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November 05, 2009

Comments

I'm sorry. This is so much horseshit. I wonder if you did such careful accounting prior to either of our latest foreign wars.

Nope?

Didn't think so.

But now that millions of Americans' health and thousands of lives are at stake, it's suddenly time to crunch and scrutinize and balance and weigh and...

Fuck.

People are dying, suffering. We have the money. The Republicans don't give a shit if people suffer and die, and you reveal yourself to be the same with your "measured" accounting crap.

You really, really aren't civilized or human.

So... It lowers the deficit less than the Democratic proposals, it does nothing to deal with the growing ranks of the uninsured, it doesn't deal with the actual root causes of malpractice suits, it doesn't change any of the incentives in the health care system, and it barely increases insurance company competition by allowing people to buy over state lines. It doesn't even address the conservatives' pet issue of people getting too much treatment "for free" under their insurance plans.

"It cuts insurance costs for current enrollees "by 7 percent to 10 percent in the small group market, by 5 percent to 8 percent for individually purchased insurance, and by zero to 3 percent in the large group market.""

So...single digit decreases for small businesses and the individual market, and next to no effect for people who get passable health insurance through their employers. That's not incremental, that's miniscule. It's hyperbole to say it's "better for people who have insurance" when most people who have passable insurance get it through the large group market from their employers, and would see next to no change from this plan.

That's...not really much of a plan, honestly. It doesn't address the biggest problems, or the root problems, and its "incremental effects" approach zero.

Have you, or any other conservatives, got a response to my (and others) points about the root causes of medical malpractice suits, and why 'tort reform' of capping the amount people can be awarded is more desirable than dealing with the underlying problems?

Seems Nate beat me to the punch, but then so did Ezra.

"The health-insurance haves -- who are the vast majority of people -- probably gain more under the Republican plan than under most Democratic proposals."

How does it do this?

"The Republican plan is likely better for more folks who ALREADY have insurance."

Von, you are obviously civilized and human, but your misspelling of "cake" here is annoying.

So the Repubs offer an ounce of change out of 10,000 tons of problem and that's acceptable because it's "incremental change"? Nonsense. This is just another "We don't really ahve a plan so we'll try to stop or stall the real one" crap the Repubs have been pulling since this "debate" started.

Compare "the Bush tax cuts were obviously better for those ALREADY making a million dollars ...."

I'm, like, nonplussed.

Yes, it depends on whether your yardstick is whether health care reform addresses the problem of 47 million Americans having no health insurance.

The idea that this is a problem of concern only to those people and not to people who have health insurance is laughable - as if we don't know any people without health insurance, don't worry that we might one day be unemployed and uninsurable, don't have self-employed family who are struggling with individual-market healthcare costs. I have health insurance today, maybe not tomorrow; I would like my children to be able to afford health insurance 20 years from now; I would like my uninsured friends to be able to see a doctor.

This post - and the Republican bill - are non sequiturs in a conversation about healthcare in America. The uninsured are not the only problem, but they are the most serious problem.

Of course, what von fails to mention is that the lower premiums would result from changes that allow the insurance company to cover fewer things than they are currently required to cover.

I could buy a really cheap policy if it only covered gall bladeer surgery performed in July.

As a data point, I've been in both the large market, small market, and individual markets for health insurance over the last year, thanks to my wife being laid off, hired, and laid off again, and me working two part time jobs that don't offer health insurance for part time workers. Most individual plans cost between $70 a month and $200 a month, per person, and the cheaper ones have deductibles ranging between $3-8K, and another $3-8K for the yearly maximum, which is not much better than nothing, if you get severely sick. If you had the money to pay that kind of deductible, you could afford one of the better health plans without that high deductible. Plus co-pays, and most have co-insurance even after your limit for the year. Even WITH these plans, getting severly sick would quite probably lead to bankruptcy.

It's not just a matter of getting people to "have" insurance, the insurance has to be worth a damn, otherwise people are just giving money to insurance companies and still losing everything they have.

And the small market health plan we had at her one job was nearly identical to some of the individual blue cross plans we could buy.

This is one of the many reasons I'm skeptical of the "magic of the market" to fix any of this, and why the savings in the Republican plan don't impress me at all. 10% (at best) off inadequate individual insurance is not going to help more people get covered or net any real savings.

The Angry Bear says "feh".

Bruce Webb's capsule analysis, based on the CBO scoring:

So what do we get from spending an average of just around $800 million a year? Essentially nothing

Here's another take.

Most days, Republican public policy just looks to me like handing government over to private corporate executive boards. And I do mean literally.

Quite often I have the same problem with Democrats, but the Republicans don't even try to disguise it.

Bran, on the off-chance that you elect to return, please peruse the posting rules and adhere to them from now on.

Thanks!

von had a yard stick a while ago. if i recall correctly it was that any reform should lower the deficit, ensure the uninsured and move away from the employer based system.

the house dem bill alone completely kills the republican bill by that criteria. the house bill with a stronger public option blows away both.

will von finally admit the right is just along for the ride on this issue and not really needed for ideas?

So I have one word for you here, Von.

Recission.

The GOP plan doesn't touch it.

So, once again, if you have insurance and you don't plan to use insurance and you don't like that your premiums are so high, then the GOP plan could help you out. Of course, so could canceling your health care plan entirely.

But if you do get sick, or if you have a pre-existing condition, or if you're buying insurance on the private market, or if you get laid off, or if the insurance companies decided to say "aw fuck it" and raise premiums another 30% next year... then it doesn't help so much.

The Democratic Plan's biggest problem is that it doesn't go far enough to address exploding health care costs. This isn't a federal budget problem. It's a national GDP devoted to health care problem. And the biggest festering pustule in that problem is the obscenely high administrative costs of private health care.

If you think the current private health care system is delivering quality health care coverage, I can see how the GOP plan might be appealing. But it's not. That's why the public option is such a fundamental aspect of reform. It's also why heavy handed regulations are such a key feature in coverage.

