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August 20, 2009

Comments

Uncle Kvetch, I think that you've either misread or miscontrued my point. But thanks for playing.

"Thus, you can have single payer with either model, but it's only government provided health care where the government provides the health care."

You can keep explaining this but, we understand your point. My point is that there is no realisti difference in single payer and single provider. The effective difference is that in one model (single provider)almost everyone is an employee, under single payer almost everyone is a contractor, the difference is primarily just in how one gets paid.

The control of healthcare is effectively the same.

von, I reread the quotes from your link. Number one: there is no point where he says that he wants to outlaw private health insurance. Number two, he specifically states he wants Medicare for all. Since Medicare allows for private health insurance and in fact many private insurers make quite a bit of money off of Medicare enrollees, he by definition is not advocating the outlawing of private insurance.

On the other hand, many Republicans have specifically advocating getting rid of the SS system, as you graciously admitted to.

And how do you think insurance reimbursement works?

Insurance reimburses the hospitals/facilities that the patient patronizes. The privately run hospital/facility, which collects money from insurance premiums and out of pocket expenditures pays salaries, dividends, and other benefits, makes corporate decisions such as reinvestment, merger, expansion, etc.

Why, how did you think it worked?

Granted, the NHS has elements of centrality control that are not found in all single-payer insurance systems, but it's a matter of degree -- not kind.

Elements? Massive understatement.

The government owns the hospitals, pays the salaries, runs the health care. That's a huge difference.

von: The bolded part. Again, "would be established for all workers under the age of 55, unless they choose not to have an account."" That's the DEFINITION of opt-out.

Nate, I asked which link contained the quote you identify; I'm trying to figure out what I misread. (I am accept that you have provided an accurate quote of something I've linked, which means that I misread it.)

Okay, and now you're just being obtuse deliberately and trying to conflate the NHS with government provided insurance, which is false, and everyone has called you on so far.

Oooooookaaaayyyyy. I don't think you're following the issue.

OK, so does the US have public health care? Because a large number of US hospitals fit the definition of being run by the government (e.g., New York City Health and Hospitals Corporation, which was created by the New York legislature as a public hospital.)

It has some! The best example is the VA. Which is part of what makes the propaganda so asinine.

And yet, no one is proposing a government take over of health care. That claim is still smarmy propaganda - even if, in actuality, it shouldn't really scare people because there already are pockets of government run health care.

And the VA happens to be the most efficient, highest performing system we got.

The government owns the hospitals, pays the salaries, runs the health care. That's a huge difference.

Well, among other things, the NHS doesn't own the private UK hospitals, of course. And, since you don't address the NYCHHC, I'm still trying to understand why this is a difference in kind rather than degree.

Alas von, I'm still waiting for your answers to the questions I raised here. Ah well, I've been waiting for answers since yesterday afternoon.

von: Okay, I give up. Yes, all of us evil liberals are out to create a giant government run grandma killing monster to kill off the private health insurance market and eat all the hospitals and doctors in the country, and deny health care to Republicans. You're on to our secret plan. We've imported the blueprints from the UK, whose NHS is powered by the screaming torment of Stephen Hawking and all the other people who wouldn't benefit society. And we're going to take all the pharmaceutical companies profits and hoard the drugs so millions of people die of easily preventable diseases while we make pills to give us tons of hot sex and addict Rush Limbaugh so we can entertain ourselves by making him dance for his drugs.

Cripes, if we're going to be accused of it anyway, even by "reasonable" Republicans, why SHOULDN'T we go for it?

The control of healthcare is effectively the same.

No it isn't!!!

The effective difference is that in one model (single provider)almost everyone is an employee, under single payer almost everyone is a contractor, the difference is primarily just in how one gets paid.

Sweet jeebus, the government is not the only payer, even in single payer!!!!

You can still pay out of pocket, as plenty of people do. You can still buy supplemental insurance, as plenty of people do. You're getting tripped up because single payer is actually a misnomer, not a literal arrangement.

And regardless, private entities would be free to innovate and improve services in the hope of attracting dollars. They would still make decisions with a board, shareholders, officers, etc. They would still be a privately held interest operating in a free market.

It would not be a government agency making the decisions.

For better AND for worse. But those are important differences.

And, since you don't address the NYCHHC, I'm still trying to understand why this is a difference in kind rather than degree.

Actually, I did. I assume there was an ether delay in comment posting.

Well, among other things, the NHS doesn't own the private UK hospitals

Yes, it's not purely government run. Which is to say that even under the most extreme system in the West, the government doesn't control all of health care.

I agree with that!!!

von, yes some government entities do run facilities, clincis, etc. They are mostly toto handle the poor and indigent populations. Some states still run mental hospitals. These programs were developed to provide treatment that the private sector either couldn't or wouldn't provide.

However, although the governmental entities runs and pays for the operation of these facilities, they also accept private insurance payments when possible.

But the most important point is that if the private sector was able to take care of these services, the services provided by the governmental entities would probably not exist.

Regarding the NHS, who pays for the services at the private hospitals. Does the government or the patient?

Von,

To follow through on your point. According to you, the UK is not government run health care, but the US is government run health care.

So I say: why the scare tactics about government run health care? We already have it, so it's a meaningless propaganda tactic. After all, the NYCHHC exists, it's all a matter of degree, not kind, so everyone calm down.

It's like warning people about government run pre-college education. Right?

No it isn't!!!

Give it up, Eric. This is the definition of a hopeless case.

Give it up, Eric. This is the definition of a hopeless case.

I think I will. My ten remaining hairs thank you Uncle K.

von: Your link to the "Final Republican Plan" here.

Not that it matters, as a) the Social Security scam was defeated, and b) isn't the main point.

"As the Brits would say, bollix."

I submit they'd be far more likely to say "bollocks."

Damn you [email protected]#[email protected]#[email protected]

(shaking fist in Gary's general direction)

"No it isn't!!!"

Is too!!!!!!!

"I really think that you're drawing distinctions that are not particularly meaningful."

Since we're opining, I opine that the distinction is vital.

"You're right that no one is seriously proposing a centralized public health care system, a la the NHS. But it's the centralization that's the key distinction between the NHS and the issues at hand, not the 'government run' healthcare bit."

I don't agree in the slightest, and think this is a huge obfuscation of a vital distinction.

Since we're simply voicing opinions.

