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September 10, 2009

Comments

What's a public co-opt, and what does it have to do with health care legislation?

;)

5. It looks like the public option is dead. Public co-opts, anyone? (I'm fine with this but, again, what about House Democrats?)

This seems more like wishful thinking on your part than what was actually in the speech.

I haven't heard of anything in any of the current plans that controls costs better than a public option.

And Obama stated that he would not compromise on that principle.

So if there is nothing more effective than a public option for cost control in the insurance exchange, then why would it be dead?

First sentence, the link says "gives good speech". Typo?

It's not clear to me that the "public option" is dead. However, the type of public option that Obama outlined last night could easily be implemented as either a straight forward, government administered health insurance plan, or a non-profit, government seeded co-op. It's not clear it makes any difference at all. The major boundaries for either version are: 1) it's non-profit, 2) it's only available to people eligible to access the exchanges, 3) it's entirely funded through premiums, and 4) it will not go into effect for 4 years. He definitely left questions of how this new company, regardless of how it is implemented, will negotiate rates (based on Medicare or based on private insurers?). That's a significant question, but I'm guessing that Obama is working off of the philosophy that even if rates are based on the private market, it can still help control costs through economics of scale, enhanced competition in the insurance market, and low overhead. That's not really what was on progressives' wishlists, but it's certainly better than what we currently have.

If anything, after last night's speech, I think the public option is a shoo-in. Co-ops obviously will not achieve what the President is calling for.

+Regarding point number two, a study by the Congressional committes has found that the gold-plated plans are not union plans. A couple cities' teachers' and firemen's and policemen's plans come close, but aren't there. Most of the gold-plated plans are corporate plans for the upper middle management and above.

I have no problem with malpractice reform, but only in terms of limiting lawyer's fees, not capping actual settlements. What is interesting about malpractice insurance is that the rates have gone up and up and up while actual malpractice suits and settlements have stayed static or even dipped in some areas the past few years.

Yes, studies show some doctors practice defensive medicine, but the impact on actual health care costs is low. But even a 1% drop is significant.

First sentence, the link says "gives good speech". Typo?

Nahh. I give good law, Obama gives good speech, you give good comment. It's a continuation of the general Buffy-fi-cation of language.

Just want to push back on the idea that cost containment equals rationing.

Cost containment can be choosing less expensive among equally suitable treatment regimes. In other words, treatment selection based on value as well as outcome.

Cost containment can be emphasizing preventive care and general wellness.

Cost containment can be reducing waste and inefficiencies at a purely ops and/or paperwork level.

Conversely, rationing can be a means of allocating scarce resources, as opposed to managing cost, e.g. if there's only one liver available for transplant, who gets it?

A nit perhaps but in context IMO it's useful to observe the distinction.

It would be impossibly stupid to have a public option that people weren't allowed to choose, which I gather is Obama's plan at the moment. If a public option is available, no one should be banned from choosing it.

I just had a phonecall from someone who asked, curiously (aware I'd been following the debate more than he had) if I thought Obama was going to get healthcare reforms.

Not a chance, I said: too much pressure from the entrenched interests of the health insurance industry. Congress isn't going to vote to save the lives of 22,000 Americans a year when it's against the interests of their corporate donors: they'll come up with any story - such as the one Von has just spun in this post - to justify letting thousands of Americans die rather than instigate the kind of wholesale reform that you need.

Not a chance, I said: too much pressure from the entrenched interests of the health insurance industry. Congress isn't going to vote to save the lives of 22,000 Americans a year when it's against the interests of their corporate donors: they'll come up with any story - such as the one Von has just spun in this post - to justify letting thousands of Americans die rather than instigate the kind of wholesale reform that you need.

Jes, I always love it when folks who don't live in the US and have no experience with US health care offer their caricatures of the US health care system. It's almost as amusing as the caricatures of US cities, or crime, that I've been regaled with. (You mean that you actually walk around unarmed? And there aren't Robocop-style gunbattles on a daily basis?) I wouldn't purport to offer such a definitive opinion on UK health care, even though I have actually lived in the UK, experienced the UK system, and walked away favorably impressed.*

That said, what's your support for your claim that 22,000 Americans die a year? You can start by explaining whether you're asserting that the 22,000 Americans die because of lack of coverage, lack of treatment, bad doctors, swine flu, or untreated cases of the ricketts .... because it's just not clear what you mean by the figure (or whether the figure has meaning).

*As an American, I likely swooned over the accent -- making my judgment suspect.

The major boundaries for either version are: 1) it's non-profit

There's an old joke: "We're a non-profit company. Not on purpose; it just worked out that way."

"Non-profit" describes any number of major corporations whose C-level employees collect multi-million paychecks. It's easy to make your profit zero: all you have to do is make your payroll big enough.

An actual government agency selling health insurance to citizens would presumably pay government salaries to its employees. If it happens to turn a profit, I don't care.

So my criterion would not be "non-profit". It would be "government agency".

--TP

Non-profit private corporations also have a way of ending up being for-profit private corporations (demutualization etc).

As for the comments about Jes not knowing the US system - well, I do live in the US and have had extensive experience with the US healthcare system, and I think her characterization is accurate. By comparison to the UK system (which I have also had extensive experience with), the US system denies care to a significant number of people who need it, whether they're people dumped through rescission, or people who make too much money for Medicaid but not enough to pay for private insurance, or people with pre-existing conditions that make it impossible for them to buy private insurance. It is a fair comparison and the US comes off badly.

@ Tony P.: You're right - the important thing is to maintain low administrative costs. I'm assuming that for either a government run health insurance plan or a co-op could be chartered in such a way to mandate this. (though I admit that this might be naive)

I may be nitpicking language a bit too finely, but to me "rationing" of health care is stronger than "your health care provider refuses to pay for some procedures".

For example, we do not currently ration gasoline. That doesn't mean that I can have all the gas I want--it just means that I can buy as much gas as I can afford. Rationing would mean a cap on the amount of gas I am allowed to receive, regardless of how much money I have.

If we use the word consistently, rationing of health care would involve someone telling people that there are certain procedures that they may not have, no matter what insurance they carry or how much they are willing to pay.

Opponents of health care reform have deliberately taken advantage of ambiguity in the language to imply that limits on health care benefits ("rationing" in one sense) are actually limits on care ("rationing" in an entirely different sense).

Now, it's true that for most people, this is a distinction without a practical difference. It doesn't matter if I'm allowed to buy a supertanker of fuel if I can't afford it. There is, however, still a powerful psychological difference between "the government won't pay for this procedure" and "you are not allowed to have this procedure".

