity related disease accounts for 10% of our health care costs having doubled over the last ten years. While I'm sure there are several factors involved in the rise in obesity, my current understanding is that one of the most significant factors is the ubiquity of high fructose corn syrup which is ridiculously cheap because we subsidize it. I'm not in favor of some proposals like junk food taxes, but I think we could start by no longer subsidizing junk/fast food.
Anyway, I'll get off my soapbox, but again, I tip my hat to Von on this post.
Posted by: Shaggy | July 28, 2009 at 12:24 PM
von, overall a well reasoned post, although (surprise) I disagree with you on some of the points.
There is no evidence that coops are likely to either a) expand coverage or b) reduce costs. Health care is not produce and the market does not work in health care as it does in other areas.
Currently, 47 states have more than 60% of their population covered by one insurance company. The company may vary per state, but that is as close to monopoly power as you are going to get.
Assuming you allow multiple states to co-op together, which in theory would reduce the costs by having a larger pool (but only in theory) are you in favor of getting rid of state regulatory powers?
Or, if you allow someone from, say, Arizona, to purchase a policy offered in Illinois because it might be cheaper, who does that person go to with a complaint.
Your are correct in that tying insurance to the employer is not the best way to go about this, for many of the reasons you indicated. About the only way to decouple effectively is to go single-payor, which is not politically feasible at tis time.
Regarding providers reimbursement from Medicare and Medicaid, yes, in most cases it is lower than what insurance companies pay. However, very few providers complain about Medicare payments because 1) it is quicker than the reimbursement they get from insurance companies, 2) they actually have a higher collection rate from their patients than with regular insurance companies, and 3) their adminstrative costs are virtually non-existant with Medicare.
Medicaid is another issue, primarily due to the high level of state funding involved. Due to financial reasons, many states are unable to pay the Medicaid bills. Of course having affordable coverage would eliminate a lot of that.
That's a start, if time allows I'll be back later with more.
Posted by: John Miller | July 28, 2009 at 12:33 PM
Michael -
Let me do some research on the Swiss system. I don't know much about it.
The first step IMHO, is to get some sort of public option for small business. Once that is in place we can add the self-employed to that plan.
OK, your theory makes some sense, Blue N. But my response is that HR 3200 doesn't include, and thus can't accomplish, your first step.
I don't post much, but I felt moved to respond and applaud Von for starting this post by laying out GOALS of health care reform...Oddly (or probably not), this has been completely lacking in the public debate the last few weeks.
I thought that was odd as well, which is what inspired this post. And thanks for your contribution.
Posted by: von | July 28, 2009 at 12:36 PM
I agree with that. A rational solution would be to increase taxes on certain unhealthy foods -- something that I'd be willing to consider, but which it almost certainly DOA.
If you want to wander into the realm of DOA policy suggestions, I'd say killing certain agricultural subsidies could do a lot to reduce the prevalence of some unhealthy foods.
Posted by: Nombrilisme Vide | July 28, 2009 at 12:36 PM
I was with you for most of this, and I can even agree at this point that HR3200 sucks.
But this is where we part ways.
Look at your first two criteria:
Public option? Check.
Public option? Check.
I have no idea whether this last part is true or not. What nobody disputes is that right now people who are uninsured or under-insured frequently skip routine medical checkups and other preventative care because they can't afford it. They end up in the ER later suffering from something that would've been easily treatable if caught early, but which is now orders of magnitude more expensive to deal with.
If everyone has access to routine maintenance health care, let alone full coverage, this problem--and the staggering cost which we bear as a result--goes away. Well, not entirely, because people are lazy. But meaningfully.
Will a public option increase the deficit in the short term? Probably. And that has to factor into the discussion.
I don't like the idea of running deficits, but the fact is that we do it when we think we have to, when the alternative is far more costly inaction. When a foreign policy crisis threatens the country, we throw our military at it and spend whatever it takes to resolve the crisis. We may complain about the price tag, but we pay it in order to save American lives.
Contrast this with the health care debate. Every year at least 20,000 people die in this country because they were uninsured. Some studies put the number much higher, if you factor in deaths from causes that would have been preventable if diagnosed through a routine checkup. We've spent nearly a trillion dollars so far between Afghanistan and Iraq because some jackholes with box cutters killed 3,000 people--if any foreign enemy was causing 20,000 American deaths a year, we would spend whatever it took to defeat them.
Right now, that enemy is our own broken health care system. You will pardon me if I don't really find lectures from conservatives about fiscal discipline particularly credible or compelling anymore, especially when viewed in this context.
So no, you don't get to just wave your hand and declare deficit spending a deal-breaker, while simultaneously dismissing the only option that actually satisfies your other two deal-breakers.
Posted by: Catsy | July 28, 2009 at 12:36 PM
I probably won't be able to convince you that there are ways to handle this concern other than through a public option: your mind seems made up.
Yours too, von.
wouldn't you solve [the intrastate monopoly] problem by allowing interstate competition among insurers .... just as we do with car insurance?
Yes, Mr Rumsfeld (I kid!), it would solve the problem you yourself posit.
To me, everything in this debate flows from basic assumptions. Here is mine:
- Efficiency and the profit motive are neither identical, nor inseparable. The main objection to the public option is very obvious, and was expressed by Sen. Snowe among others: it would lower costs too much and therefore interfere with the insurance bidnis, which companies will have a hard time competing in their traditional line. You are either OK with that or you're not. I'm OK with it because broad-based health insurance is categorically unlike, say, car insurance, and I will shed no tears for those companies if they are eventually reduced to selling gold-plated insurance to rich people.
I wish we lived in von's reasonable world, of reasonable people of reasonable good will, including statesman-politicians who cared more about vital public interests than midterm elections.
BTW, heavily regulating insurance companies is inadequate, since they can always be un-regulated - not instantly, but faster than a real national component could be gotten rid of.
Posted by: jonnybutter | July 28, 2009 at 12:45 PM
Seeing as rising premiums will be a given until reforms happen, and that the people who are worried about premiums are very important to the economy and in politics, there really is no excuse for the republican desire to call things off until "maybe 2011". They know that will cause trouble for the economy, but they also know it will be on the democrats' tab in the midterms.
Posted by: Kastanj | July 28, 2009 at 12:47 PM
The only way people who get sick will be able to keep their insurance (which is to say, continue to get treatment) is for their premiums (or what they pay for them) not to go up when they get sick.
The only way to accomplish this is for people who aren't sick to pay more than the expected value of their out-of-pocket health costs in a given time period.
Healthy people without assets are unlikely to want to purchase coverage at those prices. Hence, without mandatory coverage, the sick will continue to be dropped from private insurance, or (same diff) see their premiums rise to the point where they can no longer afford them.
I simply don't see how you get to universal coverage without forcing healthy people to pay into the system before, or regardless of whether, they get sick.
Posted by: kth | July 28, 2009 at 12:50 PM
"--if any foreign enemy was causing 20,000 American deaths a year, we would spend whatever it took to defeat them"
This has been a favorite argument throughout this debate. There are two differences:
1) The assumption when someone kills 3,000 (or 20,000 Americans) is that we should defeat them before they kill or continue to terrorize ALL Americans. Very high stakes, not to diminish the need to address healthcare.
2) Wars end, the healthcare spending we are talking about becomes a permanent fixture in the budget. Quite possibly a deficit this year becomes one next year and, in twenty years, we are having a debate about "saving healthcare".
I just don't think this hyperbole is helpful.
Posted by: Marty | July 28, 2009 at 12:50 PM
To this point Shaggy:
I would direct you to the comment by News Reference:
The problem here is the one most libertarians focus on: The government is run by people who are beholden to those who are going to get them reelected (i.e., special interests). It doesn't matter if it's controlled by democrats or republicans. A plan that doesn't take this into account is, more likely than not, going to fail.