Yes, it's not purely government run. Which is to say that even under the most extreme system in the West, the government doesn't control all of health care.

I agree with that!!!

So do I!!!!! (Note extra exclamation points; they make my argument better than yours.)

Look, my point -- which you don't seem to want to see -- is that "government run" isn't a viable distinction of kind between the US and the UK systems. The US has government run hospitals. The UK has more. The US has private hospitals. The UK does as well, albeit fewer. This is a difference in degree, not kind.

There is a signficant distinction in kind, however, between the US and the UK health care systems with respect to who provides the health insurance. In the UK, it's government provided via a single-payer with (rare) private supplements. In the US, it's almost all private (save for the poor and elderly).

Anyhoo, I don't think that you're really focusing on my point. Perhaps beer will help. The next time I'm in NY .....

Thanks for the link, Nate.

Turb, I don't know what you want me to agree with. Your point seems to be that the Democratic leadership is not pushing a single-payer (or government run) system. And it's not! Indeed, that's the premise of my post! So, since I agree with you, I don't know what else you want me to do.

(I do point out that some democrats and democratic activists want to go much farther .... including, in some cases, to abolishing private health insurance. But I don't take you to be disputing that point.)

NB: Yglesias sez, re his views: "— As an equally unrealistic idea, I think the National Health Service model from the UK has a lot going for it." That seems to be second-most preferred outcome.

There is a signficant distinction in kind, however, between the US and the UK health care systems with respect to who provides the health insurance. In the UK, it's government provided via a single-payer with (rare) private supplements. In the US, it's almost all private (save for the poor and elderly).

I guess, but the proposal on the table is closer to the French/Canadian model of private health care and public insurance options. That's the point. The UK does it different than other single payer systems, and no one is suggesting replicating the UK model. That is a fact.

Yes, no system is entirely pure. But, again, that only bolsters the argument that there is nothing to be afraid of. And that the scare tactics are hollow propaganda. There's already some blend here (there's even some government provided insurance in fact).

The exclamation points, and frustration, stems from what seems like pedantry in pursuit of a lawyer's case building rather than a productive discussion. But maybe you see it that way too from me.

von, I do dispute that point. You have not given an example yet.

But, even if it were the point, what difference does it make? None whatsoever.

And yes, there is a difference in kind as long as you drop out the VA. Or, to take your side for just a second, the difference in degree is immense to the point of basically being a difference in kind.

I was the lead in my Senior class play. By your argument, there is no difference in kind of actor between me and Anthony Hopkins. Technically you would be correct, that there is only a difference in degree.

But this is a case were technically is irrelevant.

it's a matter of degree -- not kind

Under government-run health care, the doctors are government employees and the hospitals are owned by the government. How on earth is that merely a difference of degree?

Turb, I don't know what you want me to agree with. Your point seems to be that the Democratic leadership is not pushing a single-payer (or government run) system. And it's not! Indeed, that's the premise of my post! So, since I agree with you, I don't know what else you want me to do.

von, I read your post as claiming that the Dems will try to create a single payer system in the US even though they are not publicly talking about this plan. Now, even though Dem leaders are not talking about single payer, if they really want single payer as a group, then there must be some evidence of that. Like, maybe they've given speeches in the past. Or put a plan in the platform. Or written books where they advocated single payer. Or gave interviews. Or something. But if you can't point to anything that happened in the real world, then you can't really say that the Dem leadership (as a whole) wants single payer.

This seems very simple to me, so perhaps I'm confused. You're asserting that Dems have a sekrit plan to push through single payer. Either there is real evidence to support that belief or you're a nutty conspiracy theorist. If you're really saying that lots of people (not you) believe this, then either those people have evidence or they're conspiracy theorists. But if no one can provide serious evidence, then this discussion is pointless.
(I do point out that some democrats and democratic activists want to go much farther .... including, in some cases, to abolishing private health insurance. But I don't take you to be disputing that point.)

Since I've explicitly conceded that point twice, yeah, I'm not disputing it. But I don't see why the existence of individuals who support single payer tells us anything about the likelihood of the party leaders pushing single payer through congress. I mean, lots of Dems were against the war in Iraq, but lots of Dem leaders advocated for it and lots of Dem congressfolk voted for it. Right?

Von: "Your point seems to be that the Democratic leadership is not pushing a single-payer (or government run) system. And it's not! Indeed, that's the premise of my post!"

Von's actual post: "In fact, the Democratic Party's health care plans are being driven by people who want a government takeover of health care."

But there's no contradiction here!

"So, since I agree with you, I don't know what else you want me to do."

I'd suggest writing a post that actually says, and doesn't hedge, that "the Democratic leadership is not pushing a single-payer (or government run) system."

"So if we make four leaps of assumptions, then we have something to worry about. "

Hmmm, apparently in your world Gary, politicians nearly always say what they mean, and the opinions of Democrats other than the top leadership don't mean anything?

It is fascinating what counts as *leaps* of assumptions...

I'm quoting huge portions of this thread next time I hear that we can't ban partial birth abortions because scary pro-lifers really want to ban embryo abortions. (Compare numbers of Republican 'leaders' who want to ban first trimester abortions to number of Democratic 'leaders' who want single payer...)

Man, I wish we had a Democratic party like von and Sebastian think we do, where the party activists ran things and the politicians were responsive to the desires of their constituents, rather than the one we've got.

Compare numbers of Republican 'leaders' who want to ban first trimester abortions to number of Democratic 'leaders' who want single payer...

Who are these Dem leaders and why do you think they want single payer? This is not a hard question. And yet I keep asking without seeing any answers.

Sure, Nate, but at least Democratic politicians always say what they mean...

But it's equally true that some elected Democratic proponents of health care reform have suggested that private insurance should be outlawed. For instance, Rep. Anthony Weiner (D-NY).

Wow, OK, that Hot Air link . . . first of all, it completely misrepresents the context of Weiner's comments to Scarborough, which arose in the context of Weiner pointing out that many of these disruptive and mendacious town hall jacktards are being manipulated and lied to in the service of protecting insurance company profits rather than improving health care.

That's what prompted Weiner to ask why the concern of opponents is centered on insurance profits, and what exactly it is that insurance companies bring to the provision of health care that's so worth protecting.