As such, I must disagree with you von: It is not honest to say that "cost containment" is "rationing", even when cost containment means not paying for some procedures.

I may be nitpicking language a bit too finely, but to me "rationing" of health care is stronger than "your health care provider refuses to pay for some procedures".

For example, we do not currently ration gasoline. That doesn't mean that I can have all the gas I want--it just means that I can buy as much gas as I can afford. Rationing would mean a cap on the amount of gas I am allowed to receive, regardless of how much money I have.

If we use the word consistently, rationing of health care would involve someone telling people that there are certain procedures that they may not have, no matter what insurance they carry or how much they are willing to pay.

I actually disagree with your first point: We absolutely do ration gasoline. We do so by price, which reflects not only the demand for gasoline but also the supply. It only seems that we're not "rationing" gasoline at the micro level: to you, it seems that the supply of gasoline is infinite, and hence you're restricted only by what you can afford. In fact, however, the supply of gasoline is finite and there are likely certain levels of gasoline that you simply cannot purchase for any price --- the price becomes effectively infinite.

Now, that's a difficult concept to grasp with respect to gasoline, but it's a lot clearer when it comes to health care. Consider specialist health care, e.g., an orthopedic surgeon. There are a certain number of orthopedic surgeons in the world and, because of payment nuances, there are even a fewer number of orthopedic surgeons who will take Medicare patients and a fewer still number of hours in those Medicare-accepting surgeon's work schedules. (That's because the vast majority of orthopedic surgeons either cannot afford or are unwilling to afford an all-Medicare practice). The supply of surgery is finite. It's plausible that a person on Medicare could run into a situation in which a noncritical treatment would not be available -- or would not be available in an acceptable or reasonable schedule -- because of this fact. The fact of the matter is such a situation will be more plausible in the future as the demand for healthcare grows.

Ultimately, we do ration healthcare today and we'll do more rationing in the future.

The supply of everything is finite.

The construct:

['cost containment' = 'rationing'] as typically employed in the current discussion of health care reform =

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

Aren't doctors a renewable resource? I seriously doubt we are anywhere near a reasonable limit on doctor production. I understand that we have to ration organs for transplant - there are only so many of those, and their availability isn't really something we control. However, the number of doctors is very different. We could easily have mroe primary care physicians - at some point, there was mention of having incentives to go into primary care in the reform bill.

why on earth would you want to cap fees in malpractice cases?they are the most costly and difficult cases to handle and statistically plaintiff's lose 80% of the time.such a suggestion would insure that a person with a meritorious case would not be able to find a lawyer.i know something about tort reform.i handled the challenge in illinois.[best v.taylor]tort reform is about benifits to insurance companies and other chamber of commerce types.before you tout tort reform read the best case and see what the illinois supreme court had to say.warning:it is 98 pages

von, woukld like to make a guess as to what percentage of orthopedic surgeons do not take Medicare patients. I doubt if it is more than one percent. However, there may be a few more who do not accept Medicare assignment, which means they bill the patient for the difference between what Medicare pays and their regular charge.

Nonetheless, unless the orthopedic surgeon specializes in, say, sports medicine, and only treats sports related injuries, the likelihood is that that surgeon will not only take a Medicare patient, but also accept the Medicare level of reimbursement.

By the way, since I am in the healthcare field and work closely with contracting physician practices, I do have some knowledge of the situation.

And there are some physicians who do basically cater to an all Medicare patient base. However, there are few of any stripe who cater to an all-Medicare practice, simply by the nature of the business.

Medicare has nothing to do with noncritical services not being available. That happens now to any number of people, even those with "good" insurance coverage. There is an area in Kansas where, in a 200 mile radius there is exactly one oncologist. Needless to say, one can not just walk into that office and see the doctor for noncritical care.

The question here is more of a doctor shortage than anything else, but primarily in the area fo primary care, and the bills before Congress attempt to deal with that.

Aren't doctors a renewable resource?

they're even recyclable! after death they can be used to train other doctors.

Von: Jes, I always love it when folks who don't live in the US and have no experience with US health care offer their caricatures of the US health care system.

Von, my worst experience with US health care was indeed at second hand: a few years ago, a close friend developed cancer. She had a job which gave her health insurance that covered her treatment, and she had a decent employer. But because she had cancer, she could not give up her job. She was in a developing relationship with a friend who lived far away - until she developed cancer, their plans were based on "which of us will move to be with the other?" but cancer took over: she had no choice but to stay with a decent employer and current health insurance. She died - and she might well have died anyway - but she died far from where she wanted to be and who she wanted to be with, because your sucky, Third World, second-rate, gimrack healthcare system gave her no other choice but to stick with her employer until death.

Let's not forget the other American friends who have blown my mind at times by talking of how they have to "stretch" their medication, because they can't afford to take the prescribed amount: or how they have felt a lump in a tender part of the body and are worried about it but can't go see a doctor right now because they won't be able to get time off work, and they can't afford to pay for the examination, let alone any recommended tests or treatment. And I sit there reading their posts or their e-mail - but their posts are worse, followed by understanding, sympathetic comments from other Americans about how scary it is when something goes wrong and you don't know if you can afford to get treated, while I just breathe deeply, trying to imagine what that must be like - having to worry, all the time, about the cost of healthcare.

Now, obviously, you have no friends who live in that kind of situation, or you just ignore them when they start to whining about how worried they are. But I do, and I can't.

The only American friend I have who has never expressed any worry about healthcare in her own country is a dear friend whose parents both come from very wealthy families.

No, Von. Plainly, I couldn't have any idea what your healthcare system is like.

That said, what's your support for your claim that 22,000 Americans die a year?

Stan Dorn, “Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on Mortality,” Urban Institute, 2008 (PDF), via the National Coalition on Healthcare

Now, that's a difficult concept to grasp with respect to gasoline, but it's a lot clearer when it comes to health care.

And yet, so many conservatives are so foggy about the clear fact that a national health service is by far the most efficient and effective way of delivering healthcare to everyone who needs it. Because the larger the population you have to work with, the easier it is to predict healthcare needs and thus deliver them. Which is why the NHS is so greatly superior to the US system.

I actually disagree with your first point: We absolutely do ration gasoline.

If we want to begin considering limited supply due to purely market forces as a form of rationing, I have no objection. I think it would be a useful and interesting lens.

Pro-market folks might object because it doesn't really reflect the normal meaning of rationing, which typically implies a deliberate and intentional allocation of resources for which there is more demand than supply.

The market model normally assumes those kinds of allocations happening through lots of individual decisions, taken in light of individual self-interest, rather than in a planned or deliberate manner.