The GOP plan doesn't hedge administrative costs. It doesn't regulate an industry that has gone completely off the legal rails. And it doesn't offer anyone an alternative to corporate coverage.

Fail. Fail. Fail.

It cuts insurance costs for current enrollees "by 7 percent to 10 percent in the small group market, by 5 percent to 8 percent for individually purchased insurance, and by zero to 3 percent in the large group market."

It's important to note that this occurs in 2016 (check the pdf); since even the highest projected return is well below the annual rate of increase for health insurance, I doubt that anyone will notice.

Also from the report:
some provisions of the legislation would tend to decrease
the premiums paid by all insurance enrollees, while other provisions would
tend to increase the premiums paid by less healthy enrollees

Not only will it not help the uninsured, it may actually hurt the unhealthy who have insurance.

The share of legal nonelderly residents
with insurance coverage in 2019 would be about 83 percent, roughly in line with the
current share.

ie it does nothing to solve one of the two basic problems on the table (ie the other being increasing costs)

The second source of change in average insurance premiums is changes in the
average extent of coverage purchased .... Provisions in the amendment that
would reduce insurance premiums by affecting the amount of coverage purchased
include the State Innovations program, which would encourage states to reduce the
number and extent of benefit mandates that they impose.

So the CBO is projecting some savings bc of reduced coverage/increased deductibles and copays, rather than any improvement in bang for the healthcare buck.

the State Innovations
program would induce states to take some actions affecting the average health status
of people with insurance and people without insurance. For example, states that
loosened rating rules in the market for individually purchased insurance to allow
premiums to vary more on the basis of age would cause premiums for older people
to increase and premiums for younger people to decrease.

Again, 'improving' insurance costs by driving those who need healthcare out of the pools.

I was complaining a little while back that Republicans didn't have a response to Team Obama on health care. I take it all back. The GOP plan is pretty good, if you apply the right yardstick.

The only yardstick I can see where this could be preferable is if you hate the Dems bill and need an alternative to avoid being in favor of the existing broken system. Because this bill does virtually nothing to address any of the serious issues confronting healthcare today, and exacerbates some of the problems (eg driving unhealthy people out of the pools and into the ranks of the uninsured).

So Id consider this bill much worse than doing nothing, for two reasons:
1)It actually hurts more than it helps (unless you are an insurance or medical company)
2)It provides the illusion of doing something about the serious issues facing healthcare without actually doing so; should we punt and wait five years while tens of thousands die from lack of medical care, and health care insurance costs double again?

The health-insurance haves -- who are the vast majority of people -- probably gain more under the Republican plan than under most Democratic proposals

This depends on what you think people want. Personally, I find the prospect of not living in fear that a serious illness would cause my employer to find a way to get rid of me, cause me to go bankrupt, cause me to become uninsurable, and then kill me (or a family member) to be a considerably larger benefit than a 0-3% decrease in my insurance premiums (which, at current rates of change, would be swallowed up in 0-4 months of cost increases anyway).

This is a really unconvincing defense of this bill, von. Really. Honestly, I cannot imagine anyone who believes that there is even the slightest problem at all with the status quo thinking that this bill is anything other than a laughably bad response to that problem.

But the most important thing for me is that it reveals, in the starkest possible fashion, that when Republicans say they want reform and that they also believe it is necessary, they are lying. A bill that maybe lowers premiums a minimal amount for some people in a few years by by basically reducing their coverage, is not a response to a pressing problem. So that settles that issue at least.

If this is the Republican "solution" then I think anyone who is not a moron knows about just how much credence to give their protestations of negotiating in good faith.

So - the Republican plan costs much less, but provides no real benefits to anyone. Sounds like those fake health insurance plans that accept premiums but contain fine print excluding any real coverage.

See the St. Paul Star Tribune's article at http://www.startribune.com/lifestyle/health/65911582.html:

Health coverage 'plan' was no insurance at all

By MAURA LERNER, Star Tribune
Last update: October 25, 2009 - 11:10 AM

Mary Lloyd of East Bethel says she was "royally duped" into buying health coverage that wasn't insurance, and she's not alone....

Von,

I wish you and Andrew would learn one simple lesson: the moment you identify medical malpractice "reform" as a part of a health care solution, you brand yourselves as nothing more than the worst sort of republican hacks, the rest of whose arguments are unworthy of any attention.

Hmm, trade you med mal reform for more accountability for bad doctors, and the hospitals who shelter them.

Basically, in most states, you can find out more about the track record of your beautician than your health care provider.

A conservative radio talk-jock has compared people with preexisting conditions and thus no or very expensive insurance to drivers with DUI convictions and thus higher car insurance premiums. If one thinks that these two situations are morally equivalent, then you'll like the GOP bill.
If one thinks that there but for fortune go I, you will not support a plan that creates a special pool of high-medical-risk individuals slated for very high premiums. To push high risk out of the general risk pool defeats the logic underlying insurance. So not only does the GOP bill not address the uninsured, but it exacerbates the problem for sick or injured persons and encourages the practice of recission. As usual, IGMFU.

"Now, nothing in the GOP plan will satisfy someone who thinks that the current system requires immediate reform."

Thousands of people die every year due to lack of health insurance. What part of that problem screams for a solution of slow, incremental change? And what on earth gives you the idea that the republicans ever plan on tackling the tough questions? if they aren't tackling the tough questions now, then what the F are they waiting for? They aren't deferring on the tough questions, they are ignoring them just like they have for the last few decades and just like they will continue to do, because they dont care.

What, Von, you think this plan is just stage 1 of a more serious proposal? Give me a break. Yeah, the GOP plan is great if you just assume they left all the serious parts out for another day. Why didn't the democrats think of that?


How about the yardstick we use is "does it do anything to seriously address the problem" and not "is it barely more than the nothing you thought they had as a solution."