Second of all, Ed Morrissey is clearly retarded, when he gets to this:

Of course health care is a commodity. People have to produce the goods and services that comprise the health-care industry, which means that the supplies are finite and they expect to get compensated for their work. That makes it a commodity, regardless of Weiner’s socialist rhetoric. Anything with a cost is a commodity, by definition.

Anyone who doesn’t understand that much about economics has no business creating policy.

(Bolding original to Morrissey.) He's got a lot of balls here accusing other people of not understanding economics, because I can assure him that everything with a cost is NOT a commodity by definition.

You work with corporate clients, von. Next time you meet with a CFO or general counsel, conference up Ed Morrissey and ask your client if, next time his company has to publish its annual report and furnish its 10-K to the SEC, if he's OK with dumping their current financial printer for Joe's Law Shack & Disclosure Services up the street. Which, if financial printing and SEC fulfillment-- which have costs -- are a commodity, he should be perfectly willing to do.

Or ask ol' Ed if he's willing to trade in whatever he drives for a 1982 Buick LeSabre. I mean, cars cost something, so they must be commodities, right?

What about the untrue things many people believe about the current health-care proposals according to the polls? What role has Matt Yglesias played in those believes by stating his personal preferences regarding health-care reform, and how large is that role in comparison to the roles played by Palin, Limbaugh, Coulter, Malkin, Beck, Hannity in spreading misinformation? Should Matt Ygelsias not state his personal preferences for fear that some number of people might be more likely to believe Palin, Limbaugh, Coulter, Malkin, Beck, Hannity?

Hmmm, apparently in your world Gary, politicians nearly always say what they mean, and the opinions of Democrats other than the top leadership don't mean anything?

Couldn't we say this about almost any issue where there are varying opinions on one side or the other? Wouldn't it be easier if we stuck to the stuff actually in writing? If you think current proposals are the camel's nose, make the case based on the content of the current proposals, not some universally applicable generality about the nature of politics and politicians and human beings and human nature and psychology and honesty and intentions and blah, blah, blah, blah, blah....

I mean, if something is a commodity, then there's a futures market in it. Can Ed Morrissey quote me the spot price in arthroscopic knee surgery and whether he expects it to go up or down next week? My mom's getting it, so I might want to short some options.

at least Democratic politicians always say what they mean...

What exactly are you saying here Seb? It seems to me that you're saying that

(1) there exists a secret Democratic party conspiracy to create a single payer system in the US, and

(2) that conspiracy counts as its members the President, a majority of Representatives and Senators and Dem party leaders, and

(3) the conspiracy members have remained silent about their goals and never written about them in the books, mentioned them in their speeches, added them to the party platform or done ANYTHING at all to reveal to the outside world their true goal.

Is that true?

Sure, Nate, but at least Democratic politicians always say what they mean...

And this means what? That single-payer is in the current proposals? That, although not in the current proposals, somehow will happen by itself because of what's in the current proposals? That the current proposals prevent future debate on single-payer and give Democrats free reign over future health-care proposals? WTF are we talking about??? There are actual written pieces of legislation being proposed and we're going to talk about what might or might not be in some people's heads?

Sebastian: See above for my admission of our secret liberal plots.

American government works differently, society is different, culture is different so why would anyone assume the healthcare system that works somewhere else would work here?

Posted by: Marty | August 20, 2009 at 02:33 PM

I guess this is what is called American exceptionalism at work. In reality, US and Canada are culturally so close that most foreigners can't tell the difference. Australia (single payer)and New Zealand(mostly government run) are a little different, but not by much. Some people indeed argue that that the USA, the UK, NZ, Australia and Canada together comprise a single culture-the Anglosphere.

http://en.wikipedia.org/wiki/Anglosphere


Thats a little controversial, though.
Let's just say that culture should not be an argument against the USA adopting universal health insurance

Apologies to Shygetz, but the more I read the back-and-forth here and elsewhere, the more I think the healthcare reform we wind up with will be something "uniquely American."

You can put a fig leaf over the camel's nose and secrete your death squads inside the Trojan Horse before the cart, but never let it be said that I say it's spinach, and to hell with it.

Ummm it isn't secret that many Democrats, including Senators and House of Representative members would like single payer. They say so, and in the past have said so.

And we're getting forest for the trees here. I have other problems with the House bill (assuming that is the one we are talking about, which isn't at all clear). The camel's nose issue isn't my big objection.

The camel's nose issue is about how your average your more average voter sees things. The question in THIS post was why Democrats are having so much trouble with the idea that they are for single payer when this bill (if we are talking about a particular bill, which is not clear) is not.

The answer is that many important Democrats in the past have talked about single payer (or in some cases actual government run) health care systems as if they would be a good idea. The VA is often brought up as a potential model in such discussions, and it is in fact government run health care. The long and the short of it is that your average voter associates—and rightly so—Democrats with single payer systems or systems with even more government ownership.

The average voter does NOT read a bill that has thousands of pages. He lives on the impressions he has built over the years. Those impressions—even among non-Republicans—rightly note that Democrats have long been associated with wanting health care systems that are at least single payer.

That makes it very easy to insinuate that this particular bill (which none of you have read either) might have really be a first step towards the Democrat's ultimate goal of single payer.

Now this could be counteracted by clear statements from high level Democrats repudiating single payer (not just in this bill, but as an idea to work from) along with statements about why we should not want it. But that will not ever happen. Why is that? Because you actually want it, perhaps? I am not sure, but that is definitely the impression.

We also seem to be getting bogged down in a control/ownership distinction. Government control of something does not necessarily imply that it is technically owned by the government. Just ask people who own Lake Tahoe property.

Be honest with yourself. Are you really imagining that the majority of the savings you believe that single payer offers will come purely through administrative streamlining? Really? Because I would have sworn that I’ve seen hundreds of words over dozens of comments over multiples of years across many commenters on this blog suggesting that it will come through the increased market power of a single payer. And that is about controlling medical care, NOT just technically paying for it.

Or look at it another way. When you say that an insurance company is denying care, you really just mean that it is refusing to pay, right? No insurance company actually sends thugs to your hospital to keep the doctor from performing a surgery they don’t like, right? And that is controlling the available care to a large extent? Right?

Sure if you're rich you can avoid that, but generally your insurance company is controlling your care, right?

Be honest with yourself. Are you really imagining that the majority of the savings you believe that single payer offers will come purely through administrative streamlining? Really? Because I would have sworn that I’ve seen hundreds of words over dozens of comments over multiples of years across many commenters on this blog suggesting that it will come through the increased market power of a single payer. And that is about controlling medical care, NOT just technically paying for it.