The market model also assumes that demand will eventually drive up either supply or price (or both), which is also normally not part of what we mean by "rationing".

But it might be an interest concept to introduce into a market analysis.

Either way, I think what we were originally talking about was whether rationing was synonymous with cost containment.

I don't think that's been demonstrated by your gasoline analogy.

Jesurgislac is correct.

Jesurgislac is correct. OBAMA IS LYING! The US corporate health system kills at least 50.000 people per year. Obama could save those peoples lives if he pushed for single payer. Their are 60 VOTES IN THE SENATE. If Obama wanted single payer he could get it, but HE WOULD RATHER LET THOSE PEOPLE DIE THAN DISAPPOINT HIS CORPORATE OVERLORDS. We need a real president who will fight for people, not profits.

Hooboy.

THIS IS THE VERY DEFINITION OF FASCISM! I don't use the 'f' word lightly, but this is it. Fascism is not just about gas chambers and dictators with moustaches. FASCISM IS ABOUT USING STATE POWER TO PROTECT CORPORATE ECONOMIC INTERESTS AND COERCING CITIZENS INTO SUBMITTING TO CORPORATE RULE! This is exactly the economic system of Mussolini's Italy. Obama will not have the government provide health care to needy people even though HEALTH CARE IS A RIGHT NOT A PRIVILEGE. Instead he will force people to give money to corrupt corporate interests just to enjoy a basic right. OBAMA IS FASCIST!

yay! FASCISM! FASCISM! FASCISM!

it's even more true when you spell it in all-caps.

Hooboy, hooboy

no more red bulls for ricardo.

I can't recall which of our former trolls this reminds me of.

What is your definition of fascism. And please remember that fascism is not the same as NATIONAL SOCIALISM. Fascism does not have to be a racist ideology. PEOPLE THINK THAT OBAMA CANT BE FASCIST JUST BECAUSE HES BLACK! But its not true. Last nite he said he'd include provisions AUTOMATICALLY CUTTING HEALTH CARE FOR POOR PEOPLE if the insurance companies dont 'voluntarily' come up with 900 billion in savings. DO YOU REALLY THINK THE COMPANIES WILL PAY THE MONEY? No, it will come out of the pocket of workers who are coerced into half their paychecks to corporate insurance rackets.

FASCISM IS ABOUT USING STATE POWER TO PROTECT CORPORATE ECONOMIC INTERESTS AND COERCING CITIZENS INTO SUBMITTING TO CORPORATE RULE!

In that case we've always had a fascist government.

Looks like I picked a bad day to quit methamphetamines.

Ricardo: (a) Please don't CAPSLOCK. It's yelling. It's not nice to yell. (b) I strongly disagree with Obama's position on many things, but I also disagree with your assertion that this is "exactly the economic system of Mussolini's Italy": it's not. (c) Any comparison to fascism should not be lightly made. I feel that you are making this comparison without much thought and without sufficient justification. (d) Thank you for agreeing with me. Please try to justify your agreement without CAPSLOCK or inflammatory references to Mussolini and fascism.

"really, additional rationing"

No; *different* rationing. I, for one, would rather have to wait for non-life-saving measures while others go first (much like in the emergency room) rather than being able to get same-day appointments for a head cold while poor people with chronic diabetes can't afford insulin, or get dropped by insurers.

ricardo has also been, er, gracing Matt Yglesias' blog with his presence.

I do not make the fascist comparison lightly; as I already said. Hogan says that we've always had a fascist government. But that's not true. LASIEZ FAIRE PROTECTS CORPORATE INTERESTS BY DEFAULT; BUT FASCISM GOES BEYOND LAISSEZ FAIRE. It actively uses COERCION to FORCE PEOPLE. That is what Obama is doing. Single payer supports human rights. AN INDIVIDUAL MANDATE TO BUT CORPORATE INSURANCE IS FASCIST!

If you want to understand what fascism really is please read this interview with Noam Chomsky.

i highly recommend that nobody click on ricardo's link.

i'd also recommend banning him.

Seriously ricardo, definitions of fascism are a little bit squishy, but basically all of them include features that are not in evidence in the US at this point.

Not to say we could never tilt toward fascism, or come with something equally horrendous that had our own special aroma, but the political, social, and economic environment of the US is not fascist by any definition that respects the historical meaning of the word.

If you'd like to pursue the question maybe we can discuss what some of those features are, or you might want to do some homework on your own.

But dude you have to turn the caps off. They hurt our eyes.

"i'd also recommend banning him."

Well, we do agree on something.

ricardo,

good lord, I hope you get some help.

but basically all of them include features that are not in evidence in the US at this point.

The militarization of the manufacturing sector since 2000 is another interesting feature.

Concentration and cartelization of sectors of the economy;shift of power to the executive

Dave & Sara may focus a little too heavily on the street-level social manifestations and not enough on the governing structures, but that is how the history and analysis was usually written.

Oh, ricardo is our teenage troll who thinks it's funny to link to the goats ex image. Maybe someday he'll grow up.

I actually disagree with your first point: We absolutely do ration gasoline. We do so by price, which reflects not only the demand for gasoline but also the supply.

I'm with russell on the response to this statement, for the most part. I think it might be useful to explore market forces as a form of rationing, in that they act as a mechanism to determine who can and cannot have something of which there is a limited supply. If nothing else, it would help puncture some of the conservative shibboleths that come pretty close to deifying the free market as an absolute good.

The problem is that doing so renders the word "rationing" essentially meaningless as a descriptive term, particularly in the current context. It turns the word into a catch-all that basically means "any process that results in some people getting a thing and others not". Using this logic, every market and financial transaction in the world would qualify as a form of rationing, and frankly that's absurd. There is a nontrivial distinction to be made between having the right or permission to buy something but being unable to afford the price, and having the money to afford the price of a thing but lacking the right or permission to buy it.

While I appreciate the usefulness of refuting the idiotic FUD arguments that health care reform will result in "rationing" by pointing out that our current system has a similar effect--particularly where the purveyors of said FUD cannot usefully define "rationing"--I'm concerned that doing so is contributing in its own way to the corruption of the term.

The way the insurance companies currently approve or deny care does not amount to rationing of health care in any meaningful way--there is no actual shortage of the care itself. What they "ration", if you can call it that, is their own profits: every time they approve a claim and provide the service for which they are paid, that hurts their bottom line. We've gone over this to death.

The term for what they're doing isn't rationing, though--it's fraud.

I should correct my last line because I'm sure that the industrial history of 20s Italy & 30's Germany has been studied extensively.