You bring up a really good point about farm subsidies. See when programs in the government fail, we just dump more money into them. See our various wars on drugs, poverty, terrorism. Just look at how much is spent per child on education in places like DC with little or no improvement int outcomes.
I cannot speak for von, but I can speculate that he has a certain skepticism about what the government can accomplish, and he tries to bring forth policy suggestions which account for that explicitly.
If we reform the health care system and increase the deficit, we're really just solving the problem for a short period of time. Eventually we're going to have to pay for it. It's just honest to face these costs now, and it's simply immoral to push them off on future generations.
Posted by: John Harrold | July 28, 2009 at 12:53 PM
I agree with decoupling insurance from employment, but I don't see how it changes the competitive disadvantage for American business. That disadvantage will continue so long as we are paying more for healthcare, regardless whether it is through taxation and central payor, or through direct payment for employees insurance. In the end, the businesses will be either paying higher taxes, or paying higher salaries so employees can pay insurance tax. Companies with the highest payroll will continue to subsidize those with insufficient income to cover healthcare costs.
So it comes back to eating right and exercise if we want to reduce our corporate burdens.
Posted by: jrudkis | July 28, 2009 at 12:55 PM
Yikes, the new CRS report you link makes my oft-repeated point about government spending even more powerful. According to the report the US government spends about $2,684 per capita and covers about 27% of the population. Canada spends about $2,209 per capita and covers 100% of the population.
So as of 2006, the US government spends about 21% more per capita than Canada yet covers only 27% of the population. That is crazy.
Posted by: Sebastian | July 28, 2009 at 01:01 PM
For example, there are plans -- Democratic plans, even -- that provide for a refundable tax credit that allows individuals to purchase their own insurance
And if you're a fan of cost inflation and putting healthcare cares rising costs on the same scale as we see for tuition, that's certainly the way to go.
But for the most part subsidy just increases prices. That's what makes opposition to a public option absurd on its face (even moreso when combined with opposition to an employer mandate)
We are trying to produce an outcome (universal coverage) that's not market driven. The idea that if we just give the market money, we'll see cheaper prices and cover everyone just doesn't work. It's against the laws of economics. You can't create demand and expect prices to be steady. There has to be cost control at some end of the spectrum. Whether it's public option or heavy regulation. You didn't put cost control in your criteria, but healthcare costs impact the debt via medicare so it's not something to be ignored.
Basically it comes down to this. Assuming we seek universal coverage, the employer mandate expands coverage and cuts coverage costs to the government. The public option expands coverage and depending on how it works out, may or may not cost the government money (or heavy regulation in lieu of a public option). Tax credits expand the coverage but also expand government spending and have the nasty effect of cost inflation. Or we could have a combination of all these. But you can't just do one of these things and expect everything to be solved. And if you do choose one, the tax credit idea is the worst.
Posted by: Derek | July 28, 2009 at 01:04 PM
OK, your theory makes some sense, Blue N. But my response is that HR 3200 doesn't include, and thus can't accomplish, your first step.
I haven't read all 1,018 pages of the bill, but the summaries claim it includes a public option. That is the first step. LINK I am not sure why you think HR 3200 won't accomplish this first step.
Posted by: Blue Neponset | July 28, 2009 at 01:07 PM
Sorry to double post but a few more points:
I left out the fact that we can also expand medicare as a way of dealing with coverage. But that conflicts with criteria 3 (well, so do tax credits but I didn't want to belabor the point, like i said, the criteria conflict. That's not a bad thing, it's just the reason for why this isn't easy).
Posted by: Derek | July 28, 2009 at 01:14 PM
I'll say at the outset that I'm not addressing von's post and his three-part test directly.
Instead, I'm addressing partisan Democrats who advocate support for the apparent best result that we can get out of the current Congress, which is H.R. 3200.
Even in the unlikely best-case scenario, in which the House bill emerges intact from the conference committee reconciliation with the Senate version, the results will stink -- in both the policy and political terms.
The best case is unlikely because the Senate exists to weaken popular legislation. It's the deliberative body where a man who represents fewer people than the mayor of D.C. is allowed to set the parameters for a bill affecting the personal welfare of almost every person in the country. He's not even pretending to represent the interests and opinions of his nominal constituents, the 675,000 people of his state, but those of his real constituents, the corporations who've provided 95% of his campaign funding.
Without changes to the Supreme Court's established framework of considering corporations as persons and money as speech, the terms of debate on health care and most other issues are never, ever going to be set by individual citizens.
This is the background to the current situation, where everyone from Pres. Barack Obama to Speaker Nancy Pelosi to more than half the U.S. public acknowledges that some version of single-payer offers the best prospects for actually solving the defects of our current health care system -- massive and growing numbers of uninsured citizens, denial of care and coverage to those nominally insured, burdens on workers and employees because insurance is so closely tied to employment, dollar costs out of all proportion to results achieved, and crushing administrative burdens on health care providers.
These defects have created enormous political pressure for serious health reform, and -- without anything in the way of national leadership -- large-scale popular support for a single-payer (Medicare for all) solution.
But the scale and political power of the finance and insurance sector are so great, and the structure of our politics so corporate in both parties, that those with power in the Democratic party decided years ago that, however great the popular demand, single-payer cannot be won directly in Congress, because it means taking on the entire FIRE sector.
On the other hand, Dems have to pass some real health reform or they will be swept out as quickly as they were swept in. (The converse of this is that if Democrats manage to use significant majorities in Congress to pass health reform that people recognize as a serious improvement, Republicans will be a minority party for a good many years to come.)
So the pols and the policy wonks who work with and for them came together to figure out how to thread the needle. The solution was a reform proposal that leaves the insurance sector and employer-provided insurance intact, while creating a public insurance pool for the uninsured. The argument to the base was that this public option would be both a way of checking the power of the insurance companies and a path to a single-payer future: It would be big enough to force the insurance companies to compete on both price and cleanup of their abusive practices. If the companies couldn't compete, they'd get out of the business.
This plan, backed by the AFL-CIO and a collection of Democratic policy shops led by the Obama-aligned Center for American Progress/Campaign for America's Future, was sold to the activist base as the only real route to single payer. We were asked to get on board and accept that single-payer would be "off the table": testimony shut out of the hearings and town hall meetings, legislation not costed by the Congressional Budget office.
Some of us who accepted the pragmatic need to win some health reform in the 111th Congress objected early on that it was still strategically stupid to silence and strangle the single-payer flank and make the public option the leftmost edge of the reform, as it almost guaranteed a loss before the battle began. Much better for the half-a-loafers to be able to threaten the insurers by pointing to a strong, active demand for single payer and paint their own version as the necessary compromise.
But the Obama-CAF plan had already been developed, sometime in 2007, their guy was in the White House, and he was determined to get health care reform (of whatever kind) passed this year. We were never to be shown a specific proposal and asked to fight for it -- only to keep pushing for the concept of a public plan and to back the best choices offered by the Congressional committees.
Well, now we see where that's landed us: right where we "little single payer people" said we'd be: forced to stick with crappy employer-provided insurance if available, forced to buy crappy, overpriced, abusive private insurance if our income is too high, and, on the chance that we're eligible for the longed-for public plan, forced to wait for it, uninsured, for four more years.
No public plan will be available until 2013. Now, perhaps that doesn't affect you personally: You're not one of those tens of millions of us without health insurance and unable to get any due to cost or pre-existing conditions. But aren't you a bit worried about the political impact? After all, we're not all low-voting, low-information voters: a significant proportion, and the fastest growing segment of our numbers, are active voters who are losing their health insurance as they lose their jobs.
The public plan, because of restrictions on who can sign up, will never be nearly big enough to pose any kind of competitive threat or enforcement hammer for the insurance companies.