Being honest means admitting that single payer is not a magic bullet for costs. It will control some by increasing leverage vis-a-vis drug companies, clearing up the byzantine record keeping system necessitated by having dozens of insurance forms, use technology to improve same, and a few other niceties.

But in the end, we'll have to think of cutting costs in other ways, including, perhaps, revamping our pay-for-procedure not outcome approach. And there are two imperatives, ensuring coverage for all Americans and lowering costs. Single payer does real well at the former, and has some advantages for the latter.

Private insurance, on the other hand, offers nothing but an additional charge as a middleman.

But even if single payer does not pay for a given procedure, it's not controlling health care. As you said, people with means can afford it anyway. Cosmetic surgery, for example, will still largely be an out of pocket endeavor.

The camel's nose issue is about how your average your more average voter sees things.

I'd like to reiterate this point, since von didn't address it before: the poll he cites does not show a concern about camel noses. It shows a misunderstanding about what is contained in the current bill.
Pretending that these concerns reflect a "camels nose" concern is covering for the people who have intentionally misled the public about the actual debates and proposals occurring in Washington.

I don't know of any evidence that the general public is concerned about future proposals, just evidence that they're being lied to.

Ummm it isn't secret that many Democrats, including Senators and House of Representative members would like single payer. They say so, and in the past have said so.

Can you tell me which Dem party leaders have said so? As in, which party leaders have not only said that "single payer systems have good results in other countries" but "I'd like to see single payer in the US"? Can you name names?

The answer is that many important Democrats in the past have talked about single payer (or in some cases actual government run) health care systems as if they would be a good idea.

Name them please.

The VA is often brought up as a potential model in such discussions, and it is in fact government run health care.

No, the VA is often brought up to illustrate problems in the current system, not necessarily as a model to replace the whole thing. After all, it is much easier to force healthcare providers to use open standards based electronic medical records than it is to convert the entire health care sector into a single payer system.

The long and the short of it is that your average voter associates—and rightly so—Democrats with single payer systems or systems with even more government ownership.

Cite please? And did the average voter do this before the tea baggers and their friends in the media went hog wild with their lies?

Now this could be counteracted by clear statements from high level Democrats repudiating single payer (not just in this bill, but as an idea to work from) along with statements about why we should not want it. But that will not ever happen. Why is that? Because you actually want it, perhaps? I am not sure, but that is definitely the impression.

I guess this never happened:

What are not legitimate concerns are those being put forward claiming a public option is somehow a Trojan horse for a single-payer system. I’ll be honest. There are countries where a single-payer system may be working. But I believe — and I’ve even taken some flak from members of my own party for this belief — that it is important for us to build on our traditions here in the United States. So, when you hear the naysayers claim that I’m trying to bring about government-run health care, know this — they are not telling the truth.

That's something that both von and Sebastian haven't answered yet, what exactly DOES the giant health insurance sector actually DO that makes it so worthy of protection from government competition? How many grandmas does private insurance kill?

And if it turns out that the government can kill more grandmas and cheaper than the private sector, and everyone ended up turning to the government for their grandma killing needs, would that be evil communist grandma killing, or red blooded capitalist grandma killing?

"Now this could be counteracted by clear statements from high level Democrats repudiating single payer (not just in this bill, but as an idea to work from) along with statements about why we should not want it. But that will not ever happen."

This statement turns out to be extremely untrue. How many cites would you like?

von, I do dispute that point. You have not given an example yet.

I've lost track of which point you're dispute, John.

And yes, there is a difference in kind as long as you drop out the VA.

That's not true: something like 2/3rds of US hospitals are government run. The New York Hospitals that I cited above, for example, were created by and are run by the government of New York. There is a difference in that, with the notable exception of the VA, these public hospitals are run by the states .... which is why, by the bye, I was pointing out the "centrality" of the NHS as a distinction from the US system way, way, upthread.

von, I read your post as claiming that the Dems will try to create a single payer system in the US even though they are not publicly talking about this plan. Now, even though Dem leaders are not talking about single payer, if they really want single payer as a group, then there must be some evidence of that. Like, maybe they've given speeches in the past. Or put a plan in the platform. Or written books where they advocated single payer. Or gave interviews. Or something. But if you can't point to anything that happened in the real world, then you can't really say that the Dem leadership (as a whole) wants single payer.

My argument is much more Yglesias-specific. Yglesias makes a number of assertions how voters are completely crazy for thinking the Democratic plan is to do x, y, and z but then goes on to say how he'd really prefer x, y, and z and calls the Obama approach an "incrementalist" approach .... presumably towards a system that includes x, y, and z. That strikes me as a really silly on his part. Put it this way, if I tell you that I want to destroy social security and then provide a "incrementalist" plan to reform social security that doesn't actually destroy social security but takes some steps in reducing social security's reach, would you be "crazy" to wonder if social security destruction wasn't part of the plan?

Now, it's not just Yglesias who has this disconnect: as Yglesias notes in the linked posts, a lot of the loudest voices are just like him.

You're right that virtually all leading Democrats aren't on board with this view, but you wouldn't expect them to be. You would, however, expect that they would be influenced by their constituents and some cynical types might think that they may share some/all of the broader, activist agenda even if they don't voice it publicly for political reasons.

For the vast majority of folks and the vast majority of procedures, government-run* health insurance and government-run health care are functionally identical.

I have no idea WTF this statement means or how to make sense of it in anything resembling the real world.

I'm not asking you to unpack it, because I doubt that can be done in any useful or sensible way. Why waste both our our time?

I'm just saying it makes no freaking sense, at all.

Having said that, I'd assert that this should not be necessary: "Now this could be counteracted by clear statements from high level Democrats repudiating single payer (not just in this bill, but as an idea to work from) along with statements about why we should not want it."

All that's necessary are "clear statements from high level Democrats repudiating single payer in this bill," and then it's up to you to demonstrate that, in fact, passing this bill will lead -- somehow -- to single-payer, and to explain how that will work.

I've already asked you for a timeline on when you expect such a change to single-payer will be proposed as a bill with a chance of passage, and I'd like to know when you think it is we should start having realistic reactions to that possibility. Thanks.

Sorry, not true. Here was the final (?) Republican proposal regarding GROW Accounts. Note that these were opt-in accounts and that did not divert SS money.