The usual precursor is called "corporatism"

(Here was a sentence about the National Recovery Administration, but the suspension of the Anti-Trust laws was only a small part of an incredibly complicated series of initiatives.)

"I'm with russell on the response to this statement, for the most part. I think it might be useful to explore market forces as a form of rationing, in that they act as a mechanism to determine who can and cannot have something of which there is a limited supply. If nothing else......."

In many waays I am with Catsy(and Russell) on this point. The argument around rationing is circular and not meaningful as "rationing".

More or less services will be denied by various solutions. I would also add that while I know of as many insurance denials as anyone else there are two things I don't think have been mentioned.

For those on Medicare the service levels are very well defined. In any ongoing care situation the provider usually checks with Medicare to see what will be covered and only provides that care. There are advocates who actually help justify additional care under the rules, but care is regularly changed, more often than denied, to be within guidelines.

Second, I have been lucky enough to have reasonable to excellent coverage for years. Several years ago my doctor recommended a relatively ne drug for my pain management and the insurance company refused to pay for it. I was not in a position to pay for it myself so the doctor gave me the older version of treatment. Thus, I never took Vioxx three times daily for multiple years right up until they took it off the market.

My initial reaction to being denied was much tempered by the risk I never took.

All insurance denials are not fraud. Some are based on coverage levels, some on non-approved experimental treatments or new drugs. The things I have fought for over the years, getting waivers so treatments will get paid for, have given me an appreciation of the vast array of products that insurance companies have to review, along with your doctor. Luckily for me in many senses, I have had employer sponsored health insurance so recission was never a possibility.

Not to defend those cases where they set automatic denials so those who don't challenge it don't get it paid for, I've had to fight those battles also.

It is just more of a mixed bag and even a public option would struggle with some of the challenges.

The militarization of the manufacturing sector since 2000 is another interesting feature.

Concentration and cartelization of sectors of the economy;shift of power to the executive

See, *now* we're talking.

The integration of the industrial and business sectors with the state was definitely a feature of fascism. However, in classical fascism, if we can use that term, the goal of the integration was to bring industry under the control of the state.

No more capitalist entrepreneur seeking his or her personal highest self interest.

The transcendent good in Italian, Japanese, and German fascisms was the state, both in its operational apparatus and its role as embodiment of a superior people, where "people" is used in a collective rather than an individual sense.

If and when the US finally goes to the dogs, IMO it'll be other way around. The government and all of its institutions will not be master of capital enterprises, but rather their slave and instrument.

I'm not sure what the proper name for that will be but it won't be fascism, precisely.

Maybe something more along the lines of British / East India Company imperialism. Only shinier, with a better public face.

Like Disneyland, only with tanks.

All insurance denials are not fraud.

That's true, and all of your points here are good ones, Marty.

But I think we can all agree that recission, by which I mean taking someone's money in the form of premiums for X years, then aggressively reviewing their medical history to find reasons to deny them coverage when it looks like they will present a net negative to the bottom line, is fraudulent.

If someone is an unacceptable risk, the time to decide that is before you take their money. Once you take their money, you own the risk.

Cases of insureds deliberately concealing information is another story, but I don't think that's what we're discussing here.

Russell: I'm not sure what the proper name for that will be but it won't be fascism, precisely.

My suggestion would be corporatocracy.

Marty: All insurance denials are not fraud. Some are based on coverage levels, some on non-approved experimental treatments or new drugs.

Not all, but I would venture to say a significant majority are, in the sense that the actual reasons for denial of coverage are merely a pretext--they literally start with the objective of denying coverage, and look for any reason to do so. Your anecdote about Vioxx is fortunate for you and forms an interesting counterpoint, but I don't think it really bears on the point I was making.

The practice of rescission, now--I have no qualms in making an absolute statement to the effect that any case of rescission that does not involve deliberate fraud--not mistakes, but actual provable fraud--on the part of the patient amounts to fraud on the part of the insurance company.

Here's a link to a CNBC article on Una Merkel's policy Kurzarbeit in Germany, and it's surprising success. I read a litte more detailed article in the econosphere, but can't find it. Merkel was much more reticent about bailing out banks, and got a lot of heat for it. There is a lot of attention now being paid to Germany from the world economic community.

Just to point toward a different recovery policy than Bush/Obama's tax cuts and financial bailouts, and to, ya know, ask the question as to why.

Don't worry, russell and bob: Before long, the activist conservative justice on the Supreme Court will make it simpler for corporations to simply buy the government. Then we can see exactly what results.

If and when the US finally goes to the dogs, IMO it'll be other way around. The government and all of its institutions will not be master of capital enterprises, but rather their slave and instrument.

I'm not sure what the proper name for that will be but it won't be fascism, precisely.

no, it won't be fascism. but it will be exactly what is predicted by hundreds of near-future sci-fi books, movies and video games. the all-seeing Corporation, with hooks into everything we do, controls the government.

we could call it "AllMart".

"The practice of rescission, now--I have no qualms in making an absolute statement to the effect that any case of rescission that does not involve deliberate fraud--not mistakes, but actual provable fraud--on the part of the patient amounts to fraud on the part of the insurance company."

This I could not agree with more. It is number two on my HCR priorities (after insuring the 47M).

Jes, your friend's experience is precisely why I want to separate health care from employment -- something that neither President Obama nor the House Democrats want to do. Which is why, despite Obama's modifications, I still oppose this particular "reform" effort.

The data that you rely upon, however, is for crap because it fails to account for other salient factors that probably have a much greater impact on health than the presence (or lack) of insurance, including: income, diet, education, and location. It also fails to distinguish the reasons why and the character of the purported lack of insurance.

The practice of rescission, now--I have no qualms in making an absolute statement to the effect that any case of rescission that does not involve deliberate fraud--not mistakes, but actual provable fraud--on the part of the patient amounts to fraud on the part of the insurance company.

Wait a minute ... these rescissions are about pre-existing conditions. Why should a patient be charged more, or have to interact with an insurance company more, or be penalized at all, because that patient was sick before? What kind of disclosures are they asking for that would inspire someone to lie (defraud)? The fact is, medical history should have absolutely nothing to do with the cost of future care. Explain why it should.

No; *different* rationing. I, for one, would rather have to wait for non-life-saving measures while others go first (much like in the emergency room) rather than being able to get same-day appointments for a head cold while poor people with chronic diabetes can't afford insulin, or get dropped by insurers.

And additional rationing, BitchPhD. That is what it means to bend the cost curve: it doesn't all come out of efficiencies.

Now, we hope that this additional rationing will come from procedures with low cost-benefit (e.g., not ordering a CT when the indication is headache caused by head cold and the likelihood of brain tumor is remote).