If you apply the yardstick of "incremental change" than an F looks great compared to an F-, but they are both still failures.

We'll file this one under, "Von understands only first order effects, and doesn't want to evaluate incentives when it comes to anything other than taxes."

Aside from the problems other people have mentioned, von's argument that this helps the large majority of people who have health insurance only holds if you assume that the percentage of people with health insurance remains a constant. Now, given the trajectory of health insurance premiums, what do you think the chances are that employers who are currently purchasing large group insurance, the group that doesn't see price drops, are going to continue to provide insurance?

This is nothing new, of course. I pointed out a long time ago that von's hobby horse that the bill does nothing to break the linkage between employment and health insurance only holds if you assume that the incentives for employers to drop coverage don't have any effect upon behavior. I wonder if he has been taking the same approach to discussions of marginal tax rates?

Another problem - a severe one - is that one of the methods that the GOP plan proposes to reduce costs is to limit what care is covered by insurers.

As a means of reducing the deficit, I agree with your analysis.

But that isn't really the whole purpose of reform, is it? Part of it is to reduce costs. The other part is to reduce the number of uninsured and under insured by a considerable margin. The Democratic House plan, according to CBO, reduces the percentage of uninsured from 17% to 4%.

It also reduces the deficit more. So even if we use the cost yardstick alone, the Democratic proposal is still far better. We have one plan, that has survived multiple committees, which reduces costs and the percentage of uninsured. And we have another plan, submitted as is, that reduces costs by less and doesn't reduce the percentage of uninsured at all.

I also find it consistently amusing that a political faction that loudly proclaims its support of States' Rights also loudly proclaims its support for Federally-mandated limits on civil suits that take place in State courts.

The Republican bill includes explicit language about recission. I'm not sure if it's meaningful because IANAL, but it says something about recission not being allowed.

You might just as well staple together 8 pages of A4 saying "No serious interest in reform". This plan benefits next to no-one, collects meaningless fluff into supposed policy, and in general illustrates that no-one in the GOP seriously cares about governing. If you want to find some sort of merit in that, you don't need a yardstick, you need a trip to the optician. Six months of supposed thought later, and this is the best the GOP can do? Pathetic!

This bill is largely unobjectionable, then, because it doesn't really do anything? Woop de doop. I guess we can give the Republicans credit for not proposing that we sacrifice virgins or kick puppies to solve our health care problems.

In all seriousness, though - there are a number of possible alternative plans, most of which are better than the one about to be passed, albeit probably politically difficult. Why are the Republicans not proposing one of these? Answer - because the have no balls. This is the Republican party of shameless pandering, which means it can only stand for things that are populist, pointless, and explicable in a 30 second sound-bite. Slightly lower premiums, mmkay?

Mr. Duncan, the 'anti-recission' part contains the exact loophole that insurance companies use today to rescind, i.e. "fraud" like misspellings on forms, forgotten 'preexisting conditions' ("you did not tell us that you had nausea one day in 1st grade and pimples in 3rd grade, you maliciously concealed that you had a bloody knee after soccer on July 7th 1962 etc. and now you expect us to pay the treatment for the Lyme infection you got from that tick last Wednesday? Be grateful that we do not sue YOU")etc.

Getting to the point of the "health insurance 'haves'" benefitting from this proposal. Not necessarily. Not likely It is my understanding that the GOP tries to accomplish this little bit of legerdemain by allowing insurance companies to cross state borders with their policies (as opposed to the current situation in which state laws must apply to the folks living in those states, regardless of the state out of which the insurance company operates). Currently, insurance companies must abide by the rules of the individual states if they sell policies in those states. They try to get around it in various ways, but the bottom line is that states still can demand certain behavior from insurers. If this system is changed, as the GOP plan would like to change it, there is going to be a slide to the lowest common denominator. So while it might cost the customer less out of pocket initially, what these "haves" will find is that their insurance covers less than they previously had. There is no free lunch here: the "haves" will be paying less for less -- and probably much, much less than the lower payments imply -- because these companies are "for profit" not "non-profit" and Wall Street just loves it when companies post bigger earnings. In this case the bigger earnings come not from economies but from denials of coverage while raking in premium payments.

Thanks, von. I can't wait to buy my health insurance from a Delaware corporation.

I am also grateful to finally know that all discussions and disagreements can be smoothed over by simply finding a different yardstick. That really helps.

This blog is adrift.

Von, I see no evidence of any measure of success I would recognize here. I regard a system of payment for health as having four goals:

(1) Improve the general public health;

(2) Embody a sense of fairness and social solidarity;

(3) Enable entrepreneurship and economic risk, i.e. avoid locking people into the waged work force, and avoid locking companies into escalating health care costs;

(4) Foster best medical practices, and techniques which contain costs.

This blog is adrift.

Feel free to disembark.

This bill is largely unobjectionable, then, because it doesn't really do anything? Woop de doop. I guess we can give the Republicans credit for not proposing that we sacrifice virgins or kick puppies to solve our health care problems.

Well, it does something: It improves the defict and it lowers health care costs for most folks. But your fundamental point is right: The Republicans have effectively proposed doing serious reform later .... presumably, when they're in charge.

I wish you and Andrew would learn one simple lesson: the moment you identify medical malpractice "reform" as a part of a health care solution, you brand yourselves as nothing more than the worst sort of republican hacks, the rest of whose arguments are unworthy of any attention.

Nice to see the plaintiff's bar represented here, Casey.

The health-insurance haves -- who are the vast majority of people -- probably gain more under the Republican plan than under most Democratic proposals

Von, as a "have", in that I have access to an employer-sponsored HDHP (which is a terrible mis-match to the health care needs of our family and is our only option for insurance) can you explain how I gain ANYTHING in this proposal? I might, possibly, save 0-3% on my insurance by 2017 if you assume that my employer would pass those savings on to it's employees. On the other hand, my premium cost grew nearly 20% just last year. It grew almost 18% the year before.

