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October 21, 2009

Comments

You are right. Shoulda been done long ago because Medicare E is a lot harder to demonize as a socialist plot than the public option.

However the deomonizing and lying would have happenned no matter what the label.

I don't think it's a huge advantage in branding for convincing the general public. I do think it will totally defang facetious GOP attacks that Dems are lowering Medicare spending. If you make it part of Medicare and count the thirty billion (or whatever it ends up being) in startup funding as Medicare funding you can make it about budget neutral as far as Medicare goes.

What would've helped more, I think, is a concerted effort to define and publicize a single version of a public option. People support a public option when it's accurately defined but if you ask them to define what Congress is thinking about they don't have much of an idea. My guess is that the most common response would be subsidized or free care for the poor, or care for people who insurance companies won't touch...

IMO, Dems everywhere should stop worrying about what the cynical, lying, demagogic GOP thinks and just do what's best for the f-ing country.

the idiots had their chance to make America a better place and the f-ed it up. to hell with em.

Zach raises a very good point; the "public option" will cover people who the insurers do not want as customers. Appending the phrase "to compete with private insurers" * to descriptions of a public option tells far less than half the story.

* Credit Jeff Darcy.

If it only covers a fraction of the population how is this the public option you seem to be in favor of and why do you seem to be celebrating. This seems more like an expansion of medicaid. Regardless of the outcome no substantive change will have been made. The same two groups will continue to be covered (the most wealthy and the poorest) leaving the middle class, again, to fend for itself. I understand you are a liberal blogger, but you do not seem to see that the R's and the D's are cut from the same cloth. The cloth of self interest - and the willingness to spend other peoples money in irresponsible ways. In the end it looks the same as the beginning. Remember these guys are perpetually campaigning. They have elections to fund and will say anything to get elected. This does not mean they will do what they say.

-This is all aimed at elderly voters.

@elm - That's actually the opposite of what I meant. The public option is supposed to compete with private insurers on the same playing field. Barring discrimination and rates based on preexisting conditions and providing subsidies that are applicable to public or private insurance (and pooling risk through the exchange) means you should be able to choose either option regardless of how sick/old/wealthy you are.

Zach is right. The analysis by Jeff Darcy that Elm links to completely ignores the insurance reform elements of the proposals. Insurers won't be able to dump sick people on the public option because they'll be required to sell the same insurance to everyone.

Did I read somewhere that Medicare is going broke? Where is the money going to come from to pay for all of this? Higher taxes? Surely that will stimulate the economy. Publius writes as if there is no cost to any of this. There will likely be a substantial cost, and if it is more than the economy can carry, the good intentions behind all of this--leaving aside whether the services that are actually delivered will measure up to those promised--will be for nothing as we find ourselves extricating from a colossal administrative and bureaucratic entanglement.

The idea that a government that can't fix the cost overruns and fraud issues in a relatively limited context, i.e. medicare and medicaid, can take over health care delivery for 300,000,000 people as diverse as America strikes me as hubris in the extreme. But, as long as the intent is good, perhaps all will just fall into place. Or not.

What would've helped more, I think, is a concerted effort to define and publicize a single version of a public option. People support a public option when it's accurately defined but if you ask them to define what Congress is thinking about they don't have much of an idea.

Perhaps if the Obama Administration had made a particular public option a "line in the sand" this would have been possible. In the absence of that, 535 people are trying to work out which public option is acceptable to the largest majority of them under the various funny rules on the functioning of Congress. Mark Twain's observation about the making of laws and sausage applies: asking the public their opinion what they think of the various intermediate steps is largely a waste of everyone's time.

@I Hate Chavs - note that I said "supposed to" ... without rewarding insurers for taking on risk I imagine they'll find enough loopholes to make the public option the de facto home for the uninsurable. It's just that this is a bug and not a feature, and I doubt Joe Public would guess that's the case.

Zach,

How would they be able to avoid taking on high risk insureds? It's my understanding that the exchange would offer standardized policies that anyone eligible for the public option would be able to buy. So how can the insurance companies keep sick people from buying their insurance?

can take over health care delivery for 300,000,000 people as diverse as America

which bill proposes to "take over health care for 300,000,000 people" ?

@I Hate Chavs - the obvious way is to advertise your plan to markets that are cheap to insure. I imagine young people, for example, will be profitable to insure after reforms. Instead of marketing "hip" plans that don't cost much and are terrible insurance they'll be marketing "hip" plans that cost a lot, are usually subsidized, and meet the minimum federal guidelines.

