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July 17, 2009

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of course, a legitimate questions is whether or not that cost is excessive for what it will provide, assuming the cost estimate is reasonable (which I question). Personally, the cost is well worth it.

Of course, the CBO has stated that it will not put into any kind of numbers the savings of having more preventive care, lower utilization of high cost care (i.e. ER's) and better chronic disease management. The CBO admits savings will be accrued there, but is unwilling to make a commitment to numbers.

Yes, what you really need is a fully-socialized National Health Service, not Obama's half-assed attempt to remedy the US's problems while protecting the health insurance companies who are responsible for the US having the worst healthcare system in the developed world.

I don't see where you acknowledged making any mistakes in any of your earlier posts - mistakes which were quite obvious. Am I being lazy in disregarding what you have to say out of hand? Note that I can also link to articles like this:

In other words, since many of the savings from reform won’t be reflected in the federal budget, Elmendorf does not consider them. But modernizing the health care system (implementing electronic medical records, health information technology) and reforming the way Medicare and Medicaid reimburse providers will save money for the system as a whole. As Melinda Beeuwkes Buntin and David Cutler pointed out in a recent analysis, these savings can total to some $2 trillion. In fact, even the industry is on record as saying we can reduce the growth rate in annual health spending by 1.5 percentage points a year over the next 10 years . . .

Still, what’s most peculiar about the Elmendorf statement is the suggestion that lifting the tax exclusion for employer-sponsored health benefits is one of the few ways to bend the cost curve. Technically, such an approach would save the government a good deal of money, but would it bend the curve? As Elise Gould points out in a brief for the Economic Policy Institute, there is no evidence that the exclusion — or this idea that health care costs are increasing because Americans are “cavalier” about the price of health care — “is a primary driver of price increases in health care. In fact, the tax exclusion has been around for decades, even during periods of low health care inflation.”

And in fact, your quote seems to be - at the very least - out of date:

In testimony before the House Ways and Means Committee, Elmendorf walked back his comments, saying that in some ways federal spending will increase and in some ways it will decrease. When pressured by the Republicans on the committee, Elmendorf did not directly confirm his accusations.

I'm sorry to say this von, but you appear to be unaware that you've got to be persuasive and convincing. You've got to put together a case for your views. Instead, you come across as mindlessly partisan, flipping all too often into the 'if you can't make me say I'm wrong I win' mode. Just the opposite of the usual application of argumentation and the scientific method.

lower utilization of high cost care (i.e. ER's)

And what is your evidence that under a government managed system ER use would be lower?


Ok - but this is all sort of beside the point. The issue is whether you want national health care reform or not.

If you don't, that's fine -- but you shouldn't pretend like it's cost that's holding you up.

And if you do want reform, what cost-cutting measures do you prefer instead? (Ezra Klein had a post on this yesterday).

If people genuinely want to do health care reform, then there are various ways to cut costs -- all of which will probably be easier once legislation is passed. But if you fundamentally oppose reform -- and want to maintain the status quo -- then all of this is basically beside the point.

John Miller, those are good points but I haven't seen anyone attempt to quantify them -- except to say that they will somehow exceed the costs. Leave aside the CBO. Has anyone shown their math & model re how these hypothetical savings will work, so that we can test the idea?

SoV -

Don't know how to respond to your first point, except to encourage you to follow your own advice and disregard my posts.

Regarding the Thinkprogress piece, it's an Op-ed. Not really analysis, and not contrary to what I wrote. Of course there are proposed offsets: I discuss them in my very article, and criticize the WaPo for not mentioning them. It begins "Elmendorf is fundamentally right, here, but the issue is a lot more complex than this Washington Post article describes. That's because the Washington Post's report fails to account for all the costs of the proposed health care reform, and at least some Democratic bills are circulating that would offset some of those costs." Did you miss that section of my post?

Your last paragraph is pure ad hominem.

If you want to provide a meaningful contribution, why not comment on something that I actually wrote?

I think, publius, that it is also often the case that if you fundamentally oppose reform but trot out purported reasons as to why you are against supporting any given particular point . . . it shows. Simply saying that you don't oppose reform, and challenging other people to prove that you do simply doesn't cut it as a rhetorical tactic.

By the way, the report by Melinda Beeuwkes Buntin and David Cutler (referenced in the blockquote from Scent of Violets) is here: http://www.americanprogress.org/issues/2009/06/pdf/2trillion_solution.pdf. YMMV, but I find it anywhere close to a testable cost model. There are also weird parts, like on p. 1: somehow, the authors add 550 + 166 + 64 + 229 billion and get 1.5 trillion. There is a whole "Underpants Gnome" feel to the whole exercise.

SoV -

Don't know how to respond to your first point, except to encourage you to follow your own advice and disregard my posts.

I do. I also will comment on why your posts should be disregarded, up to and including remarking on previous posts of yours where you refused to admit in the smallest particle that you made any mistakes - and rather obvious ones at that.

Regarding the Thinkprogress piece, it's an Op-ed. Not really analysis, and not contrary to what I wrote. Of course there are proposed offsets: I discuss them in my very article, and criticize the WaPo for not mentioning them. It begins "Elmendorf is fundamentally right, here, but the issue is a lot more complex than this Washington Post article describes. That's because the Washington Post's report fails to account for all the costs of the proposed health care reform, and at least some Democratic bills are circulating that would offset some of those costs." Did you miss that section of my post?

Sigh. You mean that part where you said "Elmendorf is fundamentally right . . ." with absolutely no supporting evidence? That part? von? I'm waiting.

Your last paragraph is pure ad hominem.

Sigh. Do you even know what 'ad hominem' means? Because, no, what I said was not ad hominem. Look up the definition if you really don't know what it means, as opposed to just carelessly, lazily slinging that accusation around.

If you want to provide a meaningful contribution, why not comment on something that I actually wrote?

Posted by: von

I did. And it seems that other people have picked up on it too.

"YMMV, but I find it anywhere close to a testable cost model" should be "YMMV, but I don't find it anywhere close to a testable cost model."

Publius:

If people genuinely want to do health care reform, then there are various ways to cut costs -- all of which will probably be easier once legislation is passed. But if you fundamentally oppose reform -- and want to maintain the status quo -- then all of this is basically beside the point.

That seems to be the premise of a lot of liberal bloggers, but why do you think that's the case? Indeed, we've seen this argument before: e.g., cut taxes, and government will get smaller (no, it won't). What makes you think that, this time, benefits in hand, the electorate will want to pay for it?

I'm concerned that we're simply trading one problem -- a perceived problem with health care -- for another -- a spending and deficit crisis. Let's take some time to think this matter through.

All of this great except...the current bill is not Healthcare reform, it is universal coverage. The "other bills" are where cost offsets and reform are being discussed. So what we are saying, note this is a question, is that we will pass universal coverage and that will then drive reform and the offsets?

Maybe we could put all those together, let CBO cost it and then decide. Of course you can't do that by the August recess so it's a bad idea?

Scent of Violents, I don't understand what substantive point you're trying to make.

Sigh. Do you even know what 'ad hominem' means? Because, no, what I said was not ad hominem. Look up the definition if you really don't know what it means, as opposed to just carelessly, lazily slinging that accusation around.

Per Wikipedia, an "ad hominem argument, also known as argumentum ad hominem (Latin: "argument to the man", "argument against the man") consists of replying to an argument or factual claim by attacking or appealing to a characteristic or belief of the person making the argument or claim, rather than by addressing the substance of the argument or producing evidence against the claim."

The paragraph of yours that stated as an example of an "ad hominem" argument was:

"I'm sorry to say this von, but you appear to be unaware that you've got to be persuasive and convincing. You've got to put together a case for your views. Instead, you come across as mindlessly partisan, flipping all too often into the 'if you can't make me say I'm wrong I win' mode. Just the opposite of the usual application of argumentation and the scientific method."

You may be right in your argument against me, SoV. But it was an argument against me, i.e., an ad hominem.


And what is your evidence that under a government managed system ER use would be lower?

Assuming that there would be wider provision of services?

ER is often used by the uninsured because it is the only form of healthcare they have access to. Give them the ability to make appointments and they won't need to take it to the emergency room.

And von, commenting on your history on this subject is commenting about what you have said. And it's not ad-hominem to discount someone for having a track record of lying. Ad hom would be "Yeah, but you smell". (Of course, if SoV were to post half a dozen links to previous debunkings each time Von posted about healthcare that would be an even better answer).

Finally, the following is a testiment to near-invincible ignorance:

This is going to be a costly undertaking. The only thing I've become certain of is that no knows whether we're getting our money's worth -- including, ironically, the most vocal backers of reform.

Everyone with any knowledge of healthcare at a strategic level at all knows that the US is not getting its money's worth. It is being ripped off, and left bloody and bleeding in the gutters. Any approach that doesn't start from that perspective is either fundamentally ignorant or fundamentally dishonest.

And once you have that starting point, the question isn't whether radical reform is necessary. It's what.

Also that CBO estimate? Worthless if they haven't even tried to quantify the savings.

@just me:

Under the current system, the emergency rooms are required to treat the uninsured. The hospitals are later reimbursed by the government. Because emergency rooms are one of the most expensive links in the health care chain, this imposes a very large cost on the government.

With the creation of a public health insurance plan combined with an employer and individual mandate, uninsured rates are expected to decrease markedly (something like 45 billion uninsured down to 17 billion). Since almost everyone will have insurance, charity care at emergency rooms will reduce as well.

In addition, the phenomenon of deferred maintenance for uninsured or underinsured virtually guarantees that those people allow easily treatable chronic conditions (like asthma or diabetes) reach crisis level before seeking treatment. This over stresses the emergency rooms as well. Increasing the number of covered people and the quality of coverage reduces both categories.

Hospitals clearly believe this will happen since they signed a deal with the administration to reduce reimbursements for uninsured usage of emergency rooms by $150 billion. They would only have done that if they thought they wouldn't need the money due to decreased levels of charity care.

Here's what no one - either from the 'MSM' or the blogosphere - has managed to communicate to a layperson like me:

What are we spending now - in total - on health insurance? What are we spending on health care (for example, the uninsured using the ER) not covered by insurance?

What would we spend on the above given the aggregate effect of whatever basket of proposed bills would make up the final policy?

What would we spend on the above if we duplicated here the best global examples of national health care policy (what would France, or Sweden, or Taiwan or wherever cost here)?

Based on these estimates, what health insurance framework + health care regulation/policy makes the most sense for the U.S. ?

Until someone provides this type of fact based, non partisan framework, the danger is that we do nothing because everyone is confused. And, in my opinion, that is the goal of those benefiting from the current system.