It is designed so that it can never be a possible path to single payer; we have the President's and Sec. Sibelius' word on that.
It will leave ten million people uninsured. Promises of "universal coverage" are like those for "transparency"; they involve a few showy gestures in the general direction, but with no intention of inconveniencing themselves to reach the actual goal.
"Progressive" bloggers have been enlisted for the last several years to round up and limit liberal activism on this issue, promising us that the obtainable reform would be both personally worthwhile and a political prize. That was a crock.
This piece of crap isn't worth supporting, even if it were going to be the final result.
A lot of dedicated, wonderful people have continued to agitate for the only real solution despite being ignored, belittled, and told to STFU by supposed allies. Get ready to join them if you want to see anything change in this country.
Posted by: Nell | July 28, 2009 at 01:23 PM
Yes, and not surprisingly there's a reason for that: it's a fair point that you can't refute.
I saw what you did there.
The idea that Al Qaeda, the Taliban or Iraq posed an existential threat to the United States--as in, were capable of killing ALL Americans--is so prima facie ridiculous that I can't believe anyone is still willing to embarrass themselves with it.
You can leave out the "or terrorize" bit as well. It's only in there to make the "ALL Americans" part sound less ridiculous.
If that's your assumption, own it.
If you're trying to make an analogy to Social Security, the truth is closer to this: in twenty years, the same bad faith arguments get trotted out by the same people who opposed the program in the first place, who then proceed to fearmonger about a nonexistent crisis all while opposing any common-sense reforms.
Wars end, but defense spending does not. You continue supporting my arguments for me: we spend more on our military than almost every other country in the world combined, over $500 billion before even taking discretionary spending into account. That's just the normal operating budget. Our disproportionately-large defense funding is a permanent fixture in the budget just as surely as a public option. It's a question of priorities. We're willing to throw ridiculous sums of money at military programs because they might save American lives. We already throw ridiculous sums of money at health care in our current system, which is broken. But we're not willing to throw money at health care in a way which would indisputably save American lives.
You keep using that word. I do not think it means what you think it means.
Posted by: Catsy | July 28, 2009 at 01:36 PM
Overall, a good, thought provoking post.
Like other commenters here, I basically share von's goals for health care (though deficits can certainly go up in the short term, so long as overall spending comes down in a timely manner).
Like others here, I think the public option, in general, does more for these goals than against it (except perhaps, the deficit -- but like I said...).
But given this, I definitely do not think that killing this bill is the way to make these things happen. However far HR 3200 falls short, it needs to be said again and again that it's not the last word on health care reform -- the Senate still needs to report a bill*, which is likely to be very different, and there's still conference committee. And even before the vote, there's the possibility of amendments (esp now).
*BTW von -- How would you say the Senate HELP bill does by these criteria -- or at least the first two?
Posted by: Point | July 28, 2009 at 01:38 PM
So it comes back to eating right and exercise if we want to reduce our corporate burdens.
Are you suggesting a mandatory lentil bean and push-up provision in the health-care bill?
Seriously, though (I don't disagree with your general point), I think it also comes down to better cost/benefit analysis of testing and treatments. The bottom line is that provided health care has to be paid for somehow. There's no getting around that, regardless of payment from public, private, out-of-pocket, hidden or passed-on.
The real issue is getting the outcomes more cheaply. That involves getting rid of existing perverse incentives and, probably to a far lesser degree, needless red tape. I'm not sure about profits for insurers and providers. Though, since I'd support universal single-payor, I guess I am pretty sure about profit for insurers. I don't see what that gets anyone but the insurers and their shareholders. The profit motives for providers might be more manageable if there was an outcome-based reward system of some sort and an emphasis on early detection/treatment and preventive care.
It seems to me that without reducing unnecessary or unnecessarily costly care, someone's profits and unproductive administrative costs, we're going to be putting the same amount of resources into paying for health care, say, as a precentage of GDP as Sebastian points out, regardless of where the money comes from. I don't know how any currently proposed legislation addresses those things, but I think those are at least some of the most important goals, aside from portability and universality.
Can we get the insurance companies' actuaries to use their powers for good and help us figure this stuff out?
Posted by: hairshirthedonist | July 28, 2009 at 01:41 PM
"who then proceed to fearmonger about a nonexistent crisis "
Who does this exactly?
Posted by: Marty | July 28, 2009 at 01:44 PM
Posted by: Nell | July 28, 2009 at 01:23 PM = AWESOME!
Posted by: hairshirthedonist | July 28, 2009 at 01:55 PM
we spend more on our military than almost every other country in the world combined
No'almost'. We spend more than every other country combined, by a long shot.
Posted by: jonnybutter | July 28, 2009 at 01:56 PM
von, I agree with virtually all of this. It might be the most concise summary of the issues I've seen anywhere on healthcare.
I'd like to comment briefly on the "public plan". I'm a British immigrant to the US so I'm very familiar with publicly provided healthcare and how it differs from what we get here.
A lot of the comments here favouring the public plan seem think that congress can simply enact that the public plan will cover everyone to a high level and control its costs, and that it would be so, as if a public plan would be exempt from the forces that have been driving costs up, and therefore also driving coverage down. The experience of the rest of the world does not bear this out - public payers for healthcare, even if they're also the sole provider, have to control what treatments are allowed and impose waiting times for them in order to control their costs and continue to provide universal coverage, just as private sector insurers have to control costs in order to keep their premiums down.
The key question isn't who takes premium payments and then pays for healthcare, but how we change the rules for doing that so that more people are covered, those people can trust that their insurance is real and isn't going to be pulled as soon as they get sick, and the insurers can afford to provide a reasonable level of care.
Unfortunately the only way to squre the financial circle is to stop people from spending vast amounts of their insurer's money on unnecessary or very marginal care (ie. "rationing"), and use the resources saved to care for the currently un/under insured (yes, this is "redistribution"). These are the flip-sides on von's points 1 (coverage) and 3 (deficits) - I don't see anyway around it. Any bill that doesn't do both isn't going to help. The only way to get that past the currently-insured-and-complacent crowd (which would include me if I hadn't seen a fairer system in operation).
A public plan could do both, but only if its essentially a single-payer system, which isn't going to happen (the public plan in HR3200 doesn't have enough market power to impose rationing because of the tiny number of people it applies to). Since you only have to whisper "rationing" and "redistribution" to the American public to kill legislation single-payer is a non-starter, the only way to get what needs to be done, done, is something like the Wyden bill - end the employer backed system, force all the insurers onto an exchange, enforce minimum levels of coverage and no cherry-picking, pre-existing condition bullshit or recission. That way the insured are guaranteed choice and full, truthful disclosure, and insurer are forced to force patients to accept rationing because between them they have to cover everyone. A refundable tax credit for healthcare takes care of the redistribution part.
Posted by: Simon K | July 28, 2009 at 01:58 PM
Why, using those three criteria, is a strong public option a bad idea?
Or if you're opposed to a plan including a strong public option based on some other criteria, then I think you should modify your proposal to include those criteria. (Or, alternatively, modify your opposition to the public option.)
Posted by: Ampersand | July 28, 2009 at 02:04 PM
"Are you suggesting a mandatory lentil bean and push-up provision in the health-care bill?
"
I would suggest insurance premiums be partially based on some multiple of the Body Mass Index, or percentage body fat as compared to a norm for the individual. Maybe we could also data mine consumer purchases for unhealthy products and add some variation of a unhealthy lifestyle surcharge...buying a motorcycle or processed american cheese might be a charge, buying broccoli or running shoes might be a deduction. Beer would similarly be a deduction, since it is fundamental to human existence, and protected by various penumbra of the Constitution.
Posted by: jrudkis | July 28, 2009 at 02:07 PM
"I think food stamps which are limited to staples such as rice, pasta, veggies and fruit should be a part of any health reform plan."