A lot of credit cards marketed to college kids are actually pretty good deals for older people with bad credit relative to other options, for example.

McKinneyTexas: Did I read somewhere that Medicare is going broke

I'm sure you did - it's a popular right-wing meme, along with "social security is going broke", but, no matter what you read in your party news, it's not true.

Plus, if Medicare became available to the whole population, the whole population would benefit by its efficiency and effectiveness: get more, pay less. How is that a bad deal?

"Plus, if Medicare became available to the whole population, the whole population would benefit by its efficiency and effectiveness: get more, pay less."

You mean the effectiveness by which the US government spends more per capita (on the whole US population) than Canada, but only covers 27% of the population? Hip Hip Hooray! Or is there some other effectiveness that you're talking about?

Medicare for all may have lots of potential benefits, but efficiency compared to any other first world government's program is not one of them.

I agree that the Medicare plan appears to have great benefits. I also agree that until we address "costing less," we're just shuffling unpayable costs back and forth between the government, businesses, doctors, and citizens. Note who is not on that list? Health Management Organizations. They are here to make a profit, not reduce the cost of medical care. Their interest in continuing to make a profit out of our medical care is what is pushing (imho) that which is wrong with the attempts at health care reform. Having driven "medical costs" (i.e. doctors + their salaries) up to a level where they are making a ton of money, they just can't accept that this will not go on forever, even as they've already squeezed out however-many uninsured Americans out of their market. They're only INTERESTED in them that can pay, and them that can pay THEIR idea of what it should cost. Public option or not, we're not addressing any damned thing except whose checkbook the money comes out of until we find a way to REDUCE the cost of medical care. Which means, as far as I can tell, getting the giant parasites out of the medical business. As Sebastian said, we're obviously not doing nearly as well as Canada if we can charge more than Canada in taxes and provide medical care for fewer people. As Sebastian DIDN'T say, obviously, we COULD provide medical care for everyone at reasonable cost if we were just willing to look at where the money is going now.

I could be wrong, but I believe that the money is being wasted (Oh, I'm sorry, not "wasted," "earned") by the so-called "insurers." And they have enough money and power now to demand that government not do anything that will stop them from milking the public for every cent available. That includes lowering cost of health care, whether by mandating or by providing a lower-cost option.

That's why they fear the 'public option.' Even as inefficient as Medicare is, it's still cheaper per capita than what THEY're pushing, which would mean customers would leave them in DROVES.

"Plus, if Medicare became available to the whole population, the whole population would benefit by its efficiency and effectiveness: get more, pay less."

You mean the effectiveness by which the US government spends more per capita (on the whole US population) than Canada, but only covers 27% of the population? Hip Hip Hooray! Or is there some other effectiveness that you're talking about?

While I appreciate the naughty by nature allusion, this reply makes no sense. Health care costs are so high in the U.S. because of the for-profit private insurance system, which is exactly the problem Jesurgislac is trying to address.

but, no matter what you read in your party news, it's not true.

I am now reassured. We have all the money we need, it's just a matter of getting it out of the hands of the greedy, inefficient private sector and into the hands of a caring and efficient government. It works so well everywhere else.

And, great idea on cutting doctor's pay: that will motivate people to bust their butts in college so they can spend another 4-12 years learning how to cure sick people.

Market forces are a fiction and good intentions, from the progressive left, fix everything.

@Sebastian - I generally agree, but a lot of owes to the government covering the 27% of the population that's far more expensive to insure. A better comparison would be the cost per capita of the elderly and impoverished populations in Canada, scaled by their proportion relative to the States. Canada would still come out on top, but not by nearly as much.

Sebastian: What figures are you using? I find a combined outlay for Medicare and Medicaid of 657.4 billion in 2008 (page 9 of pdf) and a total population of roughly 300 million. Outlay per capita is then roughly $2200 per person across the whole population (though only a minority are covered).

By comparison, Canada's 2007 (Medicare and out-of-pocket) expenditure on health care was $3895 (USD, PPP) (Sheet 3 of the linked Excel file).

Medicare and Medicaid are probably less efficient than Canada's system, but not to such a degree. Additionally, the U.S. system covers principally the most-expensive population to treat (the elderly). According to this story, it's over 10x as expensive to care for someone aged 85-89 as for people aged 0-63. Adjusting for the larger cost of treating the elderly and those impoverished-by-illness, the U.S. system may not look so bad, but I have no conclusive evidence either way.