I am going to miss hilzoy more than I can say.

Just a plea to keep comments civil and substance-focused.

But again, von, I think you're dodging the big question. Why wait? What will change? If you want health care to happen, then we should do it now. Waiting is basically code for killing the effort. Now maybe that's what you want.

But I'd still like to know what your ultimate position is on whether pursuing national health care coverage reform is a good idea or not.

And von, commenting on your history on this subject is commenting about what you have said. And it's not ad-hominem to discount someone for having a track record of lying. Ad hom would be "Yeah, but you smell". (Of course, if SoV were to post half a dozen links to previous debunkings each time Von posted about healthcare that would be an even better answer).

Actually, although that may be a more persuasive ad hominem, it would still be an ad hominem. You're still attacking the messenger, not the argument. (I would distinguish pointing out that I'm wrong or lying regarding a point material to my argument.)

In any event, saying that someone has a track record of lying regarding extraneous isn't productive to the conversation that we try to maintain here. (See, for instance, the posting rules.)

On Francis D's substantive point:

Everyone with any knowledge of healthcare at a strategic level at all knows that the US is not getting its money's worth. It is being ripped off, and left bloody and bleeding in the gutters. Any approach that doesn't start from that perspective is either fundamentally ignorant or fundamentally dishonest.

I agree that we get very little "bang for our healthcare buck" -- at least compared to other developing countries. We already spend more and get less. But you too easily discount the possibility that it could be even worse.

This plan requires us to spend even more, without a clear direction of where we're going. In a sense, I agree with Jes's point at 11:17 a.m. -- we seem to be doing something big, expensive, and half-assed.

just me, although others have made the rather obvious case as to why ER use would decline, let me point out that the question you asked was irrelevant as noone at this point is talking about a government managed system.

One other thing that nobody that I know of has mentioned is that the cost of your private insurance will also, in all likelihood decrease.

One of the things (though not the only) driving the high cost of care (particulalrly at hospitals and places such as ERs) is that charges for people with insurance are inflated to cover the loss of revenue from the uninsured, underinsured and even, in many cases Medicare or Medicaid patients.

If more people have insurance there is more of a cash flow coming in, thereby reducing the need to cover those loses. Overall charges can decrease, thus reducing payment costs by the insurance companies thereby reducing the cost of premiums.

I second publius on civility.

That said: I think that this might or might not lead to higher deficits, depending both on what cost-control mechanisms end up in the final bill and what measures we adopt to pay for it. Given any kind of decent cost-control (which I don't think is at all inevitable), we should be able to drive down the cost that people pay for health care, where this includes taxes spent to pay for government programs, insurance premiums, and out of pocket costs. That's my benchmark.

On the other hand, I also think that the Republicans, and the centrist Democrats, are being disingenuous here. A lot of cost-control measures will involve some degree of government influence on the health care system. This doesn't have to be heavy-handed: it could involve, for instance, a public plan adopting the results of comparative effectiveness research, which would provide a market incentive for others to do likewise (assuming that this did, in fact, hold down costs without making consumers unhappy; if not, no advantage for doing it.) It could involve incentives (not coercive measures) to adopt electronic records, and/or to make these records as compatible across plans as possible. Etc., etc.

The problem is, every single one of these measures is being portrayed as a Horrid Expansion Of The Federal Government, allowing bureaucrats to come between you and your doctor -- regardless of whether this has even the slightest basis in reality. (See comparative effectiveness research.)

If someone demagogues every single cost-control measure, it's hard to turn around and decry their absence in good faith.

But again, von, I think you're dodging the big question. Why wait? What will change? If you want health care to happen, then we should do it now. Waiting is basically code for killing the effort. Now maybe that's what you want.

Because there is not enough time to absorb -- or adsorb, even -- all of the thousands of pages of changes, modifications, and revisions.

But I'd still like to know what your ultimate position is on whether pursuing national health care coverage reform is a good idea or not.

I'm undecided. I generally support some version of a single-payer system, because, ultimately, that's the only way to take the burden of healthcare off of employers. A modified single-payer system is also the only way to limit care, which is where a great bulk of the cost savings will come (private hospitals and insurance companies will always be fearful of lawsuits, and thus will over-test and over-treat.) But I don't know that creating a new public option that will "compete" with private plans is a good way to go. I am also concerned about the main detriment of single payer systems, which is that experimental and extraordinary care seems to suffer.

ER is often used by the uninsured because it is the only form of healthcare they have access to. Give them the ability to make appointments and they won't need to take it to the emergency room.

I am not really sure I agree ER use will go down.

My experience with military care was that ER use was encouraged when same day appointments weren't available. I was told on several occasions to take my children to the ER for conditions that weren't emergencies because appointments were not available for several days. Something that in the end drove me to pay more for a private doctor than continuing to keep my children in the military system.

I am just not convinced that ER use is going to go down substantially. Although I understand that a lot of people without insurance use ER's, I am not sure giving them insurance will result in fewer ER visits.

granted what is being proposed isn't exactly what the military system is-but my experiences in the military system and with the VA system make me very skeptical of success with the government taking on a larger role with medical care.

Publius: "If people genuinely want to do health care reform, then there are various ways to cut costs -- all of which will probably be easier once legislation is passed."

What makes you believe this? How many government programs become easier to reform later if they aren't set up properly from the beginning? How many government programs start off expensive but become cheaper after they are implemented? Do you believe that it is routine for government programs to become cheaper and easier to reform once implemented?


"But again, von, I think you're dodging the big question. Why wait? What will change? If you want health care to happen, then we should do it now. Waiting is basically code for killing the effort. Now maybe that's what you want.

But I'd still like to know what your ultimate position is on whether pursuing national health care coverage reform is a good idea or not."

You seem to often want to attack the motives of criticism without actually attacking the substance of the criticism.

Here is my position. Health care should be reformed so that everyone has at least Medicare level of coverage available to them at all times. Getting there involves hard work at looking at why things are expensive, and why the government already spends enough to cover 100% of the population but actually covers only 27%. That is work that should be done, but is pretty much being ignored in favor of "pass my bill or you just don't care enough about the issue" rhetoric.

"Just a plea to keep comments civil and substance-focused."

Great, so lets focus discussion away from motives (which you don't seem to believe even when disclosed anyway) and back to the actual criticisms.

The government already spends more money per capita on coverage than Japan or the UK, and as much as Canada. Instead of covering everyone like those countries, it covers only 27% of the population. Given that actual track record, what makes you believe things like "then there are various ways to cut costs -- all of which will probably be easier once legislation is passed." Where precisely are these cost savings coming from and *why in the world hasn't the government already done so, and thus covered the whole population with the money it is already spending*?

That's a bit self-righteous Seb.

I think the ultimate position is the key to everything. You can't weigh whether the costs of something are worth it unless you have a position. If I'm anti-reform, then I don't think a single dime is worth it. If I'm pro-reform, then I think it's worth a lot.

The cost issue is necessarily dependent on that answer. If you say (as you may) "I'm pro-reform, but these costs are too much." At that point, you need to think about the alternatives then -- which, as hilzoy noted, have all been demagogued.

And for the record, yes, a lot of people are citing cost for improper motives. I don't see that as particularly controversial

"Under the current system, the emergency rooms are required to treat the uninsured. The hospitals are later reimbursed by the government."

Based on my experience, the hospitals will also send you, the uninsured user, the person who demonstrates they have no assets and no money and no income, a bill for over $2,000 (several bills, actually, that tend to add up to about $2500, from the various technicians, etc.) for the very simplest procedures, such as examining you for one minute, and giving you some pain killer for your toothache. If you can't pay these bills, they set collection agencies on you to harass you for years.

I have several such of these bills; I've in the past emailed copies of them to people when asked for proof of this point. I'm currently being dunned for over $5,000 in current charges from two ER visits in the past year; let's not even go into the many more thousands I've been dunned for in the past for visits in previous years. I'm stilling getting daily robophone calls of threats, etc.

This little element of visiting an ER seems to go constantly unstated. "Just go to the ER" means "and either then pay several thousand dollars, or suffer the results if you can't."

It's just tons of fun.

@Gary:

I believe you have those bills. Even the simplest procedure I've needed at the emergency room has set me back at least a thousand. Hospitals are required to serve those without ability to pay in the emergency rooms, but that doesn't mean that they don't do everything they can think of to try and squeeze non-existent money out anyway.

"And for the record, yes, a lot of people are citing cost for improper motives. I don't see that as particularly controversial"

Ok, but they aren't HERE, which makes you raising it against the people HERE a little annoying.

So anyway, back to my substantive questions???

@just me:

You're talking about an entirely different category of emergency room use. I never said that people using the emergency room because they are sick after hours or because their doctor isn't able to see them will go down. However, charity care and crisis treatment of chronic conditions due to deferred maintenance will.

People using the emergency room for reasons you stated have nothing to do with your insurance being government administrated or not. Regardless of whether you use the VA or some private doctor, there will probably be times when your doctor will tell you to go to the emergency room or an urgent care facility if you need to see a doctor immediately, but your doctor is fully booked (however, they really should be pushing urgent care, not emergency rooms). This fact has little bearing on the more serious issues of the uninsured and under insured using the emergency room because they mismanagement of health conditions due to their inability to afford a primary care doctor.

Am I the only one who is, frankly, astounded that von referred to the US as a "developing country"?

That doesn't strike me as a trival description. If the US is a "developing" country, then its peer nations are places like Indonesia, Mexico, and Kenya, rather than places like Canada, Australia, and Europe.

Which sure seems ridiculous... unless it's a deliberate bit of reframing, so that we compare our healthcare system to Indonesia's, Mexico's, or Kenya's, rather than to the healthcare systems of the developed countries.

Because, yeah, our healthcare system maybe isn't too bad... for a developing nation.

Is that the idea, now? Redefine the country as 2nd World, so we don't have to live up to 1st World standards?

I don't see how you can have a meaningful discussion about the potential problems inherent in any particular proposal unless you can compare it to something else.

If you want to use the status quo as your reference point, fine - then let's have an honest, non-reflexive discussion about the myriad ways the market has failed with regard to healthcare.

"I generally support some version of a single-payer system, because, ultimately, that's the only way to take the burden of healthcare off of employers."

And on Hilzoy's last day, von revealed himself as a socialist.

Turns out, Democrats are working on this as we speak*.

*er, type

Am I the only one who is, frankly, astounded that von referred to the US as a "developing country"?

That's a typo - I meant to write "developed".

And on Hilzoy's last day, von revealed himself as a socialist.

IT IS THE SECOND SIGN.