As for the debate over "rationing": I'm using the term as economists do, which is appropriate because there's a market for health care as much as there is a market for gasoline. I recognize that some folks don't get it -- or, worse, might maliciously misuse the term for political benefit -- but I'd rather keep on using the appropriate term.

(Third paragraph of my 6:45 comment was to Russell [and others], not B-PhD.)

Marty: Second, I have been lucky enough to have reasonable to excellent coverage for years. Several years ago my doctor recommended a relatively new drug for my pain management and the insurance company refused to pay for it. I was not in a position to pay for it myself so the doctor gave me the older version of treatment. Thus, I never took Vioxx three times daily for multiple years right up until they took it off the market.

My initial reaction to being denied was much tempered by the risk I never took.

And whenever you hear conservatives trumpeting about NHS "death panels" deciding who will or will not receive expensive new medical miracles: consider that the NHS puts all its figuring right up front on NICE or on NHS Choices - and if you're not happy about that, you can ask your MP to take it up in the House of Commons. None of which public information and discussion was apparently available to you, Marty, under the US system.

This I could not agree with more. It is number two on my HCR priorities (after insuring the 47M).

Number three, then. Since number two is getting 47M uninsured, and number one is apparently "protecting the profits and wellbeing of the health insurance companies".

The fact is, medical history should have absolutely nothing to do with the cost of future care. Explain why it should.

but a person's medical history does affect the cost of future care. many illnesses have a good chance of recurring. many illnesses are chronic. having one of those illnesses in the past raises the probable cost of care in the future.

von: Jes, your friend's experience is precisely why I want to separate health care from employment

But so long as you're glommed on to the idea that healthcare has got to be profitable to a corporation, you're going to be stuck with a system that is worse than that of any other developed country.

Worse things could have happened to my friend than being stuck in a job she no longer wanted when she was dying of cancer. She could have had no health insurance at all.

The data that you rely upon, however, is for crap because it fails to account for other salient factors that probably have a much greater impact on health than the presence (or lack) of insurance, including: income, diet, education, and location. It also fails to distinguish the reasons why and the character of the purported lack of insurance.

*claps claps* Thanks for demonstrating that you didn't bother to read the study I linked to before you dismissed it as "crap". As you would know if you had read it, the studies demonstrating that 22,000 people die in the US each year because they do not have health insurance, do in fact control for
socioeconomic status and other factors.

Your preference for ignorant rejection of data that proves you wrong is noted.

Now, deal with it: the conservative preference for protecting the profits of healthcare insurance companies over the welfare of Americans kills 22,000 people each year. You defend that preference. Didn't you use to call yourself "pro-life", once upon a time?

"but a person's medical history does affect the cost of future care. many illnesses have a good chance of recurring. many illnesses are chronic. having one of those illnesses in the past raises the probable cost of care in the future."

Sure. Agreed. So, if I'm an expensive case, I should have to pay more for my right to be covered for a broken arm? Give me a break - the fact that I am predisposed to sickness has nothing to do (in a civilized world) with my right to be treated. How is it my fault if I have a genetic predisposition to heart disease? Or porphyria? Or osteoporosis? Sure, it's predictable that I'll cost more, but why is it my fault - should I have to be an investment banker instead of a social worker in order to excuse myself?

cleek, in other words, you're buying into insurance risk schedules as a model for societal healthcare. Is that what we, as a society want, that people who have chronic medical conditions should pay a premium for health care because of it? It's a lottery then, based on genes. That's the model we want? Good model for eugenics.

, I should have to pay more for my right to be covered for a broken arm?

oh no. i'm absolutely not arguing the rates should be any different. but it's inescapable that the insurance company can expect to pay more for some people based on their prior medical history. but the only way for a system to be just, IMO, is for all to pay the same amount. the healthy subsidize the sick.

This is a bit of mind reading, but I have always thought that the rescission issue was the insurance companies looking into a future where genetic markers might inform them who would suffer from expensive chronic illnesses. If they can get to a point where DNA tests are routinely done, a marker appears that the patient didn't follow up on, and when the chronic illness appears, they rescind the coverage.

cleek, thanks - sorry to be so outraged - I totally agree.

I agree with comment upstream about "rationing" -- i think it's wrong to equate them. Rationing is a subset of cost containment, but not the only type. It's like all squares are rectangles, but not vice-versa. All rationing is cost containment, but not all cost containment is rationing.

So I disagree with the use of it. There are other ways to save.

Also, "rationing" refers to a finite resource. We have 100 widgets, so everyone gets only 1 and no more. That's not the case here at all. Anyone can buy any additional supplemental they want.

So in addition to being politically loaded, I just don't it accurately describes what the Dems want to do

"Taxing high benefits incentivizes folks...to make better decisions regarding the kind of coverage that they want."

For most people, high benefits come into play only in the case of disastrous non-elective medical conditions. Few people have significant choice about the kind of coverage they get anyway.

Expansion of coverage will be paid for with taxes no matter what kind of gimmicks are put into the bill, and the best way to do this is to provide a minimum amount of coverage with general tax income and let people choose what they want above that.

I think one can use rationing to mean either (a) any means of allocating a finite resource whose supply is not adequate to the number of people who would want it if it were free, or (b) some means of allocation that caps the amount you can get even if you are willing to pay.

But I think that if one chooses (a), it shows good faith if one objects every single time someone yells: OMG, rationing!!!, and points out that any market system rations, according to definition (a). So long as health care is not available for free to all comers, the dreaded rationing is taking place. If one chooses (b), on the other hand, neither the Obama plan nor any other plan I know of that's under consideration now involves rationing.

Indeed, the falsest line in Obama's speech was "I am not the first president to take up this cause, but I am determined to be the last[.]" I'm pretty sure his claim will turn out to be untrue.

He was making a claim about what he wants, not making a prediction about what will actually happen. The statement's truth value is not proven by events- he is either accurately reporting his internal state or he is not.

I actually disagree with your first point: We absolutely do ration gasoline. We do so by price

"Rationed" already has a definition. Perhaps you'd like to make up a new word for "resource that is not infinite". This would be easier to understand than trying to guess when you're redefining pejorative words so you can use them on Obama's proposals.

Cos let's face it, this is all about getting to say "admit it Obama, you want to ration care." Even if all it means under the new definition is "Obama, your proposal does not provide infinite healthcare at reasonable prices."

Jes, you write:

claps claps* Thanks for demonstrating that you didn't bother to read the study I linked to before you dismissed it as "crap". As you would know if you had read it, the studies demonstrating that 22,000 people die in the US each year because they do not have health insurance, do in fact control for
socioeconomic status and other factors.