Because the more paternalism we impose on the poor, the better.
After all, we know better how poor people should spend what little money they have, and we should command and control how they spend it.
Posted by: Gary Farber | July 28, 2009 at 02:16 PM
"A rational solution would be to increase taxes on certain unhealthy foods -- something that I'd be willing to consider, but which it almost certainly DOA."
Although still regressive, I'd much favor that then trying to mandate that poor people not be allowed comfort food, even if it is "unhealthy."
If we're going to be food police, let's be food police on everyone, at the least, not just on the backs of the poor.
(Although it's still, being regressive, partially on the backs of the poor, since the well-off can afford to pay such a tax, and the poor, obviously, not so much. But at least a tax is less absolutist than mandates on food stamp spending, which are already ridiculous -- for instance, you can't buy unpackaged cold cuts from a deli counter, because they're "prepared food"; you can only buy them when sealed in a package; food stamps are filled with these sort of idiotic restrictions, which bother few people, most people not being on food stamps, or even the slightest bit aware of what it's like to be dependent on them.)
Posted by: Gary Farber | July 28, 2009 at 02:20 PM
There's a lot that I would like to respond to, but can't due to time pressures. I also should note that, even where I disagree with a commentator, I think that the quality of the arguments being made is first rate.
I do want to pivot off a point made by John Harrold, however. He writes:
I cannot speak for von, but I can speculate that he has a certain skepticism about what the government can accomplish, and he tries to bring forth policy suggestions which account for that explicitly.
Feel free to speak for me on that point, because you've nailed it. There's a lot of focus on the alleged ill incentives afflicting insurance companies, without recognizing that the public option is subject to its own series of unhealthy quirks and distortions.
And it bears noting that I'm not viscerally opposed to a public option. I don't think it's the best approach, but it's hard for me to get all good and lathered up about it. I lived in the UK for a time as a child, under a "real" socialized medicine program. (This was in the 80s, when the UK was even more "socializier" than today.) The UK's system is a far cry from the grandma-will-be-left-on-the-ice-floe-to-die hysteria.
Posted by: von | July 28, 2009 at 02:24 PM
@ Simon K
Exactly. You can't achieve Von's desire for universal coverage without finding some way to "bend the cost curve." A strong public option bends that curve. A heavily regulated insurance exchange bends that curve. Once the premise of universal coverage is accepted, opposition to things like a public option become plainly ideological.
Posted by: Derek | July 28, 2009 at 02:25 PM
"1) The assumption when someone kills 3,000 (or 20,000 Americans) is that we should defeat them before they kill or continue to terrorize ALL Americans. Very high stakes, not to diminish the need to address healthcare."
No, the assumption is that we should prevent them from again killing sizeable numbers of people; nobody nowhere is in a position to "kill... all Americans," or even most Americans, and even killing a significant percentage of Americans is solely in the hands of Russia and/or China.
Our goals in Afghanistan, for instance, however rightly or wrongly, include trying to prevent attacks that are the equivalent or greater than those of September 11th; they're not to prevent every single American from ever being threatened.
Similarly, the goals of health care are not to create immortality, nor to eliminate all disease and injury; the goals are, well, pretty much as von stated, but essentially to greatly improve the situation for people without health care, those in danger of losing health care, and those with poor health care insurance options.
And the only way all Americans can be terrorized is if they terrorize themselves. Your claim, in short, is highly muddled, and untrue, and your analogy fails.
"2) Wars end, the healthcare spending we are talking about becomes a permanent fixture in the budget."
Really? What are the conditions for ending "The War On Terrorism," exactly? I'd really like to know.
"Quite possibly a deficit this year becomes one next year and, in twenty years, we are having a debate about 'saving healthcare'."
Fine; we'll have that debate then; meanwhile, we'll have tens of millions of people, and families, with twenty years of health coverage they won't otherwise have. Sounds good to me!
Posted by: Gary Farber | July 28, 2009 at 02:32 PM
"So as of 2006, the US government spends about 21% more per capita than Canada yet covers only 27% of the population. That is crazy."
Which is why we need to change the system; this is not an argument for preserving the status quo while we debate some more what we've been debating since at least 1948, when Truman's health care plan was defeated by the Republicans.
But let's give it some more time, to work out a better plan. Why do now what we can put off another sixty years?Remember, Obama is leading the country down the road to Muslim communism!
Posted by: Gary Farber | July 28, 2009 at 02:36 PM
"If we're going to be food police, let's be food police on everyone, at the least, not just on the backs of the poor."
My most fervent hope is that we get to the point where this is the most important thing we have to debate. For now, let's not be the food police for anyone.
Posted by: Marty | July 28, 2009 at 02:37 PM
@Marty
I'm always suspicious of comparisons with war, but your two objections to this comparison don't make sense:
1) The assumption when someone kills 3,000 (or 20,000 Americans) is that we should defeat them before they kill or continue to terrorize ALL Americans. Very high stakes, not to diminish the need to address healthcare.
No war has ever done away with the entire population of any country. And the entire population of the U.S. is at risk to lose their health insurance. I don't think this is a meaningful disanalogy.
2) Wars end, the healthcare spending we are talking about becomes a permanent fixture in the budget.
In fact, America's wars never end. At least this time, with the "Global War on Terror," our leaders have been relatively honest about this fact. This is a war which can have no meaningful conclusion. More importantly, we have been at war or on a permament war footing in this country for the last sixty-one years.
@Nell - I agree one hundred percent with your analysis of public support for single-payer and elite efforts to insure that it won't come about. A few comments on your analysis and conclusions:
First, Americans who say they support single payer have never been willing to vote for politicians or parties who endorse it. To a certain extent, you do get what you vote for. As I've said over and over again in publius's comment threads decrying Democratic failure: the Democrats are behaving exactly as one would expect them to behave. The only thing I'm surprised about is that anyone who's been paying attention is surprised at their behavior.
Second, real social reform tends to happen when power in the streets makes it the less scary option for our political elites. Sit-down strikes and fear of social revolution helped bring about the Wagner Act. The Black Freedom movement helped bring about the Voting Rghts Act (the bullet or the ballot, as Malcolm X put it). There's been an extraordinary amount of organization on healthcare, but it has all taken the form of petitioning our leaders (often with publius's fatally optimistic assumption about what they really want for us). That's not the kind or organizing that usually brings results.
Finally, in the short run, as is so often the case in our political life, supporting the lesser evil is the best we can do. And in this case the lesser evil is the House Bill. We shouldn't pretend that it's something it isn't. But we also shouldn't be so frustrated with the corruption and failures of the system that we turn down a quarter-filled glass when the alternative is an empty one.
Posted by: Ben Alpers | July 28, 2009 at 02:37 PM
"A strong public option bends that curve."
Again, (and again, and again), I don't understand why you believe that. We already have Medicare and Medicaid. The US government already spends more per capita than Canada yet only covers 27% of the population.
If it can do so, why hasn't it "bent the curve" already if the US government is *already* spending enough to get Canadian health care?
If it were really that obvious that the US government can bend the curve, why hasn't it already done so? Why don't we already have universal health care instead of spending more than Canada and only covering about a quarter of the population?
And since it didn't, why do you think that suddenly it will be able to?
Posted by: Sebastian | July 28, 2009 at 02:39 PM
"This piece of crap isn't worth supporting, even if it were going to be the final result."
Nell, so the status quo is better? Or are you saying we can somehow drastically change the political environment so that in another two, or four, years we can pass single-payer? Or what? What alternative are you proposing?
Posted by: Gary Farber | July 28, 2009 at 02:40 PM
Again, (and again, and again), I don't understand why you believe that.
Mostly because the CBO says it.