@elm - I think the figures he's using are total public expenditure on health (similar to Canada's total public+private figure) and the fraction of Americans covered by the gvmt. Seems about right.

And, total public expenditure is medicare + medicaid + schip + state contributions for all of the above + vha. Probably missing something, too. Canada spends about half as much per capita as the States and about half of medical spending in the States is public.

'which bill proposes to "take over health care for 300,000,000 people" ?'

And where can I sign on?

And, great idea on cutting doctor's pay: that will motivate people to bust their butts in college so they can spend another 4-12 years learning how to cure sick people.

Where do you suppose doctors in France and Canada and the UK and Germany come from? Mars?

Elm, you are comparing US Medicare (government only expenditures) to Candaian government care + personal expeditures. I was comparing government (US) to government (Canada) spending. You can choose to compare government only or government + private, for various reasons, but comparing government only in the US to Candadian public + private can't be the right way to do it.

Your linked excel file has the numbers from the US, so I'm mystified by why you would choose two different sources to make your point.

If you want to use total outlays (which seems completely off point in the discussion, but still) then you get Canada $3895 and US $7290 per capita.

You can see where I get my numbers from here. It boils down to the Canadian government spending about 6.7% of GDP on health care, while the US government spends about 6.6% of GDP on health care. The US has a higher GDP per capita, so the spending is about the same per person. But in Canada, 6.7% of government-spent GDP covers everyone, while in the US 6.6% of GDP covers 27% of the population.

The higher cost of treating elderly people has nothing to do with this, because Canada treats both old and young with its 6.7% of GDP government spending while the US treats pretty much just the elderly with its 6.6% of GDP government spending.

You can see a similar trend in the data that *you* linked by using the total expenditure numbers and multiplying them by the "Pulic expenditure as % of total health Expenditures" tab which is immediately after the tab you drew my attention to.

For 2004 for example (which I use because much of the data I originally cited was from that year) we have Canada $3,320 per capita with public expenditures being 70% of that for a per capita public expenditure of $2,324.

Compare to the US. $6,194 per capita with public expenditures being 44% of that for a per capita public expenditure of $2,725.

As you can see, in 2004, the US GOVERNMENT spent $401 per capita more than the Canadian government. But the US government doesn't have universal coverage, while Canada does.

Elm, I do want to thank you for linking that source. It is the cleanest statistical overview that I've seen. I'm totally bookmarking it for future use. :)

"Where do you suppose doctors in France and Canada and the UK and Germany come from? Mars?"

I don't know, but a bunch of them have been coming to the US for the higher income they can get here.

@Zach - Fair enough, thanks for informing me. I had overlooked several aspects of U.S. government spending on health. That, combined with uncertainty in the figures and the fact that Canadian Medicare doesn't cover 100% of expenses could easily make up the difference.

On your earlier response to me (10:38), I don't think we have a significant disagreement. A "public option" is important on several fronts. One is to offer coverage to people whom private insurers don't want to touch. Another is to set a standard for cost and coverage.

Such a publicly-owned insurer should be free to offer insurance to everybody -- sick or well, high or low income.

Pragmatically, the existence of a public choice will make the biggest difference to the poor and ill. I have insurance today, so a public plan would give me two choices vs. one. My friend has no insurance, so a public plan gives him one choice vs. zero. That's a more significant improvement.

"As virtually everyone agrees, Medicare is a very good program "

You keep saying this, and it is, for people who would have no chance of getting coverage any other way. However, it is not a very good program, it is a program that meets the basic needs of the elderly. Those are really two different things, thus the 10 million on Medicare plus.

People on Medicare are incredibly satisfied with what they have, because the alternative is nothing.

However, it is not a very good program, it is a program that meets the basic needs of the elderly.

I'm sure the NHS is better than Medicare, since the UK has so much higher standards for healthcare.

But Medicare is demonstrably a better healthcare program than Americans under 65 can expect. People on Medicare are satisfied with what they have, according to the data available, because they've experienced the alternative - the private health insurance scams that younger people have to fight with - and they know they have it better: as Medicare beneficiaries, they have "fewer problems getting access to care, greater confidence about their access, and fewer instances of financial hardship as a result of medical bills" than the poor sods who aren't old enough for access to Medicare yet. cite

People on Medicare are incredibly satisfied with what they have, because the alternative is nothing.