It would've diverted SS surpluses into private accounts. That strangles SS, since it's paid into by current workers. The surplus was created to pay for the Boomers' retirement, take that money away and SS cannot pay for the Boomers without becoming a huge liability on the balance sheet in the near future. Once we reached that point, the bill wouldn't matter anyway, there would be no SS surplus to distribute. All it will have done is sequester money away from the Boomers' retirement and force us to borrow to meet their SS payments.
In some long, long run, after the Boomers are dead, maybe this puts us on different footing (we will have borrowed a bunch of money and would have changed SS from 'pay as you go' to something more like a retirement account.
Much more likely, it screws SS long before we get to that point.

But it's all irrelevant- you must admit that Dem objections such as mine, even if you feel they're unfounded, are based on the actual bill and our perceived consequences of that bill. Even, if you like, our misperceived consequences. But *not* on the idea that there was some future bill that we had to stop by stopping this bill which we found unobjectionable on its own.

"You would, however, expect that they would be influenced by their constituents and some cynical types might think that they may share some/all of the broader, activist agenda even if they don't voice it publicly for political reasons."

Oh, how we wish. Oh how we wish.

"Are you really imagining that the majority of the savings you believe that single payer offers will come purely through administrative streamlining?"

No, I believe we also have to change the incentives offered to doctors and medical institutions so that they aren't incentivized to increase costs, per Atul Gawande, as I've written here more than a dozen times, including directly asking you what you thought many many many times.

I've further stated that I believe the changes to the Medicare Payment Advisory Commission can be very helpful.

Also, are we positing
A) that politicians never say one thing and mean another

I would rather this assumption than the one where von gets his camel to put his choice of words in their mouths.
I think a dose of political reality is also in order- nothing like single-payer will pass this time around, and this set of reforms will dampen enthusiasm for reforms for the immediate future. If the camel is coming into the tent, it won't be for a while, and it'll be because the public wants him in based on the results of the current reforms.
Which, IMO, is the real fear here.

Once you have a public plan -- no matter how small -- it becomes easier to expand the public plan.

If it works and it's popular, yeah. If it doesn't work, I don't see how expanding an unpopular program will be a political winner at some point in the future.
Again, I think the concern is that the camel is going to be *invited* in, because we will *like* it.

First of all, the more people covered, the lower the costs overall. That has been pointed out several times.

Secondly, single payer increases providers' incomes while at the same time lowering over all cost. Right now, much of the reason for higher charges by providers is that they have to write off an extremely large amount of their costs. That is why many of their contracts with insurance companies are 150% of what Medicare pays and why their billed charges are 3 to 4 times what Medicare pays.

Although I could make a very good argument for increasing the Medicare level of reimbursement, and in a single payer system would definitely argue for it, it is not low Medicare reimbursement taht is driving the cost.

Rather it is insurances low reimbursements for out of network providers, both in terms of the draconian Usual and Customary repricing they do as well as the lower percent level of reimbursement.

The other factor is high administrative costs for providers to collect reimbursement from patients and insurance companies post provision of services.

With a single payer system, with a pricing such as Medicare has (which is based upon specialty and geographic area) and with almost universal coverage (thus insuring some payment for services where right now many providers see nothing)the overall cost would decrease.

This doesn't even take into account the reduction of high cost care which takes place due to people putting off care because they can't pay.

People talk about the administrative savings on the payers side, but neglect the adminsitrative costs on the providers side having to deal with multiple payers, trying to keep their policies and requirements correct, maintaining systems to make sure payments are accurate, etc.

In 2007 it was estimated that providersz spent 100 billion dollars just managing the submission of claims and had over 60 billion dollars in bad debt.

One thing most providers will tell you about Medicare is that they don't have to jump through hoops. They will also tell you that reimbursement from Medicare is quicker and more accurate than through private insurers.

So yes, I want single payer, but the fact is we aren't going to get it for a while.

BTW, Obama has declared single payer off the table and when asked specifically about the Canadian system said that that system works fine for Canada but wouldn't work here.

I may disagree with that assessment, but you can't a much higher Democrat that has said single payer is not a goal.

Eric, "But in the end, we'll have to think of cutting costs in other ways, including, perhaps, revamping our pay-for-procedure not outcome approach."

When you say "we'll have to think of", in a single payer system, don't you mean that the government will decide?

Russell, "For the vast majority of folks and the vast majority of procedures, government-run* health insurance and government-run health care are functionally identical.

I have no idea WTF this statement means or how to make sense of it in anything resembling the real world."

When an insurance company denies coverage for a procedure, for MOST people, that means that they aren't likely to get the procedure unless they are really rich right? In that case the difference between controlling *payment* and controlling medical *care* is very small.

Are you really imagining that the majority of the savings you believe that single payer offers will come purely through administrative streamlining?

Medicare overhead is, depending on who's doing the estimating, somewhere between 2 and 5.5%.

Private insurance is, ditto, somewhere between 15 and 25%.

That's a lot of daylight.

Because I would have sworn that I’ve seen hundreds of words over dozens of comments over multiples of years across many commenters on this blog suggesting that it will come through the increased market power of a single payer. And that is about controlling medical care, NOT just technically paying for it.

In what meaningful way does, frex, Medicare limit access to actual medical care in ways that private insurance does not?

What can I, with my Harvard Pilgrim HMO, get that a Medicare insured cannot?

In concrete, real world terms, how do any of the existing public health insurance programs "control medical care" in detrimental ways as compared to any of the non-C-level-executive private plans?

To be honest, we're all more or less in dancing-on-the-heads-of-pins territory. Nothing approaching anything we're discussing here is likely to happen anytime soon. Probably not in this generation.

But it's fun to talk about, isn't it?

"von, I do dispute that point. You have not given an example yet.

I've lost track of which point you're dispute, John."

This point: "I do point out that some democrats and democratic activists want to go much farther .... including, in some cases, to abolishing private health insurance. But I don't take you to be disputing that point.)"

You haven't given an example of that (and don't point back to that link because nowhere does he say he wants to abolish private insurance).

And would you provide a cite regarding the 2/3 of hospitals are privately run claim please. (Again, taking out of the equation VA hospitals for obvious reason, although even with VA hospitals I doubt it would come anyway near that level.)