Posted by: Derek | July 28, 2009 at 02:40 PM
Posted by: Gary Farber | July 28, 2009 at 02:42 PM
Derek - I'm somewhat bought into the ideology that prefers a strongly regulated exchange to a strong public option. The UK national health service shares a number of un-attractive features with all socialist bureaucracies, but does in fact acheive reasonable health outcomes for almost everyone. For various reasons, though, I think its unattractive features would tend to be accentuated if it were replicated here. Something that enforces the overall model of rationing and redistribution while delegating actual execution to the private sector would seem to fit better with the American system of governance overall.
Regarding the grandma-will-be-left-on-the-ice-floe-to-die thing - I don't think this argument can be made in good faith against rationing. It applies just as well to the current mostly-private eat-what-you-can mess if grandma omitted a pre-existing condition in her paperwork or missed a premium payment some time in 1972. A least rationing based on on medical best practice (which is what the NHS tries to do and somewhat succeeds at) is justifiable in overall cost/benefit terms.
Posted by: Simon K | July 28, 2009 at 02:46 PM
But to respond in full to Sebastian:
A) to achieve universal coverage money has to come from somewhere to give 50 million people insurance. Either we pay for them to get insurance on the private market (expensive) or we pay for them to get a plan that costs less. If the public option has the same bargaining power as medicare or something like that then it will cost less per person to insure, which brings me to point B
B) Medicare/aid's costs have gone up less than private costs over the years. Which suggests that putting people on these plans or plans with the same ability to bargain down prices (strong public option) would cost less than paying for them to get private insurance.
Posted by: Derek | July 28, 2009 at 02:46 PM
"I would suggest insurance premiums be partially based on some multiple of the Body Mass Index"
This might make some sense of the BMI had anything to do with health, but all the recent studies have been revealing that that's a crock. See here, here, here, and here, for instance.
Posted by: Gary Farber | July 28, 2009 at 02:48 PM
Similarly, on BMI having nothing to do with one's health, here, here, here, and I could keep going indefinitely. Just google on "Body Mass index" and "flawed."
Posted by: Gary Farber | July 28, 2009 at 02:50 PM
@hairshirthedonist: Thanks. I've needed to get that off my chest for a while. (At first, though, I didn't see the '=AWESOME' and thought you were identifying me as a culprit in answer to Marty's question... ;>)
Point: However far HR 3200 falls short, it needs to be said again and again that it's not the last word on health care reform -- the Senate still needs to report a bill*, which is likely to be very different, and there's still conference committee. And even before the vote, there's the possibility of amendments (esp now).
There is no chance -- none -- that the Senate bill will be an improvement on H.R. 3200 from the point of view of anyone but the insurance companies. Amendments are a Hail-Mary hope. Their prospects depend heavily on the commitment of the Speaker and Majority Leader and the rules they set up for voting. If you honestly think that amendments serious enough to repair what's wrong with the House bill now will be introduced in House or Senate with rules that allow them to pass... well, I admire but am unable to share your optimism.
Posted by: Nell | July 28, 2009 at 02:54 PM
"Again, (and again, and again), I don't understand why you believe that. We already have Medicare and Medicaid. The US government already spends more per capita than Canada yet only covers 27% of the population. "
Sebastian, can you clarify the above for me? Why is a per capita $ figure comparison appropriate for comparing the percentage of the *total* population covered by health insurance in each country? If this is a we're-not-as-efficient-a-government-as-Canada argument, isn't it important that public monies are being used in the US to cover the poor and elderly (high risk/cost) pool?
Not being snarky - I just don't understand the reasoning. I also can't find the per capita figure you cite earlier in this CRS report - have you done some analysis to break out the total per capita spending of over 6k in the US to get that number?
Thanks
Posted by: Audrey | July 28, 2009 at 02:55 PM
Without campaign finance reform, there's no possible way an adequate bill can come out of Washington.
I think it's reasonable to look to the states for better solutions and let it work its way up. What became the Canadian single-payer system started out as a provincial plan.
Posted by: Dave | July 28, 2009 at 02:55 PM
"No war has ever done away with the entire population of any country."
Carthage delenda est.
But I suppose some Carthaginians got away; I think this claim might depend upon the definition of a "country," as regards pre-Middle-Ages civilization, though, or even through today. Certainly you have lots of Biblical era populations wiped out to the last soul, and even plenty of modern tribes around the world, including Native American ones, which had plenty of the attributes of a "country."
But I digress.
Posted by: Gary Farber | July 28, 2009 at 02:56 PM
"No war has ever done away with the entire population of any country. And the entire population of the U.S. is at risk to lose their health insurance. I don't think this is a meaningful disanalogy."
I don't know that any war has or not, it is the fear of the intent that is the motivation for the expense.
I think the risk of everyone in the US losing their insurance would be an equally great motivator, I haven't seen that documented or even discussed as a possibility.
Keep in mind, I believe strongly in a public option of baseline insurance for everyone (Medicare extension etc.)
I also believe we should provide for portability and continuity of coverage through an individual payer system supported by tax credits. Specifically to separate work from healthcare.
We should make exclusion for preexisting conditions illegal.
We should pay for any and all of that out of reductions in the defense and human resources budgets.
Then we should actually reform healthcare.
Posted by: Marty | July 28, 2009 at 02:58 PM
"If it were really that obvious that the US government can bend the curve, why hasn't it already done so? Why don't we already have universal health care instead of spending more than Canada and only covering about a quarter of the population?"
Ah, that would be because Republicans consistently, for the past sixty-plus years, have successfully denounced it as "socialism" and "communism."
Posted by: Gary Farber | July 28, 2009 at 02:58 PM
I would like to go on the record now and state that I'm uncomfortable with the government having access to this level of information about anyone. Truthfully, this is one of the things that concerns me about universal health care. I really don't want the government using: Well we pay for your health care as an excuse to micromanage every aspect of my life.
Posted by: John Harrold | July 28, 2009 at 03:02 PM
von:
I hope you're right that killing this bill is not synonymous with killing health care reform altogether, but I'm not optimistic about that.
Posted by: tgirsch | July 28, 2009 at 03:07 PM
Carthago delenda est.
Point well taken,
CiceroGary.I should have stated my point more narrowly: no industrialized nation has ever been had its population entirely wiped out by war.
Marty's larger point, of course, is that everyone is threatened by modern warfare, and that is certainly true. But everyone other than the independently wealthy and senior citizens--who are already covered by a "public option"--is at risk of losing their insurance in the U.S. today.
Posted by: Ben Alpers | July 28, 2009 at 03:13 PM
""who then proceed to fearmonger about a nonexistent crisis "
Who does this exactly?
Everybody who claims that there's a Social Security crisis looming. You need a list of names?"
Not really, just a recognition that it is a long list and a nonpartisan list.
Posted by: Marty | July 28, 2009 at 03:14 PM
"Ah, that would be because Republicans consistently, for the past sixty-plus years, have successfully denounced it as "socialism" and "communism." "
How does this keep it from bending the curve? It exists, it has a huge pool, and while some costs have gone up slower than private health insurance, they have gone up in real dollars.
So, to answer my own question, we haven't reformed healthcare law, delivery or practice.
Posted by: Marty | July 28, 2009 at 03:21 PM
Gary: Nell, so the status quo is better? Or are you saying we can somehow drastically change the political environment so that in another two, or four, years we can pass single-payer? Or what? What alternative are you proposing?
The status quo is one in which I will be unable to afford health insurance forever, and "pre-existing conditions" make me near-uninsurable. Actuarially, I'll probably live another twenty years. A public plan that kicks in in 2013 means that I can hope not to be injured too badly or fall ill in the next four years, at which point I might be able to obtain insurance I can afford. So on the personal Nellometer, score that one for: H.R. 3320 better than nothing.