Seriously, I don't think that universal coverage is a bad thing. I do, however, share Sebastian's concerns. Whether or not other governments have managed to create managable government-run health-care systems, the US has not. We are spending as much, or more, than our peers to cover a much smaller percentage of the population. I've also experienced health care in, e.g., the UK (where I lived for seven months as a child). The sky did not fall.

So, while I generally approve of a public option, I don't have faith in the folks who are crafting the current public option on the Democratic side. It's a case of "don't trust, let's verify."

I think anybody who worries about how health care reform is implemented is right to do so. But unlike the Constitution handed down to the Honduran people by their warrior gods, the legislation in question is emendable. What matters now is the big pieces (i.e. 'public option') and getting something serious passed. Von and Seb may be completely sincere in their concerns, but they don't get to pretend-away the reality of our politics. Passing nothing is a defeat for the very idea of health care reform - don't kid yourself. Or, kid yourself if you must, but don't expect others to buy into it.
I wish sincere, honorable conservatives like Von and Seb had a little more influence with the GOP than they do, but back in the real world, the 'conservatives' at hand are mortal enemies of any healthcare reform (other than some sort of devolution). And, perhaps even more, they are committed to delivering a defeat to Obama and the Dems., damn the consequences. That nice Mr DeMint quipped today that healthcare reform could be Obama's 'Waterloo'. Nice to see 'conservatives' continue - as they have for decades - to focus on what really matters...


I also favor single-payer, but I certainly don't oppose the current legislation (w/real public option) because of that; the current leg is much better than nothing. There's nothing quite so convenient as holding out for an option which is virtually guaranteed to not happen.

"I wish sincere, honorable conservatives like Von and Seb had a little more influence with the GOP than they do, but back in the real world, the 'conservatives' at hand are mortal enemies of any healthcare reform (other than some sort of devolution)."

Why? Sincere honest Democrats could listen too, right? Why should serious questions only be addressed by the opposition party? Wouldn't it be kind of nice if Democrats bothered to deal with important questions instead of suggesting "it's health care, you're with us or you're against us"?

Let's boil healthcare in the US down to the brass tacks, shall we?

1) The US Government already pays the costs for the most expensive healthcare demographics: The elderly, and the disabled.

2) Hospitals and Emergency Rooms are not allowed to turn away patients based on inability to pay. Meaning that if you show up at the ER, you WILL be treated, even if you have no money. That cost is passed on to the insured in terms of higher costs.

What does this mean? It means we have universal health care in the US. We just make sure it's as expensive as possible. That's not even getting INTO the profit layer for private insurers (or the inefficiencies and extra costs they introduce into the system, since their profit motive can and does conflict with their patient's need).

Short of letting the poor die at the ER rather than treat them for free, anything is going to be cheaper and more effective than what we have. I'd be hard pressed to design a system that cost more and worked worse than what we have.

Ezra proposes rules:

In the least surprising revelation of the day, the Congressional Budget Office doesn't see much in the way of savings coming from health-care reform in the next 10 or so years. This is because the bills under consideration do not save much money in the next 10 or so years.

I would, however, like to propose a couple of rules for commenting on this story. Politicians who are going to use this CBO report against the existing health-care reform proposals must do some combination of the following:

a) Support, as the CBO says you should, the eradication of the tax exclusion that protects employer-based health-care insurance;

b) Support, as Lewin and Commonwealth say you should, a public insurance option that can bargain at Medicare's rates;

c) Support, as the Office of Management and Budget and every health-care wonk in town says you should, one of the various policies floating around to give MedPAC authority to continually reform and modernize Medicare;

d) Support some form of aggressive cost-sharing that would make people extremely angry because it will save money by reducing their access to health-care services;

e) Support comparative effectiveness review that can judge not only the effectiveness but also the cost-effectiveness of various treatments, and give the federal government authority to use that data when deciding reimbursement rates.

I would also like to propose a related rule: any reporters who receive a quote from a politician referencing this CBO score should be required to ask the politician which of these policies -- or which alternative cost-saving policies -- they support. And that should be on the record. I think it's perfectly legitimate to criticize health-care reform for not saving enough money. In fact, I think it's important. Health-care reform should save more money. But it's not legitimate to do that if you also oppose any and all measures for saving money.

Comment?

"I agree that we get very little "bang for our healthcare buck" -- at least compared to other develop[ed] countries. We already spend more and get less. But you too easily discount the possibility that it could be even worse."

Defensive medicine is a reflection of your tort laws- If the goal was to reduce costs you need to change the rules -or set up no-fault medical negligence insurance. Control of incompetent doctors would then have to be undertaken in some other way.

I'm pretty impressed by Obama's judgment, in balancing political reality against desired change. Labour negotiations always seem to require deadline pressure to accomplish anything. So i see why he wants to keep up the pressure to pass a bill sooner rather than later.

To the excellent argument that rushing things through may leave one with great errors, couldn't an answer be to pass reform that is to take effect Jan 1, 2011; giving time for egregious errors to be corected by supplemental legislation?
(while writing this I see Jonnybutter posted a similar idea to this paragraph)

Like the US, Canada is a federal country. One of the purported advantages is that different states/provinces can pursue different courses so we learn what works and what doesn't. In Canada, one province led the way (back in the 1950's); the federal government got into the act by picking up a substantial part of the cost, provided each province met minimal standards, including portability throughout the country.
(I don't understand how Mass. system operates or would if federal plan goes ahead)

"2) Hospitals and Emergency Rooms are not allowed to turn away patients based on inability to pay. Meaning that if you show up at the ER, you WILL be treated, even if you have no money."

Setting aside the point I made above about being billed thousands of dollars, this statement still isn't true in any reasonable sense of "treated."

If "treated" means that some hospital employee, with some basic level of medical training, such as a medical student, or a physician's assistant, or a licensed practical nurse, will come by for a single minute to hear whatever story you can give them in that minute, and then will give an order as to what to do with you, such as "send them home with some tylenol," or "refer them to a [SPECIALITY] clinic," which won't take them without insurance, or the ability to pay thousands of dollars upfront, then you can say that everyone receives treatment.

I wouldn't use that word, myself.

For the severe tooth infection I had, the "treatment" was an antibiotic, some painkiller, and advice to somehow find a dentist who works for free.

For the broken foot, I was given a cast, and referred to an orthopedic clinic that wanted a thousand dollars or more upfront just to examine me. I declined, and fortunately my foot mostly got better, aside from the ongoing gout afflicting both of them on and off.

That was my "treatment" at my last two ER visits. One can supply plenty of similar anecdotes from people with actual experience of going to ERs without insurance. Endless numbers of problems won't earn you any more, or if anything, less, "treatment" than I describe. Need a procedure that costs money, but won't kill you in the next two days? Find somewhere else to go than the ER, and lots of luck, buddy!

Shorter me: "2) Hospitals and Emergency Rooms are not allowed to turn away patients based on inability to pay."

This actually means "2) Hospitals and Emergency Rooms are not allowed to turn away patients based on inability to pay if turning you away means you will die in the next 24 hours."

But that's about all. And lots of hospitals have been known to violate these rules, anyway, and literally just take patients, drive them some distance from the hospital, and dump them on the street.

Dumping:

[...] Public Citizen’s Health Research Group recently published the sixth in a series of reports on US hospital emergency room practices, entitled “Questionable Hospitals: 527 Hospitals That Violated the Emergency Medical Treatment and Labor Act—A Detailed Look at ‘Patient Dumping.’” Passed by the United States Congress in 1986 as a section of the Social Security Act, the EMTALA provides that when a hospital emergency department denies medical screening, denies stabilizing treatment it has the capacity to provide, and/or inappropriately transfers an individual with an unstabilized emergency condition, that hospital is illegally “dumping” the patient.

Public Citizen examined the US government’s Department of Health and Human Services (DHHS) enforcement of the act. Through the Freedom of Information Act, the group obtained the names of hospitals that have violated the act. The violations were confirmed by the Health Care Financing Administration (HCFA), a federal agency within the DHHS. (HCFA was renamed and is now called the Centers for Medicaid and Medicare Services.)

The current report primarily covers the years 1997, 1998, and 1999, with some violations from 1996 (not covered in previous reports) and 2000. The data demonstrates:

* For-profit hospitals violate the act nearly twice as often as not-for-profit hospitals.

* A patient’s insurance status influences hospital compliance with the act. A patient may not be covered by insurance or may have coverage, such as an HMO, which requires preauthorization for treatment and frequently denies payment when the exam rules out an emergency condition.

* Over 90 percent of the hospitals guilty of violations had breached the screening, stabilizing treatment or transfer provisions of the act, the most serious categories of offenses.

* Less than one-third of the hospitals identified as engaging in illegal patient “dumping” were fined, and the total of such fines averages barely $1 million a year—a pittance for the trillion-dollar health care industry.

[...]

The EMTALA requires that all hospitals with emergency rooms medically screen everyone who “comes to” the ER and has a request for examination or treatment made on his or her behalf. Violations include: outright denials, “referrals” to other facilities, and requests for payment. In some cases patients are not told that they have a right to an exam regardless of their ability to pay, and thus “refuse” the exam when they are asked for payment. In some cases, a hospital’s screening standard can be so low that it amounts to no screening at all.

Several examples describe hospitals’ violation of the requirement for appropriate medical screening. A pregnant patient came to Arrowhead Community Hospital in Glendale, Arizona on July 10, 1997. The hospital’s own documentation stated: “This labor patient was in the care of an RN without any MSE [medical screening exam] by an MD.” She was discharged four hours later, and came back the following day in active labor and was admitted to the hospital. Her unborn child had died and the patient herself died the day after admission. An autopsy revealed that she died of internal hemorrhage because of the rupture of an aortic aneurysm (abnormal dilation of an artery). Staff members who were interviewed said: “The doctor may give labor instructions or discharge orders over the phone...” and “A physician is supposed to see all the patients, but they don’t always do it.”

In Baltimore, Maryland, on July 27, 1998, a 70-year-old man accompanied his daughter to the hospital with a sick child. When they arrived, the man told his daughter he didn’t feel well and would wait outside the hospital. Passersby noticed something was wrong and called security. The security officer’s log stated: “911 notified intoxicated male ... ER notified (refused)” An emergency medical technician with a private ambulance leaving the hospital initiated CPR while the officer contacted the emergency department for assistance. The emergency department again refused assistance. Another ambulance arrived and transported the man to the ER. About one-half hour after the man was first seen lying in the grass, he was pronounced dead of cardiac arrhythmia.