My argument is much more Yglesias-specific. Yglesias makes a number of assertions how voters are completely crazy for thinking the Democratic plan is to do x, y, and z but then goes on to say how he'd really prefer x, y, and z and calls the Obama approach an "incrementalist" approach .... presumably towards a system that includes x, y, and z.

Yglesias has a tiny audience. 99.99% of the people in this country have no exposure to Matt Yglesias. He does not have a TV show. He does not have a radio show. He does not have a column at a big newspaper.

Now, it's not just Yglesias who has this disconnect: as Yglesias notes in the linked posts, a lot of the loudest voices are just like him.

Who? Name them please.

You're right that virtually all leading Democrats aren't on board with this view, but you wouldn't expect them to be. You would, however, expect that they would be influenced by their constituents and some cynical types might think that they may share some/all of the broader, activist agenda even if they don't voice it publicly for political reasons.

Should I expect them to be as influenced by their constituents as they were when it came to the Iraq War? Or telecomm immunity? Or impeaching Bush?

The naivety on display here is...shocking. It is like I'm talking to a young child.

Just an aside, to illustrate the quality of the debate.

From here we have this:

If we exclude taxes and profits, as well as sales commissions, then the total administrative costs decrease to 8.9% overall and 8.0% for large group policies. I do not agree that commissions should be deducted from this this figure but profits and taxes certainly should. Medicare does not pay taxes and does not make a profit so any fair comparison should exclude these items.

So, if we exclude the fact that private insurers take a profit, the overhead cost difference isn't that large.

Really, you have to just laugh at this stuff or you'll go f**king nuts.

I'm quoting huge portions of this thread next time I hear that we can't ban partial birth abortions because scary pro-lifers really want to ban embryo abortions.

Again you are making the opposite point you think you are making. People who support reproductive freedom are suspicious of bans on partial-birth abortion because they fail at their stated intention--protecting fetal life, because they only force doctors to use other procedures, possibly more dangerous to the woman carrying the fetus--which means we have to look elsewhere for their real intention.

It isn't a slippery-slope argument when you point out that, because a proposal fails at its stated objective (or doesn't even address it), the real reason for it must lie elsewhere. It's an argument you may disagree with, but formally it doesn't invoke the slippery slope at all.

von,
To be clear, I believe that your original post contained a misstatement of fact:
It's also crazy for Yglesias to blame "lies" for the fact that most voters have reasoned, correctly, that some of the louder folks pushing Democratic health care want "coverage for illegals," a "government takeover" of health care, and "tax-payer funded abortions,"* and to fear to some or all of these proposals are coming -- if not this year, then soon.

That is not what the poll showed and that is not what Yglesias argued. He is blaming "lies" because people have been lied to, as he demonstrated.

I would appreciate you tackling this point- it seems that your entire post is based on this inaccuracy, in 1)misrepresenting Yglesias's position, 2)creating support for your 'camels nose' theory where none exists and 3)implicitly pardoning those who have lied to the public about the actual contents of the current proposals.

When an insurance company denies coverage for a procedure, for MOST people, that means that they aren't likely to get the procedure unless they are really rich right?

And do, in fact, the public providers of health insurance -- Medicare, Medicaid, any of the state systems -- deny access to treatment in any significant way more than private insurers do?

Or is this another theoretical "what if"?

You would, however, expect that they would be influenced by their constituents and some cynical types might think that they may share some/all of the broader, activist agenda even if they don't voice it publicly for political reasons.

As russell said, "you" might expect it, but it would fly in the face of the evidence. Everything we have seen in Washington over the past several weeks makes it patently clear that no bill will be brought forward that threatens the profits of the health insurance industry. The public option is dead and the Progressive Caucus is being told to go sit in the corner with their hands folded and wait to be called upon. Greenwald is 100% right on this.

So, for the camel's nose argument to be compelling, you'd have to not just posit a slippery slope--you'd have to posit a wholesale shift in the ideological moorings of the leadership of the Democratic Party. Not "some voices," not this blogger here or that congressman over there, but the leadership. Show me how we go from a Democratic Party that panders to and then ignores the wishes of its progressive wing to one that acts on those wishes. Show me how we get a Democratic Party that is no longer beholden to money from insurance and pharmaceutical companies. Connect the dots. Show your work.

Medicare does not pay taxes and does not make a profit so any fair comparison should exclude these items.

A fair comparison of which program is more efficient, perhaps. But for a comparison of which program costs less, I would think we would want to include all of the costs that each incurs, regardless of whether it is an indictment of that program's efficiency.

When an insurance company denies coverage for a procedure, for MOST people, that means that they aren't likely to get the procedure unless they are really rich right?

And do, in fact, the public providers of health insurance -- Medicare, Medicaid, any of the state systems -- deny access to treatment in any significant way more than private insurers do?

Or is this another theoretical "what if"?

What does more or less have to do with the question? My point is that we think insurance denials as controlling health care just like we OUGHT TO think of a government plan doing the same thing as controlling health care.

You are correct that Medicare does it much like an insurance company, *which is precisely why the alleged payer/control dichotomy breaks down for most people in real life*.

My point isn't that Medicare is worse, or that the single payer will be worse, but that it is exercising what you readily admit is control in the insurance case.

So Eric's whole--how dare you talk about control when it is really just single payer thing--breaks down.

Well, I have a different question. von argues that the fact that many Democrats want a public option is the key to why the health care package seems to be in trouble. Yet I cannot reconcile that claim with the data I have. Such as:

Survey USA national poll sponsored by MoveOn.org Political Action, 1200 adults surveyed August 19, 2009:

Question: In any health care proposal, how important do you feel it is to give people a choice of both a public plan administered by the federal government and a private plan for their health insurance--extremely important, quite important, not that important, or not at all important?

Extremely important....58%
Quite important........19%
Not that important..... 7%
Not at all important...15%
Not sure............... 1%

That poll is interesting but has a pretty serious amibiguity that you don't see if you have been following the debate closely.

I wonder how many people saw "extremely important" as safeguarding private plans...

A fair comparison of which program is more efficient, perhaps.

Yes, and even at that the private providers do worse. When you factor in the costs that come along with -- including profit, commissions, etc -- the net cost is multiples of the net cost of Medicare.

My point isn't that Medicare is worse, or that the single payer will be worse, but that it is exercising what you readily admit is control in the insurance case.

Fair enough, and in that context I'd like to offer an apology to von for dismissing his comment as I did upthread.