Von: and it lowers health care costs for most folks.

I think you mean that it lowers health insurance costs for most people.

Their health care costs are likely to be even higher.

von, with all due respect, your last comment makes no sense.

Supposedly the Republican plan improves the deficit, but insignificantly and nowhere near what the Dem plan does.

Supposedly it lowers health care costs for most people, but as Jes points out what it really lowers are insurance costs. And it does that, as pointed out several times, by reducing coverage. So, in fact, actual out-of-pocket costs for healthcare for most people will rise.

And nice mind-reading of Casey. Might be worthwhile to discuss the substance of her comment. I keep hearing the phrase "tort reform" but I have yet to hear what type of reform you are talking baout that the Federal government can do.

Perhaps it would be worthwhile to define what you mean so people can respond more appropriately.

The Republicans have effectively proposed doing serious reform later .... presumably, when they're in charge.

I think we know what their real reform plans are. To my knowledge they still dream of at last killing Medicare and Medicaid (not to forget Social Security). It's not as if it was a well kept secret. They just haven't found a way to do it without committing suicide yet.

Here's the flaw in the reasoning:

Bush: PEW PEW! KABOOM! And that's how we're going to TOTALLY demolish Saddam's army, conquer Iraq, set up a democracy, improve the lives of the Iraqi people, and lead to a wave of freedom that sweeps across the entire middle east!

Advisor: I'm not sure its going to be done with little green army men.

Bush: Right, right. I'm just explaining visually. We've actually got a great plan right here.

Advisor, reading papers: Oh, yeah. This is actually pretty good. But I can't help but notice that this plan only goes up to the actual invasion.

Bush: Yeah, so?

Advisor: You said we were going to 1. take down Saddam, 2. establish a democracy, 3. improve the lives of the Iraqi people, and 4. use that as leverage to democratize the entire middle east.

Bush: Yeah, so?

Advisor: This plan is only step one.

Bush: But its a TOTALLY AWESOME step one!

Advisor: Right, but shouldn't we have a step two through four?

Bush: Why?

Advisor: Well, your critics are going to argue that their plans, which cover all of the steps up front, or which are otherwise complete plans for entirely different middle east policies, are better than a plan that covers only step one out of four.

Bush: They're using the wrong metrics. If you judge my plan only on the basis of how great it is at step one, then my plan is awesome.

Advisor: But its just step one.

Bush: Just assume that I'll come up with equally awesome for steps two, three, and four.

Advisor: Assume?

Bush: Surely you aren't suggesting that I've come up with a plan that covers the only part of the project I actually care about, and that I will swiftly lose interest in the entire matter once its implemented, having by implementation of my plan closed doors that were once open to us, locked us into a course of action for which we have no preparation, and preventing the implementation of useful, meaningful policies that might complete the work I've begun?

Advisor: ...no. I can't see why anyone would possibly think that.

von: Again, if 80% of people are in the large pools, where they get only 0-3% insurance cost decrease, how does it lower costs for "most folks"? 3% is really negligible. On a $300 policy, it's all of $9.

And why do you (and other conservatives) think that capping awards and making it harder to sue is a good way of dealing with malpractice insurance costs? Wouldn't it be better to implement checklists that would help prevent malpractice in the first place, open records so people don't have to sue to find out if there was malpractice, and do something about health care costs and the tie to employment so people don't need awards of $many millions to pay for their health care costs and "pre-existing condition" for the rest of their lives?

I hope this isn't taken as a thread-jack or a diversion, but I'm unclear on the tort-reform arguments with respect to health care. I don't know how much medical-malpractice suits and insurance play into health-care costs, but it does seem clearer to me that defensive medicine does play a significant role and is significantly driven by potential lawsuits.

One of the recurring themes in Atul Gwande's writings that I've read is the over-testing that goes on in this country contributing to our bloated heath-care spending without doing much to improve public health. In fact, I heard him say on the radio that tens of thousands of cancer cases could be attributed to the over-use of CAT scans - a case of poor risk management, I suppose, having a negative net effect on health.

With that, it seems that simply capping awards is a blunt instrument that would certainly reduce payouts in malpractice suits, might do something to reduce malpractice-insurance premiums, and probably would do very little to reduce the practice of defensive medicine, not to mention result in some cases of serious misjustice.

So my question to the group is, what sort of malpractice reform, if any, would be helpful in improving our health-care system?

But your fundamental point is right: The Republicans have effectively proposed doing serious reform later .... presumably, when they're in charge.

Huh? Well, they were in charge recently, and they did diddly-squat. And if they actually did have some alternative ideas about how to do serious reform later when they're in charge, why not out it forward now to get them a hearing?

It's obvious that the Republican party has no real interest in serious reform, and their noises to the contrary are dishonest. This attempt to give them the benefit of the doubt is pretty feeble.

Err... make that "put them forward now."

FTR, I started typing before Nate's comment showed up.

I think my main point is this: Anyone addressing the "problem" in good faith will measure a solution by how well it addresses that problem. Anyone trying to make a piece of sh*t look better is going to try to redefine the yardstick, or redefine the "problem," or redefine what "solution" means in the common use of the English language.

Yeah, the Republican's plan for comprehensive health reform is great because ... wait for it... its not comprehensive. What?

"But your fundamental point is right: The Republicans have effectively proposed doing serious reform later .... presumably, when they're in charge."

Seriously, Von, I don't want to be rude, but no one here is dumb enough to believe that Republicans plan on enacting more serious reform later. I think people like you were arguing that same point against Hillarycare 15 years ago. republicans have had the house, senate, and presidency since then and have done nothing while the problem has grown worse. This proposal confirms that they are not serious about addressing this issue.

Thousands of people die every year due to lack of health insurance.

I realize that this is kind of a rhetorical shorthand, but in all the millenia before health insurance came to be, no one ever died due to not having it.

I want to ask von again:

"The health-insurance haves -- who are the vast majority of people -- probably gain more under the Republican plan than under most Democratic proposals."