In New York City, a survey on January 29, 1999 showed that staff at St. Luke’s-Roosevelt Hospital’s ER informed uninsured patients seeking treatment that they would be responsible for a fee of over $400, before providing a screening exam. Many uninsured patients left without any examination.

Etc.
[...] Many times, however, hospitals try to transfer patients in cases where they believe the treatment will not be paid for. In Houston, Texas on August 10, 1996, a patient came to the ER at Doctor’s Hospital with symptoms of acute appendicitis, a medical emergency. Because she had no insurance, she was discharged and told to drive to another hospital, where she underwent surgery.

It is also illegal for hospitals to refuse to accept an appropriate transfer of a patient who requires the specialized treatment it can provide. Nondiscrimination violations often occur when a hospital that can provide specialty care refuses to and instead transfers the patient to still another care center, a third stop on what can be a life-threatening runaround. For example, an ER physician tried to transfer a patient with a diagnosed brain injury to Cedars-Sinai Medical center in Los Angeles, California. Cedar-Sinai was the closest facility, had a trauma service, and had 24-hour neurosurgical on-call coverage. The ER physician refused to accept the transfer and the patient experienced a three-hour wait while arrangements were made for a transfer to a county facility.

[...]

The federal act says a hospital may not delay providing a screening or stabilizing treatment in order to ask about the patient’s method of payment or insurance.

In Brooklyn, New York, Kings County Hospital’s ER posted signs that the hospital required preauthorization or referral from a patient’s Medicaid plan before treatment. As of April 2001, no civil monetary penalty had been imposed for this violation.

In Chicago, Illinois, a 19-year-old patient came to the ER of Provident Hospital of Cook County with symptoms of threatened miscarriage. The hospital sought HMO approval, which was denied. The young woman was not given an exam or treatment. Because of the delay, she began to deliver a nonviable fetus as she waited for a taxi to take her to another hospital.

Accounts and studies of this go on and on and on. There's nice theory of how our ERs work, and there's actual practice.

Just like there's the theory of "shorter me" and the practice.

:-)

I have a question: if American "health care spending" amounts to 50% of GDP in 30 years, will that be a bad thing?

I'm serious. Half the GDP in 2039 will be spent on something. Would it be better spent on "entertainment", or "financial services", or "national defense"? Before you snark, remember: it's 2039 GDP that I'm talking about. You will be 30 years older, as will I, if we live that long. The GDP will be larger, in real terms, than it is now. The economy will be producing more goods and services than it does now -- but only if we can manage to "consume" them, for goods and services not consumed are hardly worth producing. Maybe we can manage to "consume" a lot more of non-healthcare goods and services in 2039 than we do today, but maybe we can't. I know for sure that I will not be able to "consume" more than 12 movies a day, in 2039. I'm fairly certain, however, that I will be able to offer gainful employment to more doctors and nurses in 2039 than I do now -- unless I have "consumed" the services of the "mortuary industry" before then.

So what am I missing? Why is it so important to keep the "health care spending" fraction of GDP low? After all, spending on "health care" is, for many Americans, income from "health care".

Note, incidentally, that 30 years is about how long it takes to grow doctors and nurses from scratch. It's doctors and nurses who provide health care. If some people are going without health care today, and our current complement of doctors and nurses is fully employed providing care to the rest of us, then we will need more doctors and nurses to actually provide care to people like Gary without reducing the care "consumed" by everybody else. Merely shifting money around by rearranging health insurance, which is what all the fuss is about, does not make doctors and nurses suddenly materialize out of thin air.

--TP

Why? Sincere honest Democrats could listen too, right? Why should serious questions only be addressed by the opposition party? Wouldn't it be kind of nice if Democrats bothered to deal with important questions instead of suggesting "it's health care, you're with us or you're against us"?

What world are you referring to, Seb.? Certainly not the one we're in. The obvious problem here it that the dems in DC are not negotiating with YOU. Good faith - like civility - is a two way street. The dems are dealing with actors with demonstrable bad faith. The reason people here are questioning your good faith is that very thing - you refuse to deal with the context we're in which, if not you, then your ideological compatriots, are responsible for promulgating in the first place: the opposition party doesn't want any broad health care reform to pass, and more vitally, don't want any dem bill to pass, no matter what the numbers are. Get it?

So, that's the situation. What would you suggest?

von, look. If you're opposed to universal health care of health care reform, just frickin say so. If you're opposed to Obama's various programs, just say so. If you're really worried about the deficit, how would you fix it, then? Because the way you've been posting, it keeps coming off as "I'm opposed to Democratic Proposal X, and I'm using the deficit to justify my opposition", rather than being actually concerned about the deficit.

As for why we spend more than anybody else and don't cover everyone? Simple. Because a significant number of people make a LOT of money off the current model, which was put into place in a very patchwork manner by government, employers, unions, and individuals over the last 80 some years, since the "conservatives" over here have demagogued universal health care as "socialist" or would mean hospitals might have to treat "undeserving" (poor/sick/non-white/immigrant) people.

Which is why complaints of being "left out of the process" are farcical, since the Republican part has universally opted out of doing anything at all to try and extend or improve health care.

Seriously, you talk about extending Medicare level care to everyone as a base. Which is a very good idea. But would you still support it if it meant that health insurance companies woudn't get a slice of the pie and might go out of business? Would you still support it if it meant that even people who were poor through their own mistakes, or "welfare queens" got health care? Would you still support it if it meant the government would be "bigger"?

Seriously, I've seen so many self-declared "conservatives" who claim "Oh, I support health care for everybody, but not if it costs me money, or if my money goes to THOSE people, or if it means the Evil Big Government is involved, or because it'll be the start of Scary Socialism, or..."

Saying you "support the goal" but opposing every method to get there justifiably makes people rather suspicious that you really DON'T support the goal.

Scent of Violents, I don't understand what substantive point you're trying to make.

The first point is that you're in no position to accuse other posters of laziness (and isn't that ad hominem per your definition?) The second point is that you're offering nothing but your bald opinion with absolutely no sourcing or cites to back it up. Finally, you're completely unwilling to change your opinion, even when you're glaringly, obviously, blindingly wrong, with many people pointing this out. Thus it would seem to be dishonest to try to make a pitch to persuade someone to your point of view if you show no inclination to do the same. That is - dare I say it - rather uncivil.

Sigh. Do you even know what 'ad hominem' means? Because, no, what I said was not ad hominem. Look up the definition if you really don't know what it means, as opposed to just carelessly, lazily slinging that accusation around.

Per Wikipedia, an "ad hominem argument, also known as argumentum ad hominem (Latin: "argument to the man", "argument against the man") consists of replying to an argument or factual claim by attacking or appealing to a characteristic or belief of the person making the argument or claim, rather than by addressing the substance of the argument or producing evidence against the claim."

The paragraph of yours that stated as an example of an "ad hominem" argument was:

"I'm sorry to say this von, but you appear to be unaware that you've got to be persuasive and convincing. You've got to put together a case for your views. Instead, you come across as mindlessly partisan, flipping all too often into the 'if you can't make me say I'm wrong I win' mode. Just the opposite of the usual application of argumentation and the scientific method."

You may be right in your argument against me, SoV. But it was an argument against me, i.e., an ad hominem.


Posted by: von

Sigh. If I had said von is [insert undesirable personal characteristics here], and therefore his argument should be discounted, this would be ad hominem. You even quoted the definition. But saying that your 'arguments' such as they are, are bad, and indicate a complete lack of effort on your part to be convincing, or even an awareness of the obligation to be so is most definitely not ad hominem. The arrow is pointing in the opposite direction, for one thing; I'm using your arguments to reflect badly on you, not you to reflect badly on your arguments.

Care to admit that you were wrong on this one? Believe it or not, occasionally admitting you're wrong is a good thing. Never copping to it is an extremely bad strategy.

Why is it so important to keep the "health care spending" fraction of GDP low? After all, spending on "health care" is, for many Americans, income from "health care".

Tony P is onto some wisdom here. The various $50T-unfunded-Medicare-liabilities-over-the-infinite-horizon scare stories makes me want to buy stocks in stuff medical professionals like -- Mercedes, luxury home builders, that sort of thing.

Furthermore, health is wealth, literally if you look at their respective roots of heal and weal.

As a Georgist, I am not afraid of mandatory health insurance schemes because I believe "All Taxes Come out of Rents" (and land values) in the end. Adding a 10% surtax on all wage earners in return for solid-gold health coverage would not impoverish us -- we'd have a better standard of living, and in the end the higher tax burden would work its way into lower land values and rents.

The critics appear to have been right. Whatever dreams you may have regarding health care reform, the reality is messier. The actual Democratic plan is projected to increase the deficit in both the short and long term...

or, via Digby:

The headlines today were brutal on the health care front. The CBO chief's testimony that the reform bills currently on the table won't contain costs has shifted the Village chatter into shrill keening about deficits and costs and all the things the wealthy beltway celebrities love to pretend are important to average people just like them.

But there's a little problem with the reporting.

First, the bills the CBO scored aren't complete.

Second, the CBO didn't score the savings to the economy as a whole, which is the actual point of health care reform savings. From the Wonk Room:

Part of Elmendorf’s message is painfully obvious: investing in health care reform by providing Americans up to 400% of the federal poverty line with subsidies is going to cost the federal government a good deal of money — somewhere between $1 trillion and $1.5 trillion, to be exact.

Progressives have always argued that in order to reduce the growth of health care costs in the long term and avoid the kind of catastrophic spending levels that could swallow-up our entire economy, we’re going to have to bring everyone into the health care system. As Elmendorf points out, that shows up on the federal books.

But the budget outline that passed the Senate Budget Committee requires a fully funded health reform bill, and both the Senate Finance Committee and the House Ways and Means Committee are proposing different options to pay for reform and ensure that the bill does not add to the deficit.

For his part, Elmendorf, is isolating the ledger of the federal government from the context of the entire system.

In other words, since many of the savings from reform won’t be reflected in the federal budget, Elmendorf does not consider them. But modernizing the health care system (implementing electronic medical records, health information technology) and reforming the way Medicare and Medicaid reimburse providers will save money for the system as a whole.

As Melinda Beeuwkes Buntin and David Cutler pointed out in a recent analysis, these savings can total to some $2 trillion.

In fact, even the industry is on record as saying we can reduce the growth rate in annual health spending by 1.5 percentage points a year over the next 10 years, lowering spending overall health care spending by $2 trillion (this represents a 20 percent reduction in projected growth.) Elmendorf is looking at the trunk of the elephant and not the whole...

This is an obvious point, but one that seems to have been overlooked in the reporting.

Seems to be a worthy perspective to consider.

Thanks for sharing, Scent of Violents.