Setting aside the rest for a moment, why do you think this would be different for people who /currently/ have nothing? That is, after all, half the point of the PO.

Marty: so having Medicare as an alternative for people who can't get insurance, or lose their insurance and their job, or similar situations, would be bad because?

"Setting aside the rest for a moment, why do you think this would be different for people who /currently/ have nothing? That is, after all, half the point of the PO."

Catsy, I agree with this, I even agree with just extending Medicare itself to the uninsured.

That doesn't mean it is a great program. Some of us have parents and grandparents who rely on it and it is worse than any insurance my parents ever had when they worked, and I hear about it all the time. Then, rationally, they say but thank goodness I have it.

Let's be clear on what the purpose of a public option for everyone should be. It wouldn't be to drive all the for-profit insurers out of business, it wouldn't be to cover every possible option of every possible current plan. It would be to set a floor. "This is the basic standard of health care that everyone in America should have, at the very least." For things above and beyond that, private insurers would still exist. And if it turns out they can't compete when they can't cherry-pick out the healthiest people, or drop people's insurance when they get sick, or deny claims until sick people and their families fight through ranks of phones for six hours?

Well, too bad for them. That's what the free market's supposed to do, right?

Any kind of publicly provided health system is designed, first and foremost, to set a bare minimum standard of care for our fellow citizens. One that provides people care when they're sick, some basic dignity, and the ability to not go bankrupt and lose everything they have if they get sick, and don't have to stay tied to a crappy job just so they have some access to medical care.

I don't give a crap if that involves "unfair" subsidies, "non-transparent" taxes, or an "unequal" field of competition with insurance companies. This isn't about protecting insurance companies, it should be about providing a basic standard of care for our fellow citizens, and our society as a whole.

Some of us have parents and grandparents who rely on it and it is worse than any insurance my parents ever had when they worked, and I hear about it all the time.

Obviously I don't want to inquire into your parents' private lives, so I'll offer as a hypothesis: many Americans reportedly do not realize how bad their healthcare situation is until they have something expensive go wrong with them.

At that point, they discover that the health insurance they'd always assumed would cover them, won't.

Someone who was lucky enough to get to the age of 65 and move into Medicare without having anything go really wrong while they were paying their private health insurance premiums, may compare Medicare to their private health insurance because they need Medicare more than they ever needed private health insurance.

(Further, of course, a person in the US who has and retains private health insurance until they become Medicare eligible is privileged above 40% of the population right away...)

But personal stories from individuals are anecdotal, and the plural of anecdote is not data. The data says quite strongly: overall, people have better experience of healthcare when they are on Medicare than when they are on a private health insurance scheme.

@Sebastian - Thanks for clarifying. I was unsure which quantities you were comparing. Perhaps the U.S. should seek annexation by Canada, though I couldn't adjust to bagged milk.

The department of Health and Human Services has a pretty good data set on health care expenditures as well (here). The principal weakness in that data set is that it reports "Hospital Care" as an undifferentiated item (it's one of the largest cost in all years).

I would like to see a comparison of health care systems that accounted for diagnosis, complications, treatments, outcomes, and expenditures. Are U.S. treatments more expensive than comparable treatments in Canada? Does the U.S. use more expensive treatments for comparable conditions? Are U.S. patients sicker? It's probably some combination of factors.

The summary numbers strongly suggest that the U.S. system is rather inefficient. It's plainly subject to analysis -- but that detailed analysis doesn't appear to exist.

Elm, a lot of this was discussed with Sebastian back in June this year (he cited this earlier post to me as his "source" on another thread). You might find it useful to read the discussion that went on then: Sebastian's assertions were refuted, but he appears to have paid no attention.

Jesurgislac has an interesting idea of refuted. Some people thought the fact wasn't as important as I do. It is interesting that it comes up in a different data set (the one you provided) which suggests that 'refuted' is rather Orwellian in this case.

Some people thought the fact wasn't as important as I do.

You cited that discussion as your "source". In that discussion, more facts that yours got cited. It was an interesting discussion, and yes, I think it refuted your claim that the direct comparison between US Medicare and Canada is sufficient evidence that the US can't run healthcare as efficiently as other countries.

I think it's worthwhile a newcomer reading that discussion, and then if they opt to continue to dig up sources and facts that refute your case, they do so in the full knowledge that such sources were already used to refute your argument four months earlier...