You then go on to say some nasty things about me.

The fact of the matter is that I read your link. The IOM study was very clear about how it reached its calculation. It used the following formula:


DT = DI + DU
= (PI*X) + (PU*X*1.25), where
DT = total deaths in a particular
age cohort
DI = deaths among the insured in
the age cohort
DU = deaths among the uninsured in
the age cohort
PI = percentage insured in the age
cohort
PU = percentage uninsured in the age
cohort
X = the number of deaths that would
occur if everyone in the age
cohort had insurance.

This is a direct quote from page two of the document that you linked.

As you'll see, my statement is correct: The IOM study controls for age but not for the factors that I listed.

Now, it's absolutely true that your linked paper lists alternative studies that provide different numbers on page 4, some of which the paper claims do correct for (e.g.) socioeconomic status. I'm thinking specifically about the study by McWilliams et al. (2004). Of course, the methodology of these studies is unknown and they do not provide the numbers that you've cited. So I have to assume that you're not relying upon those alternate studies.

I don't expect you to acknowledge the above; I expect that you'll accuse me again of lying. But understand that this tactic of yours makes discussion with you a waste of time. You're trolling. Please stop.

von, although I also would want insurance delinked from employers, that has less chance of p[assing than any proposal than single payer, and actually single payer would be the best way to manage the delinking.

However, it is hardly the only way to solve the dilemma Jes' friend faced. No pre-existing conditions would be another. In fact, by law, a person can move from one group policy to another (i.e. by changing employers), and there should not be any pre-existing condition riders. The problem is that it would have been difficult for her to be employed if the company knew of her condition because they would have been socked for higher premiums by the insurance company.

I wanted, also, to elaborate on a couple other comments. The first is about Medicare reimbursement. As I mentioned above, there are very few providers (take away the glamour professions like cosmetic plastic surgeon) that do not accept Medicare assignment. There are reasons for this. Medicare payments are lower than insurance payments in most cases (mental health treatment is the exception where the reverse is true). However, Medicare reimburses in about half the time or less than most insurance companies which increases cash flow substantially.

Most insurance companiers contract with providers on the basis of a percentage of Medicare. For orthopaedic surgeons (your example von) the general range is 110% to 160% of Medicare. This may sound like a significant difference, but in actuality it isn't that much.

The adminstrative costs related to working with insurance companies, including the cost of hiring someone to confirm eligibility and benefits, then to get authorization for surgery (which can take several days, phone calls and the cost of transmitting x-rays, etc to the insurance company), then the cost of administrating the claim processing and auditing of reimbursement are high and eat up a lot of the difference.

Additionally, it is not uncommon, when benefit checking and authorization may take place weeks before a procedure, that when the claim hits, to find out that the coverage no longer exists for some reason or another.

None of those problems exist with Medicare.

Concerning insurance denials. There are 3 major reasons. The first, and most controversial falls into the no longered covered category. There are a lot of reasons for this and recission is one.

However, this is really not the largest category. In fact, it is probably the smallest.

Second is for the experimental, unproven treatment category. This is frequent and is sometimes justified, particularly when normal proven courses of treatment have not been tried. The problem is that the insurance company gets to decide when a treatment no longer falls into that category. Not surprisingly, the more costly a treatment is the longer it stays classified as experimental. When I was a mental health case manager, actually in a position to approve and deny coverage (different than treatment)I was frequently looking at people requesting approval of a costly treatment for autism. Because I could override the carriers position in some cases, I would approve it under certain circumstances (I won't go into the criteria). The point I want to amke though, is that many insurance companies would deny this treatment even though it had been in existance for 20 years and been shown to be highly effective.

Finally, the last and most common reason for denial is non-medically necessary. Again this is a legitimate reason to deny coverage, but it also serves as a screen behind which many things can be denied. Sure the denials can be appealed, sometimes through several appeals, but many people never did. And believe me, the pressure was on those who did the initial review to send a certain percentage of cases to the medical directors to approve or deny, and pressure was on them to deny a certain percentage of cases. If they didn't, they may not have their jobs long.

Main point, not all denials are fraud or illegitimate, but even the "legitimate" reasons are used to cover some marginal, if that, reasons for denial.

Maybe more later.

"First sentence, the link says "gives good speech". Typo?"

Nahh. I give good law, Obama gives good speech, you give good comment. It's a continuation of the general Buffy-fi-cation of language.
Posted by: von

Buffififcation? Maint'Non! When in the newsroom, some 35 years ago, long antedating the sallow Buff, colleagues regularaly brought me problematic stories to read and slug because, it was alleged, I gave good headline...

Von, I still say by using the word "additional" you are question-begging. If a plan is passed which forbids caps on benefits or post-hoc cancellations of policies by insurance companies, then some of the current rationing will be no longer. "Additional" implies that not only will current forms of rationing continue, but there will be *more* (additional) rationing on top of it.

As for the debate over "rationing": I'm using the term as economists do, which is appropriate because there's a market for health care as much as there is a market for gasoline.

Being a general economics bonehead, I wasn't aware of the way rationing is used as a term of art in that discipline.

von is correct, here is what an economist means when they say "rationing":

In economics, it is often common to use the word "rationing" to refer to one of the roles that prices play in markets, while rationing (as the word is usually used) is called "non-price rationing". Using prices to ration means that those with the most money (or other assets) and who want a product the most are first to receive it.

So, my bad.

By this definition, it's true that rationing already happens in the current system. If you have a lot of money, you can have whatever health care you damned well please. If you don't have a lot of money, you'll get whatever your insurer will cover, assuming you have an insurer. You might get none at all.

Also by this definition, the relationship between cost containment and rationing is as follows: if you don't have the dough, you don't get the service.

So, the way we'll contain costs is simply by making sure fewer people can pay for the service.

Cost contained, QED.

Splendid.

Carleton's 8:32 is spot-on. i'd been trying to think of what was bothering me about this and he nailed it.

one can't use words that have become inflammatory and be surprised or pedantic when they inflame.

By this definition, it's true that rationing already happens in the current system.

It's not just that- using this definition, rationing is happening under any conceivable system. If this is the definition von was relying upon originally, then why make the statement?

Of course, by some amazing coincidence, this is a meme pushed by right-wingers- ObamaCare is rationed care!

Carleton, that is, of course, the whole point, to scare people. There is no conceivable system that can avoid rationing. However, von seems to think that Obama's plan would actually increase rationing by creating an increased demand on the system.