Nate, I'm going to respond to your comment at 3:20 by riffing off a comment by Johnny Canuck whilst indirectly answering Erza Klein's "options" (posted by Gary. The bottom line is that we lose a lot in the framing: Erza Klein posts his "options" as an exclusive list. Of course, however, Klein hasn't imagined all the options that are out there. There are actually a lot of ways to reduce health care costs that Klein either won't acknowledge or hasn't imagined.

Among them is Johnny Canuck's point. He writes:

Defensive medicine is a reflection of your tort laws- If the goal was to reduce costs you need to change the rules -or set up no-fault medical negligence insurance. Control of incompetent doctors would then have to be undertaken in some other way.

This problem is substantial in the US, where we tend to enforce standards of care through litigation. Litigation is a lot like war: It can achieve an aim, but it is almost always costly and messy -- and, if it persists through trial, collateral damage is almost always a given. Indeed, in the health-care context (and many others), a lawsuit is among the worst ways to right a wrong. I'm telling you this as a practicing lawyer, and this fact is why I always tell clients that I'll fight like hell for them but, if we go that route, they have to be prepared to go to hell with me.

But the lawsuit is, really, the only way to enforce a standard of care. That skews the system. It imposes costs. It drives doctors out of high-risk fields. It, basically, ruins everyone's day.

Now, how about Ezra's list of alternatives:

a) Support, as the CBO says you should, the eradication of the tax exclusion that protects employer-based health-care insurance;

b) Support, as Lewin and Commonwealth say you should, a public insurance option that can bargain at Medicare's rates;

c) Support, as the Office of Management and Budget and every health-care wonk in town says you should, one of the various policies floating around to give MedPAC authority to continually reform and modernize Medicare;

d) Support some form of aggressive cost-sharing that would make people extremely angry because it will save money by reducing their access to health-care services;

e) Support comparative effectiveness review that can judge not only the effectiveness but also the cost-effectiveness of various treatments, and give the federal government authority to use that data when deciding reimbursement rates.

What about option (f)? Support tort reform requires judgments in med mal cases by a panel of experts and caps attorneys fees, which will almost certainly make a substantial number of Democratic contributors very angry. Oh, wait, that's off the table?

Incidentally, I don't think that tort reform is the sole component of health care reform -- coverage needs to be expanded as well -- and I don't think that my option (f) is necessarily the best way to go about it. But this is a Kabuki dance on the Democratic side, not a genuine debate.

El Cid, I posted a link to the Bunton-Cutler report in an early comment. Here it is again: http://www.americanprogress.org/issues/2009/06/pdf/2trillion_solution.pdf. The report itself seems very slight, and I can't for the life of me figure out how to test their projections. Indeed, unless I missed something, the very first page of the report contains a substantial math error (the authors add 550 + 166 + 64 + 229 billion and get 1.5 trillion. How is that again?)

Personally von, I would support that type of arrangement with slight modifications. However, malpractice really has limited impact on health care costs.

Malpractice insurance, however, does have some impact. Malpractice judgements have remained fairly stable the last few years, but insurance rates have increased, in some cases quite substantially.

von: Well, you addressed maybe one of my points. But not very much. Just saying "tort reform" and claiming medical fear of malpractice is why health care costs so much is a red herring. Is fears of malpractice suits driving doctors from being GPs and into being specialists? No, you said it drives them from "high risk" jobs, but the specialists are usually higher risk than the GP's job, which is part of (in theory) why they pay more. Is malpractice suits why health insurance costs so much? Maybe a portion of it, but not the major reason.

It's kind of an illustration of my other point. I asked what your solution to universal coverage would be, and if you're actually worried about the deficit and costs of health care reform, or if you're just using that as an "acceptable" point to attack health care reform from. And in response, you... cited tort reform, the Republican Party's biggest hobby horse for the past 20 years, which accounts for a minor portion of health care costs? That doesn't make it seem like you're really that interested in actually dealing with health care reform or making it universal.

von, earlier you wrote "private hospitals and insurance companies will always be fearful of lawsuits, and thus will over-test and over-treat."

Trust me on this one, insurance companies almost never sanction over testing or over treating. After all, they are never refusing a patient's ability to receive treatment, they are just exercising their right not to cover for one reason or another.

It isn't often they lose suits for non-coverage of treatment. Probably the biggest case I remember was BCBS of MI getting sued and losing for failing to cover eating disorder treatment where the patient died. But that was really based upon limiting benefits to MH benefits rather than treating it as a medical condition.

And, hang on, isn't one of the major reason malpractice awards (when they're given) are typically so high is because the awards need to cover not just lawyer's fees, and not just pain and suffering, but also the other medical treatment required to fix (as best as possible) whatever it was that went wrong? Which means either the person suing, or their insurance company (if they're lucky enough to have one and still have it), are going to have to cover a lot of expensive medical care, on top of the lawyer's fees, the lost wages, and pain and suffering. But if medical care were already covered, in a universal manner, wouldn't that mean the person wouldn't be paying directly, out-of-pocket, for everything their insurance company wouldn't pay for, and (at least in a single payer system) the cost of the fixing would be spread out over a larger pool of people? Which would then mean that the medical costs portion of malpractice suits would be vastly lower?

But the lawsuit is, really, the only way to enforce a standard of care. That skews the system. It imposes costs. It drives doctors out of high-risk fields. It, basically, ruins everyone's day.

The Mayo Clinic and the doctors in Grand Junction CO have managed to create alternative ways to enforce a standard of care.

Beyond that, as Ezra Klein writes here, including legal fees, insurance costs, and payouts, the cost of the suits comes to less than one-half of 1 percent of health-care spending. I really don't see why you'd want to focus on your option (f); it does not seem to be significant and the research indicates that it is not a significant driver in the growth of health care costs. Can you point to research suggesting otherwise?

El Cid, I posted a link to the Bunton-Cutler report in an early comment. Here it is again: http://www.americanprogress.org/issues/2009/06/pdf/2trillion_solution.pdf. The report itself seems very slight, and I can't for the life of me figure out how to test their projections. Indeed, unless I missed something, the very first page of the report contains a substantial math error (the authors add 550 + 166 + 64 + 229 billion and get 1.5 trillion. How is that again?)

The "something" you missed was that the authors distinguished between federal government savings of $550 billion (the 3 numbers cited separately -- 166, 64, and 229 -- were components, incomplete, of what they admittedly 'guess'ed could be those savings) and overall health care system cost reductions.

The other savings are what they described as systemic, meaning savings at many other levels, such as state governments and, of course, individual consumers.

I'm not sure you really read through the document at all, however preliminary or insufficiently undocumented and unnoted it was, in order to make such a huge, silly basic error of interpretation.

Even if their numbers were entirely fictional and grabbed out of the imagination, you completely misinterpreted what they were saying.

Of course, it is a 27 page document, but I personally wouldn't want to make a huge and embarrassing error in claiming the mathematical ineptitude of the others by skimming the first page.

It could make one think that you were being entirely glib, rushed, and not at all serious in your haste to dismiss an entire type of analysis.

But the lawsuit is, really, the only way to enforce a standard of care.

No it isn't. Medical societies could start getting serious about pulling licenses from incompetent doctors. The courts were always supposed to be a fallback to that system. But it's easier for the doctors to blame trial lawyers than to clean up their own profession.

von,

I have heard doctors I respect, both liberals and conservatives, bitch and moan about malpractice suits. So I do not dismiss the importance of the issue.

But tell me this: what fraction of malpractice suits are brought ENTIRELY because of our lousy health insurance system? How many malpracticed-upon patients sue simply because they have no other way to recover the medical costs arising from the malpractice? How many malpractice suits are brought by insurers who, having reluctantly covered their malpracticed-upon customers' medical costs, are looking to repair the ding to their own bottom line?

I keep mentioning the fact that our aggregate "health care spending" pays for, among other things, the actors in all those boner-pill commercials. I mention it for the snark-worthiness, not because it's a big part of "health care spending". But the money paid to lawyers (on both sides)in malpractice suits also comes out of "health care spending" by any calculation of "health care spending" I can imagine. And you assure us it's pretty big money. We'd make a measurable reduction in "health care spending" if we could eliminate it. Okay.

But then lawyers would either lose income, or find other things to sue over. Lawyers have to eat, I presume, just like the rest of us. If we have too many lawyers to feed in this country, and too few doctors and nurses to provide actual care to everybody, the obvious solution is to steer more people into medicine and fewer into the law than "the market" has done so far. A little "government meddling" to re-arrange how much "health care spending" goes to quacks rather than to shysters doesn't sound terrible to me, but it doesn't seem obvious that it will make "health care spending" as a fraction of GDP go down much, either.

--TP

Hi, I'd just like to interject something here. I'm not a new reader to Obsidian Wings, but this'll be my first comment. It may not be profound, but I just wanted to get this off my chest to a field of intelligent people.

I just think the current state of the bill(as was said above, monstrous, expensive and half-assed) is the logical conclusion to the steps it's gone through to come into existence. Legislators disregarded the most cost-saving and effective form of healthcare, single-payer in favor of a "have it both ways" public option. Except that a public option inherently saves less than a single-payer bill because it does not have as much monopsony power.

They started off with a more expensive paradigm, kept chopping away at the factors of the bill that would be both effective and long-run cost saving out of some misguided desire for bipartisanship rather than effective legislation, and now the bill is both too expensive and not effective enough. Sigh, it's infuriating.

It's an example of the classic half-assed American approach to social programs. Instead of aiming for effectiveness, which with healthcare ends up saving much more in the long term, just ask the Canadians, they aim for short-term cost saving, which almost always ends up costing much more in the long term - see crumbling ie underfunded American infrastructure.

I am not at all surprised at this current state of affairs. It is exactly what opponents of healthcare reform have been shooting for since the debate began. They knew they could not kill it outright, their plan was to snip away at it until all that was left was a horrible, monstrously expensive bill. They of course then go on TV and say that the bill, that they puppeted into its horrible and expensive state, is horrible and expensive.

There I got that off my chest. Like I said, maybe not the most profound comment and I may be waaaay off, but that's how I see things.

By the way, I'll second SoV's comments, particularly about von's mistaken conception of "ad hominem." The fact that it is such a freakishly common mistake just makes it all the more frustrating.

TonyP: "But then lawyers would either lose income, or find other things to sue over. Lawyers have to eat, I presume, just like the rest of us"

But it isn't the need to eat, it is winning the lottery through multimillion dollar awards, far in excess of compensatory damages. It is the punitive damages and the lawyer taking a big slice.