What it isn't, is anything for which I'm willing to pick up the phone or go lobby my wholly unresponsive right-wing Republican representative. Comrade Webb, whose excuse for not supporting the Employee Free Choice Act is the current economic crisis (!), will probably not vote for the worst Senate bill. Sen. Warner probably will; he's never, unlike Webb, pretended to be a populist.
The apparatchiks who readied the activist Dem base for this shearing are already saying that the problems we might have with what emerges can be fixed after another round of elections, with the election of just a few more Democrats.
The alternative I'm proposing (for myself) is to quit being led around by the nose in that particular rigged game, and get back to work doing what I did before 2001: trying to change the political environment drastically.
I'm not going to wait to see what kind of reaction voters have to health care reform that Democrats will own. I'm not going to work for or defend something I don't believe in, a "reform" that's the product of cynical calculations and pre-capitulation. I'm going to advocate and agitate for the structural reforms that are required to make real change possible.
If, at any point along the way, this administration had shown good faith and a willingness to expend political capital on behalf of the majority of the people who voted for it on even one of the variety of issues on which those people are counting on Obama, I might not cut myself free so early on.
I knew health care wouldn't be that issue, though. It's painful to contemplate the millions of people hurting worse than I am who believed it would be. I'm not going to be part of leading any of them further down the path by pretending I don't see what's gone on here, or pretending that I think this bill or any of its conceivable future "fixes" will solve the real problem.
Posted by: Nell | July 28, 2009 at 03:29 PM
"There is no chance -- none -- that the Senate bill will be an improvement on H.R. 3200 from the point of view of anyone but the insurance companies."
From the criteria described above, they have -- or at least have the indication of having -- some advantages.
For example, though the super-secret Baucus group is talking about trying to nuke the public plan*, they're also talking about getting rid of the employer mandate. I've also heard^ that there's talk on the Senate side of taxing group benefits -- which the CBO is http://blogs.tnr.com/tnr/blogs/the_treatment/default.aspx ">supporting by the way**, meaning it would both reduce HC spending and decouple HC from employment.
*Maybe it's the optimist in me, but this sounds like a long shot if they want to block it -- it's popular, and it's HELP's turf anyway.
**(Grassley, FWIW, was a supporter of the Wyden plan, which is more my ideal.)
Posted by: Point | July 28, 2009 at 03:33 PM
Correction to my 3:29pm: H.R. 3200 better than nothing for me personally.
(For the country, for the economy, for the health of the majority of people in the U.S., and for the health of small-d democratic politics, not so much.)
Posted by: Nell | July 28, 2009 at 03:35 PM
Sebastian:
The reasons why Medicare and Medicaid haven't bent the cost curve are well-known and oft-decired (principal among them being corporate protectionism and a skewed risk pool). But I'd be a lot more receptive to your criticisms if you were actually in the business of suggesting viable alternatives. To be fair, perhaps you have, and I simply haven't seen it. Most of what I can discern from your arguments, however, simply seems to be a reflexive "government bad" response. (Which, apparently, is specific to the US government, since you correctly point out that other governments are doing it for less. Perhaps the problem, then, it's not the government's influence keeping prices high, but the private sector's influence.)
Otherwise, it seems to me that Catsy wins the thread.
Posted by: tgirsch | July 28, 2009 at 03:38 PM
Shorter Nell: "Idealism rules, pragmatism drools! If I can't have the ideal, I don't want anything at all."
[‘Shorter’ concept created by Daniel Davies and perfected by Elton Beard. We are aware of all Internet traditions.™]
Posted by: tgirsch | July 28, 2009 at 03:42 PM
Whoops, I posted my last comment before seeing Nell's 03:35 PM comment. Seems I may owe an apology.
Posted by: tgirsch | July 28, 2009 at 03:43 PM
"I don't know that any war has or not, it is the fear of the intent that is the motivation for the expense."
Anyone who fears that, somehow, by magic, al Qaeda can, by intent, wipe out the U.S., is insane. One might just as easily wear a tin foil hat to keep the Martians from invading.
Spending money on such a cause is equally insane.
Besides, the announced intent of Al Qaeda is to provoke lots of small wars by getting the U.S. to invade lots of places and bleed us economically dry. Have you never actually read any of Osama bin Laden's fatwas? I'm assuming you don't actually support his plans consciously. I used to have links to them on the sidebar of my blog, but they suffered link rot. If you really need me to, I'll look up fresh links for you to read for yourself on his strategies.
"Then we should actually reform healthcare."
You fail to mention "covering the 47 million Americans who are uninsured" in your list of priorities.
"I should have stated my point more narrowly: no industrialized nation has ever been had its population entirely wiped out by war."
True. Though nations qua nations have been wiped out as independent entities, at least for periods of time, of course, innumerable times (sorry, I love to wax historical, and this is a complete digression). Poland, the various "Republics" of the USSR, Tibet, the list goes on and on. (Okay, I suppose Tibet doesn't qualify as "industrialized"; but Poland certainly did.)
But, as I said, this is a total digression.
Posted by: Gary Farber | July 28, 2009 at 03:44 PM
"Then we should actually reform healthcare."
"You fail to mention "covering the 47 million Americans who are uninsured" in your list of priorities"
I said this (first):
Keep in mind, I believe strongly in a public option of baseline insurance for EVERYONE(Medicare extension etc.) (caps added)
I think this covers that.....
Posted by: Marty | July 28, 2009 at 03:49 PM
"Not really, just a recognition that it is a long list and a nonpartisan list."
It's somewhat non-partisan; it tilts strongly Republican -- during the last Bush Administration, you'll recall that the Democrats voted down Bush's Social Security bill and implicit claims of crisis on a strict party vote -- but it's certainly true that there are some Democrats, and plenty of Broderists, who have equally foolishly and ignorantly signed onto the "crisis" notion.
(Medicare has a looming crisis; all Social Security needs are some minor tweaks to prevent problems that won't loom up for quite a long time in the future, and those according to questionable projections at best; even the worst case requires relatively minor fixes.)
Thanks muchly for your response, Nell. I understand your position.
"Correction to my 3:29pm: H.R. 3200 better than nothing for me personally."
Sounds like it might be better for me, too. Couldn't be worse, anyway.
Posted by: Gary Farber | July 28, 2009 at 03:52 PM
@tgirsch: No apology needed, since you've acknowledged that the drools/rules post did misinterpret my views.
Which I'd shorten to:
Don't piss on me and expect me to pretend it's raining.
Posted by: Nell | July 28, 2009 at 03:55 PM
"Besides, the announced intent of Al Qaeda is to provoke lots of small wars by getting the U.S. to invade lots of places and bleed us economically dry. Have you never actually read any of Osama bin Laden's fatwas? I'm assuming you don't actually support his plans consciously. I used to have links to them on the sidebar of my blog, but they suffered link rot. If you really need me to, I'll look up fresh links for you to read for yourself on his strategies."
No need, and I am a little sorry this irritated me in the first place.
I am no fan of chasing the terrorists all over the globe expending nonproductive resources against an enemy who is completely mobile and essentially unidentifiable.
Back to healthcare?
Posted by: Marty | July 28, 2009 at 03:55 PM
"I said this (first)"
Thank you for clarifying, Marty.
Posted by: Gary Farber | July 28, 2009 at 03:55 PM
"I am no fan of chasing the terrorists all over the globe expending nonproductive resources against an enemy who is completely mobile and essentially unidentifiable."
It is sort of like playing "Where's Waldo?" for hundreds of billions of dollars.
Thanks also for clarifying on this, as well.
Posted by: Gary Farber | July 28, 2009 at 03:58 PM
Audrey
"Sebastian, can you clarify the above for me? Why is a per capita $ figure comparison appropriate for comparing the percentage of the *total* population covered by health insurance in each country? If this is a we're-not-as-efficient-a-government-as-Canada argument, isn't it important that public monies are being used in the US to cover the poor and elderly (high risk/cost) pool?"