Again, any system that increases the number of people who have access to healthcare also increases demand, thereby creating additional rationing, one can only assume that von, if he is using the word "rationing" as a criticism of Obama's plan, does not really want to see increased access to health care.

However, I really don't believe that of von. Therefore he must not be using it as a criticism. But then, the question must be asked, why use the word at all, as you ask above.

If von, you are using it to point out that people are wrong defending Obama's plan by saying it doesn't ration care, I don't know anybody that does, not in the sense you are using it. So do inform us, please, why you even bring the word up?

However, von seems to think that Obama's plan would actually increase rationing by creating an increased demand on the system.

Im not an economist, but using the economics definition from wikipedia definition- could one speak of "increasing rationing"? It seems more like a process- ie rationing is the market using price/demand info to determine allocation of a limited resource.
Whereas "increasing rationing" makes perfect sense when one is discussing the nontechnical definition- but it also seems to be inaccurate in this case.

Equivocation.

It's not just that- using this definition, rationing is happening under any conceivable system.

Actually, not that we are ever going to see a single-payer system in this country, but under a single-payer system rationing does not occur through the mechanism of price.

In other words, the cost of a medical service or product is not the means by which all of the folks who need it are sorted into who will get it and who will not.

There may be other rationing mechanisms, but "who has the most money" is not one of them.

Figuring out if that is more fair, or less fair, depends on whether you think medical care should be treated as a commodity or as a public good.

We don't ration access to mail delivery, highways, tap water, police and fire department services, or trash pickup on the basis of who has the most money. We may ration those things, but not on that basis.

"I think he's going for some kind of patchwork approach that might be used to set up future reforms ... which will likely take decades to be fully resolved." - von

Well that's depressing as hell considering it already taken "decades" to get to where we are now. Good grief...

Any non-economist, talking to an audience that is not 100% economists, who says "rationing" the way Republicans say it in the current debate, is a Frank Luntz wannabe.

I accuse no one here. Anyone who feels accused must think that the shoe fits.

--TP

I have to agree with the people who find the usage of the term rationing to be a poor choice. Yes, there is a technical term "price rationing" that economists use, but if you are writing for a non-technical audience, and want to make things as clear as possible, you should tell them that you are using a technical term and why. Otherwise it looks like you are trying to deceive your audience or use a word with a negative connotation for propaganda value, and honestly that's the way the use of the term here reads to me.

"Price rationing" as economists use it is not necessarily a bad thing, they would claim it is often the most efficient means of rationing scarce resources, so if you really meant rationing as price rationing, why would that be a criticism?

Perhaps you could describe the decrease in the death rate that would result from increased access to health care as "death rationing" in order to make it sound extra-scary. That would work two typical conservative scare words into one rant.

Most non-economists may think it is possible to avoid rationing, but most non-economists are wrong. Rationing, like death (and unlike taxes) is a necessary part of the human condition.

I don't hear anyone claiming we can avoid rationing.

The question is not whether there will be any rationing or not, the question is the basis of the rationing.

We have rationing now. If you have the money, you can get whatever you want. If have insurance, you can get what they'll pay for. If you have no insurance and/or not a lot of money, you get nothing.

The question is whether that's the way we want to live.

However, von seems to think that Obama's plan would actually increase rationing by creating an increased demand on the system.

I wouldn't say that there would be an increase in rationing. (I don't know why I wouldn't say that, but it just doesn't sound right to my ears.) I would say that there would be additional rationing, because there will be either the same -- or, possibly, fewer (more on this I hope later .... it has to do with medicare reimbursements*) -- medical resources for more people. And to an extent that's a good thing: Americans by and large overconsume health care. Some of its self-sightedness (get my kid antibiotics now); some of it is defensive on the part of doctor and/or patient (a 1% chance of a brain tumor? better order that CT); some of it is greed (I get paid more for every CT I do); and some of it is inefficient habit (we always do CTs when a patient presents with X).

Most non-economists may think it is possible to avoid rationing, but most non-economists are wrong. Rationing, like death (and unlike taxes) is a necessary part of the human condition.

You earn your name with this comment, Pithlord.

You earn your name with this comment, Pithlord.

Yeah, it's pithy, but it's not to the point.

Who is claiming that rationing -- meaning the allocation of finite resources -- is avoidable?

Pithlord's pithy comment boils down to "many people think the sky is not blue", or "many people think the sun rises in the West".

No, they don't think those things.

There are two questions that folks are discussing.

1. Whether rationing by price is equitable.
2. Whether you, von, are being disingenuous in raising the issue of rationing in the context of Obama's speech on health care.

I look forward to your, or Pithlord's, or anyone's, pithy replies.

"Rationing, like death (and unlike taxes) is a necessary part of the human condition."

'Necessary'??
I don't think so.
'Inescapable' or 'inevitable' -- maybe.

And what else is going to be inescapable and inevitable are the longer wait times we're going to see when 40 million uninsured become eligible for medical care --in comparison it will make Canada's historically slow system look like the Roadrunner on steroids...

I'd like to see Hilzoy's point address more directly too.

"Rationing" can be meant in two different ways. The first way (we allocate scarce things) is so obvious that it's not even noteworthy. Under this view, we already ration -- and in a highly inefficient and immoral way.

Under the second sense (we impose caps), it doesn't apply at all to Obama's health care plan

Most non-economists may think it is possible to avoid rationing, but most non-economists are wrong. Rationing, like death (and unlike taxes) is a necessary part of the human condition.

Do most non-economists think that all resources are infinite? I think not.
However, if they think that it is possible to avoid having some entity set limits on purchase or distribution of some products, then those non-economists are correct.

This is like saying: Many sports fans think that the Lakers victory last year was significant. But statisticians know that a single event can never be significant.

Am I the only person who tends to find von's healthcare posts mystifying or even impenetrable at times? He just seems to flip logic on its head often.

Von: This is a direct quote from page two of the document that you linked.

Actually, what I'm accusing you of is ideological convictions that make you indifferent to the human cost of denying people healthcare to make a profit.

But hey. Continue to accuse me of trolling, if it means you can avoid discussing the lives lost because people can't get the healthcare they need in your preferred system.

In the US, where healthcare is rationed by how much money you have and where motherhood is a strong indicator of poverty, 6.26 infants die for every 1000 live births. In the UK, is the worst country in Europe, 4.85 infants die for every 1000 live births. To you - to most conservative Americans - the babies who die can be blamed on the mothers, not on a system that denies them healthcare because they are insufficiently profitable: in the UK, we just figure that every woman who wants to have a baby should be cared for according to her needs, and every baby born should be cared for according to its needs. You think that prenatal care, childbirth, and pediatrics should be a profitable business and the extra cost of babies dying is just a side-effect that can be blamed away on someone else: I think that - like any other kind of healthcare - everyone deserves to get what they need, and we should all collectively pay what we can. And in your preferred system, more babies die as a result. Didn't you call yourself pro-life, once upon a time?