Another question you might want to ask is what percentage of awards are really compensating for negligence or malpractice as opposed to a bad outcome- the empathy/sympathy judges/jurors feel for the harmed plaintiff, and the belief that "making the insurance company pay" doesn't hurt anyone.

The "something" you missed was that the authors distinguished between federal government savings of $550 billion (the 3 numbers cited separately -- 166, 64, and 229 -- were components, incomplete, of what they admittedly 'guess'ed could be those savings) and overall health care system cost reductions.

I subsequently figured out what they were getting at, but thanks for the correction. I didn't notice the switch between "federal" and "system" savings in that paragraph. Part of it was because I also couldn't find the 1.5 trillion claim repeated in the document, so I assumed that it wasn't related to the other claimed system savings. It's usually phrased as $2 trillion.* In any event, there's a more detailed analysis coming on the front page.

*I did a word search to look for another reference to 1.5 trillion in system savings just to make sure that I didn't miss it, but I couldn't find it; if you located, leave a comment on the next post.

Chris, While accepting the logic of what you say, do you disagree with Obama's judgment that it would be politically impossible to institute a single payer system? In other words, he's going with the doable option.

By the way, I'll second SoV's comments, particularly about von's mistaken conception of "ad hominem." The fact that it is such a freakishly common mistake just makes it all the more frustrating.

Well, I'm frustrated by your frustration. Ad hominem does not mean insult; and not all ad hominem arguments are irrelevant. Ad hominem simply means that SoV's comment was an attack against the person rather than the argument being presented.

But tell me this: what fraction of malpractice suits are brought ENTIRELY because of our lousy health insurance system? How many malpracticed-upon patients sue simply because they have no other way to recover the medical costs arising from the malpractice? How many malpractice suits are brought by insurers who, having reluctantly covered their malpracticed-upon customers' medical costs, are looking to repair the ding to their own bottom line?

My point is that using the threat of lawsyuits to set standards of care will result in perverse (read: costly) standards of care. But that's what we're doing, by and large, in the US.

"Like I said, maybe not the most profound comment and I may be waaaay off, but that's how I see things."

I think it's basically accurate. My own simple answer is that we don't have enough real liberals, or people sufficiently on the left, such as more Bernie Sanders, or Russ Feingolds, or Barney Franks, to just create a good single-payer system. We have the Blue Dogs to placate, and every representative being paid off by the immense amounts of money the insurance companies and other interests invested in the current system have to ply our representatives with. So we wind up with a big kludge, at best. It sucks, but you got to health care war with the Congress you have, not the one you want.

And why is this urgent?

Turbulence, to repeat what I wrote above, the main problem is not "legal fees, insurance costs, and payouts". The main problem is that using litigation to set the standard of care results in suboptimal systematic incentives. Incidentally, I agree that some clinics and hospitals are very good at reducing their exposure to lawsuits and self-policing; but it isn't nearly common enough, and likely won't be common until the threat of massive lawsuits and settlement payments is resolved in some way.

The main problem is that using litigation to set the standard of care results in suboptimal systematic incentives.

If this is the case, can you point to any studies showing a significant difference in health care costs between regions with different medical malpractice regimes? Some states have been very aggressive at curbing malpractice litigation -- shouldn't we see lower costs in those states? Can you point me to any papers backing up your assertion at all? Or is this just something that feels right to you for which you have no evidence?

von: ad hominem is attacking the person to discredit their argument, e.g. "This person is smelly, so we shouldn't listen to them," not "This person's argument is bad therefore it reflects badly on their ability to make the argument."

von, let me see if I understand your malpractice argument. You're saying that malpractice lawsuits are expensive (true) even if the defender wins (also true). They are used as the way to set "standards of care" in the US. (questionable, given professional organizations and standards, as well as counter-examples, but it could be a contributing factor). Therefore, doctors and/or insurance companies are pricing in the risk of malpractice suits for the costs of care?

I can see a couple of problems with that argument, besides the questionability (is that a word?) of your claim about malpractice suits being used to set standards of care. First, I'm going to question the good faith of the insurance companies (completely justified by their actions), if they are doing this. Are they pricing in the risk of malpractice suits, or just claiming that to give them another reason to raise rates?

Second, as mentioned above, isn't part of the high reward for malpractice suits that are won by the plaintiffs due to the risk priced in of losing their medical insurance, as well as all the other medical and legal costs involved, and lost wages? Therefore, wouldn't a truly universal health care program, on its own, help reduce the costs of malpractice suits?

Ad hominem simply means that SoV's comment was an attack against the person rather than the argument being presented.

Yeah . . . no. Unless you're just deciding to invent a new definition of "ad hominem." And my frustration stems from the fact that -- whether or not you subjectively perceived SoV's comment as an attack -- it was simply not an ad hominem argument. Nevertheless, you called it such. Now, I understand that a lot of folks make the same mistake, and it is commonly understood that anything remotely personal offered in argument is ad hominem. But it just. isn't. so.

The reason "ad hominem" exists as a concept is because it describes a certain logical fallacy --- that because a person has (or is claimed to have) a particular characteristic ("you smell!"), that person's arguments should be given less weight. The shorthand of "ad hominem" is used to point out that such an riposte is, essentially, non-responsive. It doesn't address the issue.

What is definitely not ad hominem is using a person's argument to attack a person, no matter how ugly the attack is. SoV talked about the arrow, and which way it's pointing, and I think that's probably the most useful way to think about it. Here --- this is ad hominem, at it's simplest.
A: The earth is flat.
B: You're stupid, and because you are stupid, the earth cannot be flat.

And this is not ad hominem.
A: The earth is flat.
B: The earth is round. You think the earth is flat? Really? Wow, I used to think highly of you, but I guess you're a real mouth-breathing idiot.

In the first case, the insult is offered as argument. In the second, it is a conclusion. Now, it is a conclusion offered without evidence (pictures from space, etc.) but it is a conclusion based on the argument.

Sorry to go on so long, but its frustrating to have to deal with this all the time. It's not really that hard of a distinction to master.

Nate and CS, I agree with your definitions. The particular comment I called out by SoV fits into the definition*: S/he wasn't drawing a conclusion, but making an assertion in the particular statement that I identified.

*Note that I didn't broadly apply my characterization to all of SoV's comments, but called out one in particular.

C.S. I understand your distinction, but whether you offer an insult as an"argument" or a "conclusion", they are both uncivil and we would be better off without them.

Von takes the trouble to develop the post. Better to say " I fear you overlooked" or some such.

Nate and CS, I agree with your definitions. The particular comment I called out by SoV fits into the definition*: S/he wasn't drawing a conclusion, but making an assertion in the particular statement that I identified.

Ahem . . . no. Guess what? It doesn't matter if SoV was making an assertion! Assertions are not ad hominem, unless they're being deployed to attack the argument through some -- usually undesireable -- characteristic of the person making it! The question is, was SoV using an assertion about something irrelevant to discount your argument?

Let's go to the tape.

This is what SoV's comment did:
1. Noted that you did not acknowledge making mistakes in any of your earlier posts.
2. Noted that those mistakes were quite obvious (with the implication, as I read it, that you should acknowledge the obvious mistakes if you want to be taken seriously on this subject).
3. Linked to an article -- and provided an excerpt -- which s/he felt was directly on point in contradicting your position.
4. Then concluded -- say it with me: "concluded" -- in this manner: "I'm sorry to say this von, but you appear to be unaware that you've got to be persuasive and convincing. You've got to put together a case for your views. Instead you come across as mindlessly partisan, flipping all too often into the 'if you can't make me say I'm wrong I win' mode. Just the opposite of the usual application of argumentation and the scientific method."

This is not ad hominem. It just isn't. SoV made her case, and drew conclusions about you based on your argument, in this and previous posts. Now, you could say it's patronizing. You could say it is unnecessarily personal. You could say that his/her conclusion is wrong. You can do a million bleeping things . . . but you can't call it ad hominem.

Yes, Johnny, we can always be more civil. But that's not really all there is to it. The problem is that when someone improperly accuses another of using an ad hominem argument, they are -- wait for it -- using an ad hominem argument. They are saying, essentially, "you have not addressed what I said, and therefore your assertions have no merit." Deployed in this manner, it is a way of avoiding addressing substantive points raised by someone who is less than courtly. Simply saying "such language!" is not enough to deflect, say, a good argument laced with obscenities.

Instead, people cry "ad hominem" because it sounds all Latiny and therefore sounds like it is a refutation, but in fact it is only a more intellectualized way of getting the vapors at rude behavior. Misusing the term is actually a double fallacy, because it is also an appeal to authority (Latin! Logic terminology! Top that!) as well as being ad hominem itself ("you are rude, therefore your argument stinks").

I guess my point is that -- while I understand the desire to keep things civil -- it is just as important (more important to me) to maintain argumentative clarity. You can't do that with people slinging accusations of "ad hominem" every time someone gets a little salty. It's a dodge, and people should get called out for it.

"Second, as mentioned above, isn't part of the high reward for malpractice suits that are won by the plaintiffs due to the risk priced in of losing their medical insurance, as well as all the other medical and legal costs involved, and lost wages? Therefore, wouldn't a truly universal health care program, on its own, help reduce the costs of malpractice suits?"

This is certainly a leap. While the costs of losing a malpractice suit are high, the real cost is insuring against the costs of winning them on a regular basis. The insurance is priced to take care of high payouts, but what substantially drives the costs are the parade of suits that are either settled to avoid legal costs or actually litigated, no matter who wins.

I am pretty sure a universal system won't fix that....unless...it is the government and those suits are made illegal. I am sure that no one wants to take that right away from the patients.

Johnny Canuck, I mean, while I don't disagree that it's probably the politically expedient option, I just see it as a cop-out. Rather than just saying, disingenuously, "It can't pass" I wish they woudl have at least put it on the table. They didn't really do that.

Also, strategically to start with the compromise, the Public Option, rather than the real outlier is just foolish when you know that the opponents will stop at nothing to hamstring anything you do. Opponents who want the status quo to remain and who vowed to oppose any legislation with public health care, will chip away at anything presented to them. Therefore present them with the ideal and let them whittle it down to the good. Rather than start with the good and let them whittle it down to crap. It was especially poor strategy given that the Democrats only had to win over the Blue Dogs and could effectively ignore the GOP.

I'm completely fed-up with the "half-assed" approach to legislation, but I have no expectation that it is going to end any time soon.

I hope that explains where I was coming from.

To Gary Farber: Bernie Sanders is my hero.

Chris: I recall a piece I saw somewhere in Blogistan, where one of the Democratic "centrists" said "oops, we should have left Single Payer in to negotiate with" but didn't actually seem to note any remorse for their own part in screwing up.