The per capita figure is appropriate because Canada covers 100% of its population with its per capita expenditure. It is not important that the money in the US is covering the poor and the elderly, because the money in Canada is also used to cover the poor and the elderly.
One possible tweak might be that we should really compare percentage of GDP expenditure per capita. If you do that the picture improves to merely: the US government spends as much as Canada but only covers 27% of the population instead of all of it. Which still makes my point.
Posted by: Sebastian | July 28, 2009 at 04:10 PM
"HR 3200 still adds $239 billion to the deficit over the next decade while having none of its purported "curve shifting" benefits."
Yes, because it would be very bad for the government of the Unites States to spend a fraction of one year's defense appropriation to cover the 50 million uninsured Americans for ten years. And I'm sure that getting them out of the emergency room for upper respiratory infections and poison ivy and treating them in a primary care setting won't save a dime.
"Bending the curve" will require completely different public policies that address our dreadful nutrition and lifestyle problems. Tweaking Medicare payments while continuing to treat millions of obese diabetics just isn't going to do it.
Posted by: shep | July 28, 2009 at 04:13 PM
Gary, "Ah, that would be because Republicans consistently, for the past sixty-plus years, have successfully denounced it as "socialism" and "communism."
Is that a serious argument about why the US government spends more per capita than Canada but only covers 27% of the population? Did Republican rhetoric scare the naturally occuring cost savings away?
Posted by: Sebastian | July 28, 2009 at 04:15 PM
"But I'd be a lot more receptive to your criticisms if you were actually in the business of suggesting viable alternatives. "
What? My suggestion on 3 out of the last 4 health care threads that we should just straight up extend Medicare to the uninsured and put an EITC-like sliding scale on the rates doesn't count? Just because I keep raising it and no one cares to talk about it doesn't make it non-viable. It might make it boring I suppose...
Posted by: Sebastian | July 28, 2009 at 04:18 PM
Sebastian,
It is not clear to me what your point *is*. No government can ‘cover’ any amount of people (greater than 1 person) with a per capita amount of dollars.
Per capita ($/person) is a rough statistic to measure relative cost efficiency.
Because Canada’s public spending is used to cover 100% of its population with some basic level of health insurance, by definition, they have a risk pool inclusive of non poor, non elderly people. Such a risk pool will be less expensive to cover per capita, than an exclusively poor and/or elderly pool, which is what public dollars cover in the U.S.
That is why I was asking where your per capita number - that I can't find in the report - came from, and whether you are making an efficiency argument or a different argument that I'm just not grasping.
Posted by: Audrey | July 28, 2009 at 05:41 PM
This made me lawl.
Posted by: Catsy | July 28, 2009 at 06:03 PM
The war analogies are missing the point when talking about future casualties and eliminating an unknown threat.
How's this: If we knew that External Threat X killed 20,000 Americans last year, and knew that they'd kill 20,000 Americans (but no more than that) next year, and the year after, and so on....wouldn't we be willing to do some deficit spending to fight that External Threat X? Wouldn't we be willing to band together to pay higher taxes to fund that fight (when we're not in the midst of a nasty recession)?
I have a hard time believing that we wouldn't. So why are we so unwilling to go to bat for those Americans that are dying due to lack of insurance?
Posted by: ChrisC | July 28, 2009 at 06:13 PM
We just ran with five or six years of deficit spending with a more or less good economcy. When the economy is good, the government expands it programs. When the economy is bad, we keep spending at the same level and run deficits.
At some point our currency will be worthless, no one will loan us money, and we'll have not choice to cut services.
Posted by: John Harrold | July 28, 2009 at 06:52 PM
I'm uninsured, a freelance artist who works his ass off. A fate I wouldn't wish on anyone but..
"Where will the money come from?", people ask.
Well let's put it this way: I'd gladly pay $200- 400 for decent health insurance. I simply cannot afford $1,200 -1,800 a month private corporate insurers demand. Because I work for myself and am following my dream to a certain extent, private Insurers think I'm a crazed hippie for not having a corporate job.
What's wrong with this picture, in a land that extols 'small business' and 'free enterprise'?
But would my monthly $400 really just be "nothing" when multiplied by millions just like me? And that's rather steep, to be honest: people with corporate jobs and insurance don't ever see the real costts of it, work for yourself and you sure do.
"Who's worthy to live or die?" seems the distressing subtext of the health care debate. And it's a damned ugly picture. This country is absolutely a hostile place to the non-rich, no matter how much we wave the flag, speak of equality, and patriotism. This country is viciously Darwinian in an ugly way, and the mass media is fully behind the corporate HMOs to destroy health care reform. Because we hate poor people. We want them to die. They deserve it for not working hard, like the powdered hosts of TV talk shows. Where are the uninsured on these Sunday panels? Nowhere. At its heart, we are a stingy, mean-spirited country.
Corporate profits above all. And mister "von", who can't afford a capital letter to his name, acts as if we're going "too fast" on health care reform. He clearly has no fucking idea it's been a plank of Democratic politics for the entire 20th century, that the voters and the people seem to want it- look it up, bitch- but you'll never hear that on the talk shows when corporate profits are at stake. Americans are cattle to these parasites, our health and lives are their profit centers. And we put up with it.
Yeah, we're cattle, but this might change. But "von" will always be a terrible writer spouting right-center conventional wisdom like Cokie Roberts. "Wait-this is going too fast!" Oh, screw you, some change can't come fast enough to our ROTTEN health care system.
Posted by: Arundel | July 28, 2009 at 07:31 PM
@John Harrold: That wasn't true for the Clinton years.
Posted by: ChrisC | July 28, 2009 at 08:07 PM
So Arudel, you admit that you're following your dreams. And good for you! But then you seem to imply that it is up to your fellow citizens to fund your dreams --- at least the insurance involved. The implication here is that I or others like me should be a good corporate drones, so you don't have to be. Then you move into so some incoherent ad hominem arguments about capitalization mixed with profanities that don't actually address any of the concerns that von brings up.
That about sums up your side of the argument right?
Posted by: John Harrold | July 28, 2009 at 08:20 PM
Sebastian:
Yikes, the new CRS report you link makes my oft-repeated point about government spending even more powerful. According to the report the US government spends about $2,684 per capita and covers about 27% of the population. Canada spends about $2,209 per capita and covers 100% of the population.
So as of 2006, the US government spends about 21% more per capita than Canada yet covers only 27% of the population. That is crazy.
How embarrassed does everyone feel who responded, informatively and helpfully, when Sebastian pretended to be asking for information on this point last time? Or the time before that?
Now it's clear Sebastian was not asking for information, nor willing to pay attention to any of the information that was provided to him.
No: he admits here that he was just trying to score a cheap political point. Sebastian is not interested in any information that could be provided that, if he paid attention to it, would undercut this silly repetitive "point" he keeps trying to make: so the solution, it seems to me, is to quit responding to his repeated "27%!" attempts to derail any serious discussion of how to fix your broken health care system... since he's obviously not interested in your answers.
Posted by: Jesurgislac | July 28, 2009 at 08:22 PM
Sebastian: "Is that a serious argument about why the US government spends more per capita than Canada but only covers 27% of the population? Did Republican rhetoric scare the naturally occuring cost savings away?"
No, Sebastian, it's a serious argument to answer this question you asked: "Why don't we already have universal health care [...]?"
Posted by: Gary Farber | July 28, 2009 at 08:34 PM
@ChrisC
Thats true, but it doesn't seem like Obama is that committed to balancing the budget either. In his defense, he's got a lot working against him that Clinton did not: The economy he inherited is much worse. I doubt he'll be able to cut military spending any time soon, and the costs of Medicare and Social Security are only going to become more of a problem.