Again, how does it do this? It sounds like it can only do so by allowing insurance companies to offer coverage that doesn't do anything, and by allowing them to pool only healthier people. So it would only help the "haves" who didn't get sick.

Reading this reminded me of the old gag about a student who, when tasked with writing a 25-page paper, did so - with exactly one word per page.

His grade was a two-page response, and it applies beautifully here:

YOU
FAIL

There's contrarianism that's interesting and important, and then there's contrarianism for its own sake. Type #2 doesn't require much if any actual thinking from the contrarian.

I'm afraid this post is a clear example of #2. The other commenters have explained why far better than I could.

"I realize that this is kind of a rhetorical shorthand, but in all the millenia before health insurance came to be, no one ever died due to not having it."

In the millenia before health insurance, how many people were denied treatment due to not having it?

I realize that this is kind of a rhetorical shorthand, but in all the millenia before health insurance came to be, no one ever died due to not having it.

I am not exactly sure what you mean by this but it doesn't strike me as an accurate statement. Health insurance is a system implemented to try to stabilize both the risks and care for illnesses over a large group of people. Before such a system, which is to say, absent such a system, both the quality and availability of health care varied wildly and, for the most part, was proportional to wealth. Quite certainly many, many people died over the millenia because they lacked adequate care because they lacked

1. access to the shared information about illnesses and effective treatments that exist as part of a health care system like health insurance

2. a means to pay for care

3. the means to even diagnose illnesses properly.

Historically speaking, this seems undeniably true so I am not exactly sure what you are getting at in your comment.

In the millenia before health insurance, how many people were denied treatment due to not having it?

None, because there wasn't any to be had.

Almost certainly there were people denied treatment, though.

Hmm, trade you med mal reform for more accountability for bad doctors, and the hospitals who shelter them.

Yeah, I think the Dems would do well to embrace some kindof med-mal reform and undercut the Repubs a bit. It's certainly a worthwhile bargaining chip.

(Digression: Where are the Repubs who're appalled at the extension of Commerce Clause power? Congress regulating state torts? Good lord.)

But the med-mal system *is* broken. It's a lottery. Most people who should recover, don't. Some people recover big who are just lucky. Litigation is a piss-poor solution to med-mal.

But as Hairshirt noted, damage caps are a silly non-solution. If we're going to keep litigating med-mal, then egregious cases -- hospitals that won't make doctors wash their hands -- SHOULD get hammered with huge verdicts.

Damage caps just make med-mal cases too expensive to try. Plaintiffs' lawyers take cases in the hopes that the bigger payoffs will pay for the failed cases and the pyrrhic victories (verdicts too small to do much more than pay the costs of suit).

Cutting off the big payoffs simply leads to worthwhile cases getting turned down because, while they might recover, they might not, and they might not pay enough.

(And I represent nursing homes in med-mal cases, so please don't mistake me for a "representative of the plaintiff's bar.")

I realize that this is kind of a rhetorical shorthand, but in all the millenia before health insurance came to be, no one ever died due to not having it.

Wowzers. Just like, before penicillin, no one ever died due to not having *it*.

None, because there wasn't any to be had.

Hmmm. I guess I sort of see what you are saying then but I have no idea why you think its relevant. Setting aside that we are talking about now, and we do have health insurance now, it is still a perfectly reasonable statement to say that people died because they didn't have it then. As Anderson points out, you could make your same point about penicillin, but it baffles me that you think this is a more accurate or helpful view of the utility of health insurance or any element of modern medicine. People died because they lacked some of the systems of health care that we have today. People die today because they lack access to those same systems. What do you think is a more accurate way of making those points?

"Yeah, the Republican's plan for comprehensive health reform is great because ... wait for it... its not comprehensive. "

Boehner and gang have consistently said that they are not for "comprehensove" health care reform. It is not changing the yardstick to evaluate if they have moved health care reform forward in a way that allos us to take another controlled step at the appropriate time while moving in the right direction.

The Re publicans have steadfastly said that a huge monolithic all inclusive healthcare reform will cost too much, add too much government to the mix and =accomplish less than promised.

They have been accused of not offering an alternative in line with those basic concepts, now they have.

So like it or dislike it, it is completely consistent with what they have presented all along in words, amendments etc.

The alleged reform to medical malpractice here is the wrong sort of reform.

Caps on malpractice damages provide a direct benefit to malpractice insurers but it's unclear whether the rest of society benefits or not. Unfortunately no evidence exists to determine whether awards above-the-proposed-cap are justified or not. In some cases, a cap would prevent the plaintiff from receiving an unjust reward -- but isn't that the job of defendant's counsel? In other cases, a cap allows a negligent defendant to avoid justified punitive damages.

Capping damages also does nothing to protect competent practitioners who are sued due to a bad outcome -- in spite of following accepted diagnostic and clinical practice. These cases will still be cheaper to settle than to litigate.

Meaningful malpractice reform would establish standards of medical practice for medical treatment. I'm not very legally sophisticated, but if I understand correctly, medical malpractice suits today rely on dueling experts -- probably the most expensive but least reliable way to introduce evidence about what is and is not a reasonable plan of diagnosis and treatment.

von:

Add me to the growing list of people who wants you to do a detailed front-page post on what type of tort reform you want to see and why you think it will substantially lower health care costs without screwing those who have been legitimately harmed by malpractice.

It looks like I'm in substantial agreement with Anderson's 11:33 post.

I'm not the person who made the November 5 6:48 comment. john casey did, not CaseyL (me). I do agree with what that Other Casey said, but I'm not the one who said it.

If you do want to know what I say to von's post, I will be brief: Apparently von has decided to become a spoof.