Marty: If someone is being sued for malpractice "regularly", even if they win the cases, isn't that a sign that hey, something's @$!#ed up here?

Also, do you have any statistics on this "parade" of lawsuits? And my idea is "Hey, if people know they're not going to go broke from medical bills if something goes wrong, then there'll be less need for them to sue to try and cover the gazillion dollars of medical bills they might rack up, especially if their insurance company decides they don't want to cover them any more.

Nate: Of course not. I believe Max Baucus has said something to that effect. But at least he (and others opposing healthcare reform) are getting their massive campaign contributions from health insurance companies. Which is at least part of his goal. If not a goal, a perk. Good job, Max.

"Also, do you have any statistics on this "parade" of lawsuits?"

Unfortunately, I don't. The latest government assessment I can find was from 2003 that said, summarizing, the data collected doesn't allow us to evaluate the cost of the seemingly increasing number of lawsuits. My opinion is informed only by the anecdotal data I get from working with the healthcare delivery industry.

"...the questionability (is that a word?)"

Yes.

what substantially drives the costs are the parade of suits that are either settled to avoid legal costs or actually litigated, no matter who wins.

I'm not sure what you mean by "costs" here; if you mean the overall increase in health care costs, I'm really skeptical since you can't point to a study showing how total health care costs change in states that adopt medical tort reforms.

According to the CBO,
However, CBO found no evidence that restrictions on tort liability reduce medical spending...CBO found no statistically significant difference in per capita health care spending between states with and without limits on malpractice torts.

Now, you can find small studies that disagree or quibble with the CBO, but they don't seem particularly credible. In any event, if there is an effect, it will likely be quite small. There does not appear to be significant evidence demonstrating that tort related issues are a major driver of health care cost increases.

"I mean, while I don't disagree that it's probably the politically expedient option, I just see it as a cop-out. Rather than just saying, disingenuously, "It can't pass" I wish they woudl have at least put it on the table."

Chris, politics is the art of the possible. Obama had to set out a position on health care during the campaign. If he had advocated for single payer, he would have been crucified by the media as unrealistic.
And if he had "seen the light" and switched to advocating single payer after the election he would be crucified for having a secret agenda and breaking campaign promises.

I think Obama has guided this much farther and faster than the critics expected. He's steering an ocean liner, not a speed boat, it takes time to turn the ship around.

"Now, you can find small studies that disagree or quibble with the CBO, but they don't seem particularly credible. In any event, if there is an effect, it will likely be quite small. There does not appear to be significant evidence demonstrating that tort related issues are a major driver of health care cost increases."

I don't disagree, the costs I was referring to were Malpractice insurance costs.

If "tort reform" won't reduce the cost of malpractice suits, and thereby the risk needing to be insured by malpractice insurance, which should lower the malpractice insurance rates, then either a) the malpractice insurance companies are fleecing doctors and health insurance companies, b) "tort reform" is useless, or c) malpractice suits and insurance aren't as big a deal as they're made out to be.

Or some mix of all of the above.

"Yes, Johnny, we can always be more civil. But that's not really all there is to it. The problem is that when someone improperly accuses another of using an ad hominem argument, they are -- wait for it -- using an ad hominem argument."

C.S. with respect, you may well be using a technical term as used in a course on logic, webster's online defines it as "marked by or being an attack on an opponent's character rather than by an answer to the contentions made"

The Canadian Oxford gives the meanings
"1. relating to or associated with a particular person 2. (of an argumment) characterized by an attack on the person rather than their argument"

while i am grateful to learn of the more technical meaning, and I think i will continue to describe them as personal attacks, I think the way Von used it is not incorrect.

"webster's online"

While we're being technical, "websters" demarks no authority whatever; it's a generic, non-trademarked, name claimed by anyone who wants to use it, and a great many would-be dictionary authorities do; if you wish to cite a particular dictionary as your prescriptive or descriptive authority, you are welcome to do so, but "webster's" is meaningless.

"I think the way Von used it is not incorrect."

When usages are in conflict, rather than outright wrong from just about every major authority, I always advise going for the usage that increases clarity, rather than the usage that blurs clarity and increases confusion, myself. As a corollary -- and this is simply my personal preference -- I suggest it makes for better communication all around to use that clearer usage, rather than stick to a more confusing usage, despite familiarity and comfortability with the latter.

Your mileage, of course, may vary.

"Yes, Johnny, we can always be more civil. But that's not really all there is to it. The problem is that when someone improperly accuses another of using an ad hominem argument, they are -- wait for it -- using an ad hominem argument."

C.S. with respect, you may well be using a technical term as used in a course on logic, webster's online defines it as "marked by or being an attack on an opponent's character rather than by an answer to the contentions made"

The Canadian Oxford gives the meanings
"1. relating to or associated with a particular person 2. (of an argumment) characterized by an attack on the person rather than their argument"

while i am grateful to learn of the more technical meaning, and I think i will continue to describe them as personal attacks, I think the way Von used it is not incorrect.

Posted by: Johnny Canuck

Well, you could always look for something a little more clear on the subject, the wiki's not bad for this sort of thing:

Ad hominem argument is most commonly used to refer specifically to the ad hominem abusive, or argumentum ad personam, which consists of criticizing or attacking the person who proposed the argument (personal attack) in an attempt to discredit the argument. It is also used when an opponent is unable to find fault with an argument, yet for various reasons, the opponent disagrees with it...

Ad hominem as informal fallacy

A (fallacious) ad hominem argument has the basic form:

Person A makes claim X
There is something objectionable about Person A
Therefore claim X is false

The wiki goes on to make the point that this is, after all, only the flip side of the ad verecundiam fallacy: X claims statement S is true, so it must be true because X is an authority.

So, no, the accusation is false.

But in regards to civility, let me make an observation: I find von to be very uncivil indeed. Claiming to want a civil dialogue, you see, is not some sort of magic amulet. You've got to in fact, act in a civil manner. Among other things, this means acknowledging when one has made a mistake, acknowledging when someone else has made a valid point, directly and coherently addressing objections to an argument, and so on and so forth. von hasn't been doing that. In fact, when I very civilly pointed out why von was wrong about the nature of the ad hominem fallacy, I got this rather snide answer:

Thanks for sharing, Scent of Violents.

And it is precisely this sort of behaviour - Seb - which makes so many people believe that people like von are arguing in bad faith. The bottom line is that civility isn't something as trivial as refraining from name-calling; it is more like a set of procedures to be followed and a list of behaviours not considered to be proper. Namecalling is just a one-liner from the list.

Scent of Violets:

Von said:"Ad hominem simply means that SoV's comment was an attack against the person rather than the argument being presented."

Von was explaining how he used the expression. This was a perfectly valid use of the word as per dictionary.

You say to me: "you could always look for something a little more clear on the subject".

It is not an expression I tend to use, but I have provided evidence of why Von's use was a perfectly valid usage.

He was not wrong.

Empathy is so much in the forefront. It perhaps would be good if you could recognize that Von's was a valid use of the expression "ad hominem", even if it isn't your preferred definition.

I will know if you are using the expression what you mean by it.

While we're being picky about language, I will point out yet again that there are hundreds, yea, thousands of wikis on the web. A "wiki" is a format, like a blog. "Wikipedia" is one specific wiki. But "wiki" does not mean "Wikepedia," but could refer to any of several thousand different wikis.

Wikipedia isn't even the first wiki, which was WikiWikiWeb.

Personally, I use several dozen different wikis for several dozen different reasons.

If someone wants to refer to Wikiepdia, they should say they're referring to "Wikipedia": not to "wiki." This barely begins to even scratch the surface of how many wiki engines there are, let alone number and types of specialized wikis.

It's the difference between a common noun and a proper noun.

Here is a list of just a tiny sample of wikis. And what, of course, could be of more importance than this one, or this one?

And this is a sort of wiki.

Von said:"Ad hominem simply means that SoV's comment was an attack against the person rather than the argument being presented."

Von was explaining how he used the expression. This was a perfectly valid use of the word as per dictionary.

Personally, I think it's akin to using the colloquial definition of the word "theory" in a scientific discussion; that is, sloppy, imprecise (though technically correct) and not at all helpful.

Re: "ad hominem" (and CS): Y'all are not applying your own definition (and I'm not using a unique definition). As I noted at the outset -- and other noted subsequently -- an ad hominem argument is a logical fallacy, in which the writer responds to an argument by attacking the person for some failing, as opposed to the merits of the person's argument.

I'll accept, for the purposes of argument, that CS's characterization of SoV's original comment. (I happen to think that this is very generous to SoV, because proposition 3 doesn't support propositions 1 or 2 .... i.e., it doesn't support my alleged past failures to acknowledge (obvious) mistakes.

This is what SoV's comment did: 1. Noted that you did not acknowledge making mistakes in any of your earlier posts. 2. Noted that those mistakes were quite obvious (with the implication, as I read it, that you should acknowledge the obvious mistakes if you want to be taken seriously on this subject). 3. Linked to an article -- and provided an excerpt -- which s/he felt was directly on point in contradicting your position. 4. Then concluded -- say it with me: "concluded" -- in this manner: "I'm sorry to say this von, but you appear to be unaware that you've got to be persuasive and convincing. You've got to put together a case for your views. Instead you come across as mindlessly partisan, flipping all too often into the 'if you can't make me say I'm wrong I win' mode. Just the opposite of the usual application of argumentation and the scientific method."

As characterized by CS, there's a good argument that the entirety of SoV's comment is an ad hominem response to my post. That's because my personal penchant for correcting mistakes is not part of the argument that I have presented. This is akin to me saying: "The world is round" and, instead of refuting the world's roundness, someone replying: "Yesterday you claimed that the moon was made of cheese, and everyone knows that's not true." My past foibles may be relevant
to whether I'm trustworthy, kind, decent, thoughtful, smart, etc. But that doesn't mean that my current argument rises or falls on my trustworthiness, kindness, decency, thoughtfulness, intelligence, etc.

Ad hominem fallacies are not confined to clearly irrelevant insults.
Now, if my post had asserted that I was always personally consistent and corrected my mistakes, SoV's comment would be directly on point. But my post presented no argument in favor of me or my persuasiveness (or lack thereof).

Do you understand?

Personally, I think it's akin to using the colloquial definition of the word "theory" in a scientific discussion; that is, sloppy, imprecise (though technically correct) and not at all helpful.