All of that said -- the point I'd like to make is this:

The "controlling care" argument against a single payer, or any public payer, really only seems relevant to me if it ends up making care less accessible than it would otherwise be.

I don't see any evidence for that, and in fact in many cases the public payers that currently exist in this country are (to my knowledge) less restrictive than many private providers.

If there is factual evidence to the contrary I'd be interested to know about it.

What russell said.

"The "controlling care" argument against a single payer, or any public payer, really only seems relevant to me if it ends up making care less accessible than it would otherwise be."

Well that is where I think public payer vs. single payer is a huge difference. In single payer you extinguish most of the other payers and then you do what you want. The effect of the control happens AFTER the government gets rid of all the competitors. Then we have to trust it to get everything right.

With a public payer as an option, the government control takes place while there are still competitors, so we can weigh the savings versus the costs. They public and private plans provide a check on each other. That is why it is important that we don't have the government 'cheat' (say by threatening pharma companies with breaking their patents unless they give just the government (but not private insurers) a break on price. If things like that happen (which really are just abuses of power) then we can't see the real cost of the choices being made. That is a huge difference from a fiat single payer system.

And that is where controlling care is an important issue. Single payer destroys options first, then tells us what it intends to do to control costs. Multiple payer lets us see what controlling costs will look like, and we can decide if we like it while other options are still readily available.

I have been wondering if part of the cost issue we have is a "free rider" problem, where the US healthcare system is paying for a lot of the development of new techniques and medicines, subsidizing other developed countries.

While I recognize that many developments come from Europe, those developments still get patented and sold in the US at higher rates than other nations pay for them, presumably making the risk of R and D more palatable for the non-profit systems.

It seems similar to the cheaper meds you can get in Canada: Big Pharma can sell to Canada at a reasonable profit over manufacturing costs, since the US market is covering the cost of development.

substantial numbers of Democrats definitionally have no influence on Democratic leadership?

As was pointed out above, where the heck have you been the last 8 years? Show one point where "substatial numbers of Democrats" influenced the leadership on anything? In addition to the above, let's add the bankruptcy bill and regulation of the credit card companies.

Sheesh.

=============

Uncle Kvetch, I think that you've either misread or miscontrued my point. But thanks for playing.

Funny how everyone but Sebastian has done so, isn't it?

============

I wonder how many people saw "extremely important" as safeguarding private plans...

Since the private plans ARE safeguaded under every single option I've heard, I'd say the number is "N/A".

"Since the private plans ARE safeguaded under every single option I've heard, I'd say the number is "N/A"."

Isn't a big part of the storyline that lots of people are getting confused by Republican lies?

With a public payer as an option, the government control takes place while there are still competitors, so we can weigh the savings versus the costs. They public and private plans provide a check on each other.

You know, I'm fine with that. IMVHO, for this country a mixed public and private solution is probably going to be the best fit.

Whatever works, where the definition of "works" in this context is "people who don't have jobs or a lot of money can go to the doctor".

The problem is that we are highly unlikely to get even that far, because the bogeyman of Government Takeover Of The Whole Health System looms over every discussion of even more modest proposals.

Not only is it not on the table now, it has never been hinted at by anyone remotely in a position to set policy.

Von cites Yglesias as someone who looks forward to government-controlled health care. The *most radical proposal* that Yglesias has talked about is a public single-payer health insurance plan.

I get the argument about "funding equals control", although I think it's overstated. The purse is not the only lever involved, and the folks who would control the purse in a public approach are beholden to the end users in ways that simply don't apply in the private model.

But even a public payer as an *option* is likely to not occur, because it's the First Step Down The Slippery Slope To Socialism.

Public funding coexists with private actors in more parts of our economy than I can shake a stick at. In the overwhelming majority of situations, it does so effectively.

But calling for even a public *option* for health care is enough to elicit comparisons to Hitler and Stalin. Or, more modestly, here at ObWi, claims of secret (or not so secret) agendas to take over the entire health infrastructure of the nation.

Meanwhile, 15% of the people in this country -- 1 out of 7, 45 million people -- have no health insurance at all. Millions more have insurance that will require them to spend thousands of dollars out of pocket before anything they need is covered. Virtually anyone who is under the age of 65 and not in the military can lose whatever coverage they have immediately if they lose their job, and about a half million people a month fall in that category.

And you can stand up in public and say "Who cares, you can just go to the emergency room" and not be pelted with tomatoes and rotten fruit.

Seriously, sometimes I feel like just saying "screw it". This country is freaking insane.

The plain truth of the matter is that there is no credible chance of the health care industry in this country being taken over by the government. None. Not in a million f**king years.

That's fine with me, I'm not interested in having the government take over the health care industry. Neither is the government.

It's just a stupid, fear-mongering lie that's tossed out there to scare the sh*t out of people who don't know better, and who don't have the sense to find out.

So some kind of complex, ridiculous, festering turd of legislation will be coughed up by Congress, Obama will sign it, the 15% of folks who don't have coverage may slide down to, say, 12%. The insurance companies will find a way to make sh*tloads of money off of it, and everyone will declare victory and go home.

And some number of millions of people in this country will still not be able to go to the doctor.

That's my prediction. Anyone want to bet against it?

Thank you, Russell.

I have more, but who needs it?

Not me. I give up.

You know the scene in Batman (one of the earlier ones) with Jack Nicholsen as the Joker, when he has that ghastly smile surgically fixed to his face, or however it happens.

That's where I am right now.

Goverbnment sucks in America because Americans suck at government.

Cackle.

I had the surgery doen in France free of charge, suckers.

Rep Rick Boucher (one of the Blue Dogs, from Coal Country, VA) gave away their real worries, "I have a problem with this government option plan,” Boucher said. “I’m troubled that the government option plan could become very popular and if it became sufficiently popular it could begin to crowd out the other” private insurance companies." Here.

Because market competition is socialism now I guess?

"Well that is where I think public payer vs. single payer is a huge difference. In single payer you extinguish most of the other payers and then you do what you want."

Sebastian, respectfully, wtf are you talking about? Even in Britain, with the NHS, the country is full of independent-provider healthcare companies, private hospitals, and private doctors, all of whom you are free to do business with if you don't want to deal with the NHS.