I realize that this is kind of a rhetorical shorthand, but in all the millenia before health insurance came to be, no one ever died due to not having it

Likewise, no one in all those earlier millenia died from, say, not getting antibiotics that didn't exist. So would you say that people who die today of curable bacterial infections didn't die for lack of antibiotic treatment?
ie the counterfactual doesn't really work- in earlier millenia there wasn't effective medical treatment, and medical treatment wasn't incredibly expensive- both preconditions for people dying for lack of resources to pay for health care. Just as there were no effective antibiotics.
I guess Im not really sure what point you were trying to make.

Well, it does something: It improves the defict and it lowers health care costs for most folks.

It does the latter by forcing the unhealthy out of the pools and reducing coverage/increasing deductibles and copays.

And, as Jes pointed out, you are bluntly misstating the case- lowing insurance costs by reducing coverage does not necessarily lower health care costs, when those lower costs come with reductions in coverage. The CBO scored changes in insurance costs but explicitly did not score changes in health care costs- so you are either not reading your own cites carefully or intentionally misleading on this point.

But your fundamental point is right: The Republicans have effectively proposed doing serious reform later .... presumably, when they're in charge

Of course, they haven't said that- you're saying that for them, because obviously capping malpractice suits and allowing for least-common-denominator state law to control insurance practices isn't a solution. But it isn't clear that they're saying that.
This is similar to an argument you used earlier against the Democratic proposals: you imagined follow-on proposals that you didn't like, and opposed both those unappealing (to you) follow-ons and the initial (apparently unobjectionable) Dem proposal. Here, you imagine that this milquetoast bill will be followed by one you like, and therefore support both the ineffective current bill and the imaginary future bill as a package deal.
Funny, I don't find that to be a particularly persuasive argument, particularly when the GOP could put forward their real bill today (with exactly the same chance of passing as this proposal- zero), and we could see their real proposals, measure them against the current Dem bill (ie not the imaginary future Dem bill). But you want us to compare the imaginary Dem bill against the imaginary GOP bill...

I'm not going to join the von-bashing, for the simple reason that von is clearly not defending this 'proposal'. He has said quite directly that it's only marginally better than nothing - and you have to get the squinting right to make out the putative benefits.

It is by far the most clear-eyed and level-headed 'right'-leaning assessment of the 'plan' I've read so far. I appreciate the lack of smoke and mirrors.

Beyond that, my foggy brain has little to add: I will however, notice that in the world of "ordinary" business - street-level business of the usual buying-and-selling variety, a 10% discount is a 'thanks for your business' discount: a gesture of good-will, more than a meaningful savings for the customer.

A discount of *less* than 10% is no doubt significant to the counters of high-volume beans - like the ones that work for the health-insurance cos - but any human being trying to get health-care costs under control will see such a puny "reduction" in insurance rates as more of an insult - a meaningless technicality, providing no actual benefit.

Again, thanks to von for not concocting some bogus attack on sense in an effort to defend a proposal he sees little value in. This is a great example of what's good about ObWi.

It is not changing the yardstick to evaluate if they have moved health care reform forward in a way that allows us to take another controlled step at the appropriate time while moving in the right direction.

Setting aside all of the ways in which their "step" is a step in the wrong direction, Republicans have also stated that they also believe the status quo is unacceptable and they are also for meaningful reform. Their plan does not support that claim.

The argument you are positing here to defend the meaningfulness of this proposal could just as easily support not doing anything at all and calling it reform. Again, if this plan constitutes reform in any sense of that term, it is only in a context where one believes that there is no serious and pressing problem. People dying because they lack insurance. People going bankrupt despite having insurance. Employers being priced out of the market and annually paying more for fewer benefits for their employees. Seriously ill people fighting with their insurance companies on a daily basis over what they will cover. If nothing else, their proposal has clarified that the GOP has no interest at all in addressing any of these issues in any serious way despite the fact that they have said that they would. So, as I said before, at least that issue is settled as definitively as it could be.

Yeah, I think the Dems would do well to embrace some kindof med-mal reform and undercut the Repubs a bit. It's certainly a worthwhile bargaining chip.

It's only a bargaining chip if you can get something in the bargain. Can you identify any members of Congress who are now planning to vote against healthcare reform but will vote for it if some sort of malpractice reform is added?

"So like it or dislike it, it is completely consistent with what they have presented all along in words, amendments etc."

Actually, John Boehner said the republican plan would stop discrimination based on pre-existing conditions and cover millions more americans than the democratic plan. It does neither of these things. Therefore it is not consistent with what they have said all along.

http://thinkprogress.org/2009/11/03/boehner-preexisting-conditions/

http://congress.blogs.foxnews.com/2009/11/02/republicans-preparing-alternative-health-care-reform-bill/

Nice to see the plaintiff's bar represented here, Casey.

If the defense bar is going to be on the front page, it seems only right that the plaintiff's bar should be in the comments.

@Harmut:
the 'anti-recission' part contains the exact loophole that insurance companies use today to rescind

In principle, it narrows it:

A health insurance issuer may nonrenew or discontinue health insurance coverage of an individual in the individual market based only on one or more of the following: [...] (2) Fraud The individual has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage, including intentional concealment of material facts regarding a health condition related to the condition for which coverage is being claimed.

(Proposed amendment is bold.)

The key phrase would be "related to the condition". However, that the definition of fraud is expanded to allow for "legitimate" rescission while no definition of "illegitimate" rescission is given is telling, and I suspect the above loophole is indeed wide enough for much unscrupulous wiggling to pass through. I find the "anti-rescission" measures in the Boehner version generally unsatisfying.

Nombrilisme Vide, how can an "including" clause narrow the definition? It's just giving an example of one possible sort of fraud. It doesn't say other things are now not fraud.

KC, the current practice of rescission is to rescind based on non-related "factors". That this specifies the factors must be related is the narrowing I referred to. However, on consideration, you managed to identify the source of the unease this "addition" inspired in me. You're exactly right that this is already the clause justifying rescission, and all the amendment does is add an example of what we the public would count as legitimate without barring what we consider illegitimate.