Gwangung -- I generally agree, but I provided an unsloppy definition of ad hominem in my post at 12:20 on July 17, 2009. (From Wikipedia, of all places.) My prior and subsequent shorthands were intended to highlight the aspect of the definition that I thought was essential to my point. Maybe it was foolish of me to do so, because it apparently created the impression that I was applying a "sloppy, imprecise (though technically correct)" definition in general.

von, I can see you've been drawn into this absolutely riveting discussion about the semantics of "ad hominem" but when you grow tired of addressing this topic, would you mind commenting on the CBO report I linked to above?

SoV, this is one reason why I sometimes find your comments frustrating. I really couldn't care less about whether von uses the correct definition of "ad hominem" or even whether he's a jerk. But your insistence on talking about these relatively trivial matters makes it much harder to talk about substantiative issues because everyone here has limited time.

Turb -

von, I can see you've been drawn into this absolutely riveting discussion about the semantics of "ad hominem" but when you grow tired of addressing this topic, would you mind commenting on the CBO report I linked to above?

Fair point.

First, it's worth noting that the CBO didn't conclude that tort reform had no effect on the practice of defensive medicine -- only that the evidence was weak (in favor) or inconclusive. There is a need for further analysis.

Second, I would expect a weak and/or inconclusive result at this stage. Although tort reform is state by state, the effects of litigation against insurance companies and large healthcare providers are interstate. Moreover, defensive medicine is frequently learned: it follows the practicioner and doesn't respond quickly (or completely) to changes in the law.

Third, it's tort reform is one component of health care reform. It's important, but it's not the end all or be all. (I recognize that some Republicans are guilty of arguing otherwise.)

Gwangung -- I generally agree, but I provided an unsloppy definition of ad hominem in my post at 12:20 on July 17, 2009. (From Wikipedia, of all places.)

Sigh. And why did you think that I supplied the information I did from the same article? Maybe because you - wait for it - misinterpreted it? This isn't something obscure:

An Ad Hominem is a general category of fallacies in which a claim or argument is rejected on the basis of some irrelevant fact about the author of or the person presenting the claim or argument. Typically, this fallacy involves two steps. First, an attack against the character of person making the claim, her circumstances, or her actions is made (or the character, circumstances, or actions of the person reporting the claim). Second, this attack is taken to be evidence against the claim or argument the person in question is making (or presenting). This type of "argument" has the following form:

1. Person A makes claim X.
2. Person B makes an attack on person A.
3. Therefore A's claim is false.

The reason why an Ad Hominem (of any kind) is a fallacy is that the character, circumstances, or actions of a person do not (in most cases) have a bearing on the truth or falsity of the claim being made (or the quality of the argument being made).
Example of Ad Hominem

1. Bill: "I believe that abortion is morally wrong."
Dave: "Of course you would say that, you're a priest."
Bill: "What about the arguments I gave to support my position?"
Dave: "Those don't count. Like I said, you're a priest, so you have to say that abortion is wrong. Further, you are just a lackey to the Pope, so I can't believe what you say."

Or how about this:

One of the most widely misused terms on the Net is "ad hominem". It is most often introduced into a discussion by certain delicate types, delicate of personality and mind, whenever their opponents resort to a bit of sarcasm. As soon as the suspicion of an insult appears, they summon the angels of ad hominem to smite down their foes, before ascending to argument heaven in a blaze of sanctimonious glory. They may not have much up top, but by God, they don't need it when they've got ad hominem on their side. It's the secret weapon that delivers them from any argument unscathed.

In reality, ad hominem is unrelated to sarcasm or personal abuse. Argumentum ad hominem is the logical fallacy of attempting to undermine a speaker's argument by attacking the speaker instead of addressing the argument. The mere presence of a personal attack does not indicate ad hominem: the attack must be used for the purpose of undermining the argument, or otherwise the logical fallacy isn't there. It is not a logical fallacy to attack someone; the fallacy comes from assuming that a personal attack is also necessarily an attack on that person's arguments.

Therefore, if you can't demonstrate that your opponent is trying to counter your argument by attacking you, you can't demonstrate that he is resorting to ad hominem. If your opponent's sarcasm is not an attempt to counter your argument, but merely an attempt to insult you (or amuse the bystanders), then it is not part of an ad hominem argument.

Actual instances of argumentum ad hominem are relatively rare. Ironically, the fallacy is most often committed by those who accuse their opponents of ad hominem, since they try to dismiss the opposition not by engaging with their arguments, but by claiming that they resort to personal attacks. Those who are quick to squeal "ad hominem" are often guilty of several other logical fallacies, including one of the worst of all: the fallacious belief that introducing an impressive-sounding Latin term somehow gives one the decisive edge in an argument.

Sounds like somebody has von's number :-) Again, this is a well-known argument, not obscure, and easy to look up.

SoV, this is one reason why I sometimes find your comments frustrating. I really couldn't care less about whether von uses the correct definition of "ad hominem" or even whether he's a jerk. But your insistence on talking about these relatively trivial matters makes it much harder to talk about substantiative issues because everyone here has limited time.

Hammer. Nail. Head. I'd love to talk about the substantive issues. But the fact of the matter is - and you know this as well - von simply isn't going to admit he's wrong about any nontrivial point. Witness this digression! (In fact, I went on as long as I did to illustrate that when caught dead out, he still wasn't going to admit he's wrong, even on something as minor as this.) This intransigence makes it rather hard, imho, to discuss substantive issues.

And it is also, very, very, very uncivil.

Based on my experience, the hospitals will also send you, the uninsured user, the person who demonstrates they have no assets and no money and no income, a bill for over $2,000 (several bills, actually, that tend to add up to about $2500, from the various technicians, etc.) for the very simplest procedures, such as examining you for one minute, and giving you some pain killer for your toothache. If you can't pay these bills, they set collection agencies on you to harass you for years.

It seems that part of the problem in figuring out where increases are coming from is that billing does not reflect costs. In 2006 my daughter's mother was billed $60 for paper hospital gowns. This being a two-day visit, it's possible that she used two gowns, maybe three. Definitely not four. So $20 to $30 for a disposable paper item? Several years back, I had to visit the emergency room (broken glass in a hay bale); I was billed $80 for butterfly bandages.

It's easy to say, though not necessarily defensible, that these bills are simply used to defray costs elsewhere in the system. But this makes it rather difficult to ferret out where the money is really going. Is it being used to fund research? Pay for indigent care? Or is it simply going into somebody's pocket? We simply don't know with these sorts of accounting practices.

What about option (f)? Support tort reform requires judgments in med mal cases by a panel of experts and caps attorneys fees, which will almost certainly make a substantial number of Democratic contributors very angry. Oh, wait, that's off the table?
This is certainly a leap. While the costs of losing a malpractice suit are high, the real cost is insuring against the costs of winning them on a regular basis. The insurance is priced to take care of high payouts, but what substantially drives the costs are the parade of suits that are either settled to avoid legal costs or actually litigated, no matter who wins.

I am pretty sure a universal system won't fix that....unless...it is the government and those suits are made illegal. I am sure that no one wants to take that right away from the patients.

Note that absolutely no evidence is offered for these claims. Indeed they seem to be put out there merely to counter the idea that rising health costs could be the result of something else, e.g.:

a) Support, as the CBO says you should, the eradication of the tax exclusion that protects employer-based health-care insurance;

b) Support, as Lewin and Commonwealth say you should, a public insurance option that can bargain at Medicare's rates;

c) Support, as the Office of Management and Budget and every health-care wonk in town says you should, one of the various policies floating around to give MedPAC authority to continually reform and modernize Medicare;

d) Support some form of aggressive cost-sharing that would make people extremely angry because it will save money by reducing their access to health-care services;

e) Support comparative effectiveness review that can judge not only the effectiveness but also the cost-effectiveness of various treatments, and give the federal government authority to use that data when deciding reimbursement rates.

[1]

In fact, per Turbulence:

According to the CBO,
However, CBO found no evidence that restrictions on tort liability reduce medical spending...CBO found no statistically significant difference in per capita health care spending between states with and without limits on malpractice torts.

Now, you can find small studies that disagree or quibble with the CBO, but they don't seem particularly credible. In any event, if there is an effect, it will likely be quite small. There does not appear to be significant evidence demonstrating that tort related issues are a major driver of health care cost increases.

So if either Marty or von have any studies they can point to before they averred it was those nasty law suits that were to blame for rising medical costs, I'd like to see them. As it is, 'tort reform' just seems like something seized upon at random to divert from other possible cost drivers.

[1]I'm emphatically with Gary on this one:

I would also like to propose a related rule: any reporters who receive a quote from a politician referencing this CBO score should be required to ask the politician which of these policies -- or which alternative cost-saving policies -- they support. And that should be on the record. I think it's perfectly legitimate to criticize health-care reform for not saving enough money. In fact, I think it's important. Health-care reform should save more money. But it's not legitimate to do that if you also oppose any and all measures for saving money.

That includes anyone here who says they are 'for' health care reform of some sort, but who shoot down any and every plan for containing personal costs while at the same time refusing to offer up any workable plans of their own.

SoV, there's only one item in your recent missives that I think needs a response (in that it's on point and hasn't already been covered).

So if either Marty or von have any studies they can point to before they averred it was those nasty law suits that were to blame for rising medical costs, I'd like to see them. As it is, 'tort reform' just seems like something seized upon at random to divert from other possible cost drivers.

I think that I've already appropriately caveated my support for tort reform; it should be clear to the casual reader that you've mischaracterized my position. Tort reform should be one component of any health care reform package, particularly if the taxpayer is going to be on the hook for awards and/or the cost of med mal insurance. But it is only one aspect of any reform package.

You demand support for my contention that "it was those nasty law suits that were to blame for rising medical costs". Obviously, that wasn't my actual contention: litigation is only part of the reason why health care costs are increasing, and isn't necessarily the biggest reason.

Still, it's reasonable to ask whether there is any evidence that litigation increases the costs of health care in the United States.

The link between litigation and the increasing costs of health care (both via increased med mal premiums and via the practice of defensive medicine). For example:

http://blogs.usatoday.com/oped/2008/04/wasted-medical.html (noting study where 93% of doctors admitted practicing defensive medicine)

http://content.nejm.org/cgi/content/abstract/354/19/2024 (med mal analysis; 37% percent of med mal payments in the study involved no apparent treatment error)

http://en.wikipedia.org/wiki/Defensive_medicine (defensive medicine generally)

http://jama.ama-assn.org/cgi/content/abstract/293/21/2609 (defensive medicine among high-risk practicioners)

http://www.njha.com/publications/HCNJ/HCNJV11No3.pdf (effects of medical malpractice insurance in New Jersey on doctors leaving the field)

There are a lot more.

"I'm emphatically with Gary on this one"

To be clear, that's a quote from Ezra Klein, not words written by me.

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