Either he's going to have to be honest and say "we're going to have to reassess our priorities as a country." Or he's going to contribute to the problem by kicking the can further down the road.
I really hoped he would do the former, but I'm afraid he's more likely to end up doing the latter. If he signs a bill that doesn't address point number 3 of von's, then I truly don't believe he's serious about governing.
Posted by: John Harrold | July 28, 2009 at 08:34 PM
"He clearly has no fucking idea it's been a plank of Democratic politics for the entire 20th century"
Nitpick: not prior to 1933 at the earliest, I think, and not as a major campaign issue since 1948.
Which is more than long enough. The British managed to pass their National Health Service Act in 1946, after all.
Posted by: Gary Farber | July 28, 2009 at 08:39 PM
Sebastian:
Did Republican rhetoric scare the naturally occuring cost savings away?
Yes. Or at least the profit motive did.
I'm pretty sure I just saw something -- linked to by either Ezra or Krugman -- to the effect that the 27% of the population you're talking about represents more like 45% of the medical care -- because old and poor people, who are covered by the government, get sick the most.
I had been beating the "the problem is administrative costs" drum until Gawande's article came out, now I'm prepared to just blame the profit motive.
Posted by: Doctor Science | July 28, 2009 at 09:31 PM
I'm heading back with my father to Japan for an extended stay, and I am just finishing doing the rounds of his doctors, getting information about his various ailments and having prescriptions filled, so I gain a new appreciation of the Japanese system. But I see Sebastian is doing his 'The US only covers 27% of the population so obviously, there is no way that the US can be cost effective in covering more than that'. This strikes me as a sort of inverse American exceptionalism argment, in that Sebastian is arguing that somehow, the US cannot do what every other OECD country does now. There is a point there, in that it is American exceptionalism that brought the US to this juncture, in that (I think) the majority of the countries developed their versions of universal coverage after WWII, when the economies and infrastructures of these countries made it necessary to provide basic medical coverage to all, but the US could forgo that because rising prosperity made it easier to have people take on their medical costs. If that's the case, perhaps the medical system is not broken enough to get the kind of change that is necessary, though after my latest dealings, I wonder how much more dysfunctional the system can get.
Posted by: liberal japonicus | July 28, 2009 at 10:18 PM
Sebastian:
My suggestion on 3 out of the last 4 health care threads that we should just straight up extend Medicare to the uninsured and put an EITC-like sliding scale on the rates doesn't count?
It's not that it doesn't count; it's that it actually manages to be WORSE on cost than the existing proposals under consideration. Let's take what you already claim is far too expensive and EXPAND it to cover EVEN MORE people? How's THAT gonna scale?
Posted by: tgirsch | July 28, 2009 at 10:20 PM
Dr. Science, as it happens, one of the eight tabs I've had open on my browser for the last day is to the New Yorker site, where I've been catching up on articles I've only sporadically been checking on for the past six weeks or so. I hadn't gotten to the piece you link to, but I want to emphasize that everyone must read it. It's that important to understanding the problems of rising health care costs, and what's wrong with our health care system, in my ill-educated view.
Fantastic article; thanks immensely for bringing to the attention of the folks reading this thread.
Posted by: Gary Farber | July 28, 2009 at 10:39 PM
Dr. Science, as it happens, one of the eight tabs I've had open on my browser for the last day is to the New Yorker site, where I've been catching up on articles I've only sporadically been checking on for the past six weeks or so. I hadn't gotten to the piece you link to, but I want to emphasize that everyone must read it. It's that important to understanding the problems of rising health care costs, and what's wrong with our health care system, in my ill-educated view.
Fantastic article; thanks immensely for bringing to the attention of the folks reading this thread.
Posted by: Gary Farber | July 28, 2009 at 10:39 PM
Arundel, since when did von say that things were moving too fast. I think you're confusing von with Blue Neponset who said that von's proposal to decouple health insurance from employment was too radical.
So, if you can actually read what von said insetad of going on and on with your self righteous bullshit just because von happens to be centre-right on some issues(actually, mostly on abortion only), you would actually see that von makes very good points, even if I think he concedes too much to the left.
i.e. while the poor should have subsidises health care because they are unlikely to be able to afford private insurance (although I have a catastrophic plan with AVIVA which costs me about $30 - $60 a month and gets me a 6 figure payoff if I were to die or be crippled) I dont think that the subsidy should take the form of a public insurance option. The point of insurance premiums is that they collect revenue, hopefully in excess of how much the average payoff is going to be. That's why insurance agencies don't take people with pre existing conditions. Those people are sure losses.
Which is why people suffer. If you get insurance when you're young and healthy you can get a pretty good deal. However, if you change jobs in your mid forties, (as many americans do) you lose coverage with your original insurance and have to apply for insurance again (but with some other company this time). However, now, you probably have a high risk of heart attack or something, and are a greater risk to insure.
The public plan is supposed to do away with the profit motive. If, there is no need to make a profit (since everything is funded by tax dollars) why the hell shoud you have to go through the whole rigamarole in paying premiums ,processing them, making claims, collecting them etc. All that will still be present in the public option.
We could do away with the insurance framework and use some system of directly subsidising the consumer: i.e. you. Some ideas would include vouchers to buy your own insurance, or vouchers to actually just directly pay for treatment. Or maybe some kind of central fund from which you can draw money from. Or co-payments. Just covering 80%, or 90% of the cost of a tratement, or maybe 20% if you are somewhat richer.
Means testing of course has to be involved at some point in order to minimise free riding. Something a lot more like what we have in Singapore.
So, for now, a good plan would be to start taxing benefits and to get rid of the interstate commerce clauses which prevent insurance companies from operating across state lines.
The expected effects are the following
1. Insurance wouldn't be provided by employers and would be individually subscribed to instead. i.e. if benefits are taxable, employees would prefer to get it in cash instead.
2. Employees are more mobile and less afraid to quit a job if they are not happy with it. This will drive up worker salaries
3. Competition with other insurance companies would drive down premiums and increase coverage. For this to work, some transparency regulations may have to be enacted if they are not already in place.
4. If we give the market a year, or more to correct itself, then we can see who else cannot pay for their own healthcare. Then we could devise a plan to pay for their heathcare directly. I'm not even averse to government run/ subsidised hospitals and clinics.
Posted by: Murali | July 28, 2009 at 11:58 PM
Murali, you are in Singapore? I'd be very interested in knowing how the system works there. A quick google suggests that they spend less than 2% of their GDP, but their indicators are as good as the US.
Posted by: liberal japonicus | July 29, 2009 at 12:36 AM
Singapore works largely with mandatory savings accounts (medisave), supplemented with means testing and government subsidies in government run hospitals (medisave). For some of the more expensive stuff, people can also withdraw from their CPF accounts (which is another mandatory savings account some of which comes from the employer and some from the government) CPF is more a pension alternative, but non retirees have some options in withdrawing money to buy a flat or something.Some of the payment is also supplemented by people's own insurance as well as any basic health plans that may be found in employment contracts.
Moreover, there is also a strong culture of looking after one's parents (and not moving away from them once you're 18 as is the norm in the US) Hence, the elderly are often supported by their own children, while the poor usually belong to larger families who can pool more resources together.
Even so, some people inevitably fall through the cracks, but not as many as in the US. (percentage wise)
Also, public hospitals have a policy of treating the patient first whether or not he can pay. In the end the government usually foots at least some significant part of the bill for the poorer patients.
Costs are kept low because patients often have to pay at least some amount, so patients usually only see the GP if they have been running a fever for some time already.
It also helps that in terms of quality of life, we dont have that much abject poverty, even though as I said earlier, there are people who do fall through the cracks in the various social safety net.
Posted by: Murali | July 29, 2009 at 01:04 AM