It's a cute rhetorical trick, and I fell for it, albeit with incoherent reservations.

I think we need a Venn diagram.

It cuts insurance costs for current enrollees "by 7 percent to 10 percent in the small group market, by 5 percent to 8 percent for individually purchased insurance, and by zero to 3 percent in the large group market."

But followed a bit later in the letter by "CBO’s assessment was that the amendment would not have a substantial effect on actuarial values." This is a pretty blunt statement: the reductions in insurance costs are the result of reduced benefit payments, which are in turn due to fewer things being covered. So yes, people currently with insurance will be better off if they don't need treatment for the things that are no longer covered. Individuals who do require such treatment are almost certainly worse off, as the cost of treatment is no longer spread across the risk pool.

Quoting the first part without the second seems to be at least a little dishonest.

"In all the millenia before health insurance came to be, no one ever died due to not having it."

"In all the millenia before housing came to be, no one ever died due to not having it."

"In all the millenia before secure food supplies came to be, no one ever died due to not having them."

"In all the millenia before national defense came to be, no one ever died due to not having it."

This is fun.

People died from infections, or exposure, or they starved. They didn't die from not having health insurance, or from not having access to public housing, or from not having food stamps.

"no health insurance" will be perhaps be listed as cause of death on a death certificate, someday. But not now.

I can see the literal point you're making, Slarti. I'm just not sure what to do with it.

In all the millenia before tedious pedantry came to be, no one ever died due to not having it.

It does remind me of a couple of things: the Motorhead song "Killed by Death" and the old joke about it not being the fall that killed the guy, but the sudden stop at the end.

People died from infections, or exposure, or they starved. They didn't die from not having health insurance, or from not having access to public housing, or from not having food stamps.

LOL. Seriously, what are you on about? If I die while walking in the desert, it is just as accurate to say that I died because I couldn't get to water as it is to say that I died of dehydration. The former merely adds a perfectly salient detail to a reasonable explanation for my dehydration.

Now, if you really want to make the point that the most precise linguistic way to offer explanation for a person's death is to exclude such details, I guess the argument could somehow be made but, again, I have no idea what the point would be of making such a distinction. The assertion that I died because I lacked access to water would still be a true and accurate statement that adds salient and important information to the understanding of my death. I didn't, for instance, dehydrate while sitting on the edge of an oasis or with a full water bottle in my hand.

Actually it reminds me of Jonh Allen Paulos's whimsical question: given that 5% of all the human beings who ever lived are alive today, with what statistical confidence can we reject the hypothesis of immortality?

Given that vastly more insured people die in America every year than uninsured ones, with what statistical confidence can we reject the hypothesis that health insurance is fatal?

--TP

People died from infections, or exposure, or they starved. They didn't die from not having health insurance, or from not having access to public housing, or from not having food stamps.

This is just semantics, playing with different proximal level of cause.
I mean, no one dies of a ruptured aorta either- they die from the blood loss subsequent to that ruptured aorta. Or, no, that doesn't kill them either, it's the subsequent loss of oxygen to and CO2 from the brain that kills them really. Or maybe it's the biochemical reactions that occur within the brain cells in response to this lack of oxygen and excess of waste products.

I think it's pretty clear what's meant when we say that someone died because they didn't have health insurance; Im used to seeing your contributions add more than this, so Im still thinking that Im missing your point. Maybe you could restate without your usual admirable pithiness?

Or, I'll hazard one interpretation- do you mean to say that "X died from lack of health insurance" is like saying of a person who falls off of a tall building "X died from the lack of a gigantic pillow"? That is, the counterfactual isn't the cause of death itself even if it would've prevented it? That it's like saying "X died because of a lack of magical all-disease-curing pills"?

von - Regarding the idea that Republicans will do serious reform "when they're in charge". They were in charge! Not only did they not do it, they added Medicare Part D, which has changed medicare from a barely sustainable program to totally insolvent one. They're own think-tanks are telling them reform is necessary. Why did they not propose anything serious then, and why are they not saying anything serious now?

The shamless unseriousness is sickening. But if the Republicans really want to play no role in shaping legislation, and pretend this is a parliamentary democracy where the opposition can only heckle from the sidelines, they could at least say something useful. For example, they could take the unpopular but worthy high ground and point out that any serious reform effort has to start taxing employer provided healthcare benefits. Do they? No. Because they've been reduced by the Rove/Bush playbook to shameless anti-tax populists and not serious fiscal conservatives.

'Tis better to have been insured and lost then never to have been insured at all.

Give me liberty or give me death, yelled Michele Bachmann, but give me my socialist, taxpayer-funded flu shot under my socialist health plan so I can show up at the rally to yell "give me liberty or give me death".

The tree of liberty is watered by the blood-borne diseases of patriots who are too proud and too cheap to fund federal grants to fight blood-borne diseases.

Slart: "They didn't die from not having health insurance, or from not having access to public housing, or from not having food stamps."

Since we're just playing around with the language, may we say they died from not having health, or from not having housing, or from not having food?

I'm not sure where or what that gets us.


This bill is worse than crap. The only thing crappier is Von's analysis.

Title III strips all ability of States to regulate individual health insurance. It is very explicit to the point of mandating a disclaimer in LARGE ALL CAPS that policyholders have no protection from their own state on: coverage, rates, underwriting or application of Consumer Protection Laws. Since the bill also defines 'State' as explicitly including island dependencies including the Virgin Islands, Guam, American Samoa and god help us the Northern Marianas in theory by simple declaration of the insurance companies you could have all individual health insurance regulated by the same guy responsible for regulating work conditions in the Chinese owned sweatshops. And given Boehner's past tightness with N. Marianas lobbyist Jack Abramoff (which included Boehner's ex-Chief of Staff organizing a golf outting there in 1996) this is not beyond imagination. If you like what the Cayman Islands did for bank transparency you are going to love the O'Boehnerplan for insurance regulation.