Many decry this, but it's impossible to know anything about health care in Britain without being acquainted with these most basic of facts about it:

[...] The rich simply opt out of the system (the private health and care market covers about 20% of the population and grew by $200 million in 2005), while the poor and the disadvantaged have no choice.
Some favor and some oppose it, but it's a fact.

Many Britons aren't happy about aspects of increasing privatisation, but it's a fact.

We could also go through a list of single-payer countries, none of which have exerienced what you allege will happen.

In Canada, for instance, the country is full of private doctors and private medical facilities. Doctors get to choose how to work:

[...] A physician cannot charge a fee for a service that is higher than the negotiated rate — even to patients who are not covered by the publicly funded system — unless the physican opts out of billing the publicly funded system altogether.

[...]

Other areas of health care, such as dentistry and optometry, are wholly private.

[...]

Some 65% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers.[15] There are also large private entities that can buy priority access to medical services in Canada, such as WCB in BC.

Rereading von's initial post, btw, I think this is a bit rich: "Matt Yglesias writes perceptively on why Democratic health care reform is failing, but -- perhaps understandably -- doesn't see his own role...."

Matt has a significant role? We're personalizing it at that level? By this logic, should we blame you for your "role" in health care reform "failing" from the Democratic view (personally I think that, as usual, everyone is being considerably premature in judgment as yet)?

Seriously, sometimes I feel like just saying "screw it". This country is freaking insane.

Just now on the BBC they interviewed a woman in Mississippi who lost her health insurance when she lost her job, but doesn't want reform, because you'll have to stand in line, and the government will tell you what doctor you have to go to, and it "sounds like communism." And yeah, I had a "screw it" moment. Maybe this mockery of a "system" is all we, as a country, deserve.

Howard Dean beats the drum for a far more radical reform (and has written a book about it). But I can't say, whether he still counts as "leading Democrat".
---
I'd say give headbands with '#2' on them to all leading Republicans and their media allies and then send Samuel L. Jackson the list together with an Afro wig and a long katana.

Hartmut, Dean is beating the drum, through TV appearances and the Democracy for America group he founded, for the public option. How is that "a far more radical reform"?

"In Canada, for instance, the country is full of private doctors and private medical facilities. Doctors get to choose how to work: "

Sure, they can charge government rates for all patients or they can go out of business. The system supports very few purely private doctors, mostly in elective specialties.

The healthcare system is controlled by the government, I think it doesn't matter whether they can say "we aren't doing it" or "we aren't paying for it", for the vast majority of people those are the same answer.

And before we get in a big circular discussion I am fully aware that both insurance companies and Medicare do the same thing today. I am just clarifying that I believe there is little effective difference between single payer and single provider. (and, for Eric, I am not confused by the terms)

Supplemental insurance in Canada primarily covers dental, eyecare and drugs.

Sebastian:

My point is that we think insurance denials as controlling health care just like we OUGHT TO think of a government plan doing the same thing as controlling health care.

Have you ever personally dealt with an insurance denial, Sebastian? Do you realize that many companies routinely *and as a matter of policy* deny *everything* over a certain dollar amount, to "weed out" the people who don't submit a second (or third, or fourth) time? Do you know what "rescission" is? Are you aware that insurance company customer support agents get bonuses for denying claims, because every claim denied or delayed is money in the bank?

I can see how you'd get scared at the thought of a single, unavoidable government payer who acted the way insurance companies do: lying, cheating, stealing, and murdering, *and there's no way out*. But US experience with Medicare and the VA, and that of other countries, shows that this is unlikely to be a problem. The heartless rapacity of the insurance companies is the free market in action, capitalism in a nutshell -- an honestly non-capitalist system will not have to work that way.

Put it another way. Under our current system, many people become destitute because of major illness. The insurance companies have found that this is part of a good business model for them. How would you change that?

"Sure, they can charge government rates for all patients or they can go out of business."

Marty, please give a cite to support this claim. Why would they go out of business if they simply "opts out of billing the publicly funded system altogether"?

Why is it that I know hundreds of Canadians, and they all shudder at the thought of exchanging their health care system for ours, and ditto I know hundreds of Britons, all of whom unanimously feel the same way?

The healthcare system is controlled by the government, I think it doesn't matter whether they can say "we aren't doing it" or "we aren't paying for it", for the vast majority of people those are the same answer.

In Canada the public sector pays for 70% of health care, the private sector about 30%. The public sector is legally required to pay for all medically necessary care without copays or fees, so as you note, most of the private sector money is going to dental, eye care, drugs, and discretionary care like voluntary cosmetic surgery.

Cite. And yeah, it's wiki, but it's a pretty good precis of the relevant facts.

I recognize that control over the purse gives the government theoretical control over what care folks have access to. Just as control over the purse gives private health insurance that same control for folks who don't qualify for public programs in this country.

My question is: so what? Is anyone denied access to care in Canada because the government is paying for it? And if so, how does that compare to the level of access Americans have?

From the same cite, median wait times for an MRI in Canada is two weeks. I blew out my ACL a couple of years ago while building some wall, it took me more than two weeks to get an MRI on my knee.

Same cite, median wait times for a specialist in Canada is four weeks. I've seen specialists for ear nose & throat, GI, X-rays, physical therapy, etc etc. In my experience, four weeks is pretty normal here.

Same cite, median wait times for surgery is four weeks. Wait times for surgery here, including necessary, life-saving surgery, can easily be months.

So I don't see the point of the "the payer has control" argument. Of course the payer has control. The question is what the payer does with the control.

If you're wealthy enough to pay out of pocket, you can have whatever you want. Everybody else relies on insurance.

I don't see that private insurance is any more generous than any state-run program that I'm aware of.

You can cherry-pick and find particular cases where certain kinds of treatment are more readily available in one place or another, but overall I don't see much difference between the kinds of care available to insureds under state-run vs privately run insurance plans. At least in any nation comparable to the US.

We pay more, way more, and get average outcomes.

15% of the people here have no insurance at all, millions more have insurance requiring them to pay thousands out of pocket, and you can have health insurance in this country and still be bankrupted if you become seriously ill. It happens every freaking day.

None of that is true in any country remotely like the US. None. Only here.

We don't have publicly provided health care in this country because we have an ideological aversion to publicly provided services. As a result, 15% or more either pays out of pocket or goes without.

You tell me why that is a good thing.

I haven't read Dean's book but on the occasions that I heard him he made imo clear that the public option is the minimum acceptable but far inferior to single payer in his opinion.

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