At the other end of life, it's estimated that sixty thousand people die each year as a result of bedsores in the US. cite In England, about a thousand people die each year as a result of bedsores. cite. The US has just about 6 times the population of England... and 60 times as many deaths as a result of poor nursing care.

By the way, the first cite has pictures of what bedsores look like. Your ugly cost of denying people healthcare when it's not profitable.

As Russell says: We have rationing now. If you have the money, you can get whatever you want. If have insurance, you can get what they'll pay for. If you have no insurance and/or not a lot of money, you get nothing.

That's the way you want other people to live and die: but at least, don't be hypocritical about it.

In the UK, is the worst country in Europe, 4.85 infants die for every 1000 live births.

Nitpick. The UK is not the worst country in Europe. We were second worst round the turn of the millenium, admittedly. (At around 5.8). Off the top of my head, Ireland's at 5.05. Greece and Italy also have higher rates, and Cyprus has the distinction of having a higher infant mortality rate than the US.

It's worth noting that Ireland has a lot of private involvement in healthcare, and that the other named countries are ... not economic powerhouses.

What a not insane, not anti-social discussion of health care cost management looks like.

h/t tristero at digby's place.

Any chance of anything like this happening?

As always, cherchez l'argent.

Von:

As you'll see, my statement is correct: The IOM study controls for age but not for the factors that I listed.

Actually, this doesn't appear to be correct. The IOM study used estimates of mortality differential from other studies, which apparently did control for some confounding factors. I quote (my bold):

Although the two study populations differed, as did the potentially confounding characteristics for which the researchers controlled, both studies yielded estimates attributing uninsurance an overall increase of 25 percent in mortality risk for working-age adults

The formula you quoted certainly isn't support for your statement, as the formula is just a way to derive an estimate of the number of deaths based on an estimate of mortality differential derived from some other means: in this case, 25%, which is where the factor of 1.25 comes from in the formula.

So quoting the formula was either deliberately misleading, or a mis-analysis on your part. Second,

Now, it's absolutely true that your linked paper lists alternative studies that provide different numbers on page 4, some of which the paper claims do correct for (e.g.) socioeconomic status. I'm thinking specifically about the study by McWilliams et al. (2004). Of course, the methodology of these studies is unknown and they do not provide the numbers that you've cited. So I have to assume that you're not relying upon those alternate studies.

After reading the paper, this statement seems excessively weasely. In fact, the paper points to a large body of research, and "claims" that it all broadly confirms the finding of an approximately 25 percent differential in mortality rate (i.e., something on the order of 20,000 excess deaths a year). In some cases much worse.

The citations are all there, and you're welcome to go through and analyze each paper, but this looks to me like a pretty robust result.


----
The McWilliams paper does indeed appear particularly interesting--again, my bold:

However, since those earlier studies research controlling for many previously unobserved factors has continued to confirm a strong link between insurance Among the articles cited above, for example, Hadley and Waidmann controlled for alcohol use, tobacco use, disability, self-reported health status, and chronic health conditions; Fowler-Brown and colleagues controlled for obesity, smoking, self-reported health status, cholesterol levels, and chronic medical conditions; and the study by McWilliams and colleagues controlled for alcohol use, obesity, exercise habits, marital status, disability, chronic medical conditions, job stress, and wealth. The latter research team further conducted a sensitivity analysis showing “that the confounding effect of unmeasured variables would have to be even greater than the impact of smoking on mortality in our study for the increased mortality of uninsured adults to become statistically nonsignificant” (McWilliams et al. 2004).

I don't write this to object to health-care reform in the US, but because I think it's true and needs to be considered if we're going to discuss national statistics on infant mortality. It's a dicey business.

Not all countries draw the line between infant mortality and still birth in the same way when counting such occurrances. Further, not all countries health systems have the same resources generally to extract and sustain distressed fetuses/infants. If you're better at getting the fetus/infant out and keeping it/him/her alive for some period of time, you're going to accumulate, depending on how you count such things, more infant mortalities that would have otherwise been still births.

I don't know how this, if taken into account, would affect the specific numerical rankings of various countries with regard to infant mortality, but I'm pretty sure it would.

Stats are funny things.

hairshirthedonist, I got challenged about this a while back by someone who claimed that in specific countries (I think the meme was "France and Sweden") there were specific, very large differences in recording infant mortality.

I looked the facts and the stats for both countries up online, and found that no - there really wasn't much difference. Pro-lifers in the US like to make big claims for how the reason infant mortality stats in the US are higher than those in other developed countries is because in the US what would be called a miscarriage elsewhere is called a live birth, but this has not been true for at least 20 years - the US, like most developed countries including all the EU countries (at least, all of those that were EU countries twenty years ago...) started to use the WHO definition of a live birth between 20 and 30 years ago.

So while all the countries round the world don't necessarily record live births the same way, and if you look at stats over the past 50 years you won't necessarily be comparing like with like, any comparison between European countries, or Australia or New Zealand or the US or Canada, all of which use WHO definitions of live birth and still birth, are comparing like with like: the US just really is that bad at keeping babies alive after they're born. Universal healthcare is good for mothers and babies, it turns out: who'd have thought it?

When I still went to school (2 decades ago)some countries counted only children that survived their first year while others counted all live births in their statistics for life expectancy. The differences could be significant.

The problem with using the word "rationing" in this discussion--particularly in the way in which it's being used--is that it confuses the issue rather than adding clarity.

The way economists use the term is completely beside the point. Every industry has terms of art they use, and most of them have hijacked perfectly ordinary words and given them a specific meaning. Law and economics are replete with examples like this, but IT does it too--for example, where I work we refer daily to "bouncing" services or servers, which means to restart or reboot them, respectively. If I walk into a discussion about car problems, and I suggest that someone "bounce" their car (i.e. restart it)--that may be an accurate way to use the word in my industry, but it's just going to confuse everyone else.

So while economists may well use "rationing" in a way that makes it germane, that's not what everyone else in the country hears when you use it. To most people, rationing specifically involves a deliberate system for distributing a commodity that is in short supply, limited by either who can have it, how much each person can have, or both. To most people, it carries a decidedly undesirable connotation, as it's typically associated with wars or hard economic times where it was a necessary evil--which is why the Republican Party started using it to describe HCR in the first place.

You're doing their job for them. Just stop.

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