Jesurgislac, please respond to this or refrain from continuing to troll in the conversaation:

If you want a confirming source, is the OECD good enough for you?

It shows for example that in 2004 Canada spent $3,320 per capita on health care with 70% of it being government expenditures for a total per capita government expenditure on health of $2,324.

For that they cover their entire population.

It also shows that in 2004 the US spent $6,194 per capita on health care with 44% of that being government expenditures for a total per capita government expenditure on health of $2,725.

For that ($401 per capita more) they only cover 27% of the population.

I look forward to your carefully considered replies. Thanks.

Sebastian, please check out the points made to you in June, consider, and respond.

Sebastian, please check out the points made to you in June, consider, and respond.

Seriously, Sebastian: a whole lot of people made a whole lot of good points to you and about your claim back in June. You didn't respond to them then: now's your opportunity. Why not make a fresh post and attempt to refute the points made in response to your one-fact argument? Respond to the conversation that was started four months ago, rather than just repeating again what you said then as if nothing anyone said to you on that thread mattered.

Jes, that is a long thread. If you think there are unadressed points that are REALLY important, why don't you pick say the top three and link the directly?

But hey, I also provided cites RIGHT HERE. Maybe you could respond to them too?

I also provided a concrete example. Maybe you could respond to that?

Or perhaps you are engaged in trolling. I'm leaning strongly toward that conclusion.

So I'll be direct. Do you disbelieve the OECD cite I provided?

If the answer is 'yes', please let me know what kind of citation you find more helpful.

If the answer is 'no', please let me know what you think the problem with it is.

Thank you in advance for non-trolling behaviour.

"It works so well everywhere else."

Yes it does, MT.

Sebastian, Jesurgislac: I appreciate the reference to the June discussion. I haven't read the commentary and don't expect to have time to until this evening.

The contribution of pharmaceuticals cited (noted at 10%) in the June posting only includes retail sales. The chart referenced matches this HHS data set (NHE Web tables, page 2) and the term definitions make it clear that that 31% "Hospital Care" item includes drugs dispensed through hospital pharmacies for in-patient use. Notably, that includes expensive chemotherapy drugs and intravenous antibiotics. (I have friends who are nurses and the cost of drugs they dispense in a day far exceeds their daily pay.)

Of course, that doesn't account for the differences in expenditures but it is one specific hurdle I found when comparing data (even within one dataset -- the OECD data set is not uniform in this regard).

The OECD data suggests that the U.S. has relatively few hospital beds (of all types) but a high number of MRIs and CT scanners.

"Or, put in short form: requiring health care systems to be run profitably ensures that they will be run expensively. If you want best-quality healthcare at lowest cost, you need socialized health care: nothing else will do it. "

However, there is no proposal on the table anywhere that takes profit out of healthcare, just out of insurance, and probably not that. It also doesn't track that doctors who work for the NHS don't expect fair compensation as salary. And yes, Canada loses doctors every year to the US because they can make more money.

"Or, put in short form: requiring health care systems to be run profitably ensures that they will be run expensively. If you want best-quality healthcare at lowest cost, you need socialized health care: nothing else will do it."

Germany and Japan disagree with you, unless you think their health care sucks.

I don't know, but a bunch of them have been coming to the US for the higher income they can get here.

I'm going to need you to both quantify "a bunch" as a percentage of the total doctor population of those countries, and demonstrate that it's causing some kind of doctor shortage in those countries, before I even begin to give a shit about this sentence.

Germany and Japan disagree with you, unless you think their health care sucks.

Now THAT is a fact-filled rebuttal...

If you think there are unadressed points that are REALLY important, why don't you pick say the top three and link the directly?

I do think that there are many unaddressed points that were made on that thread that are really important - and which responded to the point you made then and are making unaltered now.

I'd like it if you took the time to write a post in response to that thread. Not by letting other people pick the important points from it, either.

"I'm going to need you to both quantify "a bunch" as a percentage of the total doctor population of those countries"

Phil,
Lots of references in Google here">http://www.thestar.com/News/article/201260">here is one from 2007.

Key points 1 in 9 Canadian trained doctors go to US and Ontario short 2000 doctors. Doesn't even count Canadians trained in the US that stay.

Baptism of the Dead.

When one cannot get through the door, call the door a "window." Or if Jesus is too Aramaic, call Jesus "Yeshiva."

Ugh.

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