And almost all the savings and revenues in the bill are the result of sheltering doctors from lawsuits.

This bill does exactly zero for the vast majority of the American people. It does line the pockets of insurance company executives and incompetent surgeons so I guess that is all good.

but, again, I have no idea what the point would be of making such a distinction

To troll a discussion on healthcare and denial of health insurance. What else?

Works, too, doesn't it?

Quis trolldiet ipsos trollers. So to speak.

I don't know how much medical-malpractice suits and insurance play into health-care costs

2-3%, so unless "malpractice reform" means totally doing away with malpractice lawsuits and insurance premiums, we aren't talking that much, probably 0.5% of health care costs.

matth: You are correct. The CBO estimate for the proposed medical malpractice changes would result in a 0.5% (one half of one percent) reduction in total national health care spending.

Am I the only one missing Hilzoy right now?

She could slap this siiliness from Von and have him thanking her.

She would do so without mentioning the obvious. So out of respect for her neither will I.

"I realize that this is kind of a rhetorical shorthand, but in all the millenia before health insurance came to be, no one ever died due to not having it."
..........................................
..........................................
Yes, and that's partly because the health insurance industry hadn't become a middle man that managed to get between patients and doctors. I assure you, if we took the health insurance industry out tomorrow and shot it, the American people would shed no tears. What's the next rhetorical trick - before fire came into general use, everyone ate mammoth sushi? Before the Constitution, the American people never missed their rights?

In the millenia before health insurance, how many people were denied treatment due to not having it?
None, because there wasn't any to be had.

Almost certainly there were people denied treatment, though.

Posted by: Slartibartfast | November 06, 2009 at 11:26 AM
.......................

And the fact they died as a result of not getting treatment? Well, obviously not connected to a lack of health insurance, was it? This was probably the worst ObWi posting in the past year and glib rhetoric by Slarti only makes it worse.

Hard as rocks Double Bubble and stale off-brand chocolate, the Voñata still satisfies like an unexpected invite to a birthday party where you can see through the blindfold.

The CBO's numbers are out on the GOP's health care plan and they are .... well, not bad. If you measure it by the right yardstick, that is.

Someday, von, I really hope you'll look back at posts like this and cringe, thinking something along the lines of, "did I really write that nonsenes?" Because the premise of this post is so poorly-reasoned, so strained and forced, that I'm embarrassed /for/ you.

Sure, if you entirely remove the GOP "plan" from the context of health care reform, don't compare it in an apples-to-apples way with any other existing plan, and evaluate it solely on its own policy merits, then--under these contrived conditions--it manages to not entirely suck out loud.

It does so in much the same way as my old Radeon 9800 Pro--installed on a five-year-old computer, and used to play a ten-year-old game--is a pretty good video card. But this is not a meaningful comparison. When compared side to side with my current video card at the same quality settings and on the same hardware, used to play a contemporary game, it becomes immediately clear that it's obsolete and that there's no comparison at all. And if I asked someone for a recommendation on what video card I should upgrade to for gaming, and they enthusiastically recommended this card because it wouldn't cost nearly as much as a new one and would work just as well, I'd suspect that they had a spare old Radeon that they were trying to unload.

If the PC gaming analogy flies over anyone's heads, don't worry about it; the point should be clear as day without needing to understand the specific terminology. We're not grading health care reform on a curve. The GOP isn't offering this as /part/ of a larger reform package--they're offering this as an /alternative/ to doing any of what the Democrats want to do. The fact is that when compared side by side with the Democratic plans, the GOP's so-called alternative is a farce that at best will keep health care costs from going up any /further/. It does nothing to reduce costs, address preexisting conditions, or do anything resembling actual reform. It's the health care reform equivalent of rearranging the deck chairs on the Titanic. You simply can't spin that away by holding the GOP bill to an entirely different standard than the one to which you hold the Democratic bills.

playing with different proximal level of cause

On the other hand, maybe it's going with a less distal cause. Or we could go with a more distal cause; that people die from being borne.

Or we could just settle on that this is a very subjective thing, and that lack of health insurance works as a cause of death from your POV, but not from mine.

Imagine the following situation: I get into my car and don't put on my seatbelt, while the passenger next to me does. I run into a telephone pole at 45 mph. No airbags in the car. My head goes through the windshield and I die, while my passenger escapes basically unhurt.

Looking at this sort of situation, I'd say that I died from not putting on my seatbelt. Slartibartfast would say that we should just settle on that this is a very subjective thing, and that lack of seatbelt restraint works as a cause of death from my POV, but not from his. I'd say that this is an example of arguing in bad faith.

But, Slarti, do you agree that people without health insurance have died sooner than they would have if they did have health insurance? (Everybody dies someday, regardless, of course.) Lacking health insurance in and of itself is not something that causes death, to be sure. But people have died from curable illnesses and conditions for lack of treatment due to a lack of insurance. I think it's clear that this is the meaning of "died because he didn't have health insurance." In many cases, changing that one factor would have prevented the death that occurred because of whatever other contributing factors there were. (What's so controversial about this?)

I'd break it down this way:

If (A and B), then C.

A

Therefore: If B, then C.

It's pretty obvious that we're talking about people for whom something sufficient existed to cause their deaths if left insufficiently treated - a necessary prerequisite, if you will.

It's fine if you don't like to use the rhetorical shorthand "died for lack of heath insurance." Don't use it. No one is making you. But don't pretend not to know what it means and try to characterize is as being absurd.

...they added Medicare Part D, which has changed medicare from a barely sustainable program to totally insolvent one.
It did, however, effectively transfer a lot of money from Medicare to the drug companies. Never lose sight of who the Republican party really works for.

lack of health insurance works as a cause of death from your POV, but not from mine.

Perhaps we can all agree that it sucks mightily for 15% of the people in this country to have no health insurance at all.

I hope so, anyway.

In 2010, 17% of the non-elderly in the US will be uninsured.

Under the Republican plan, by 2019, 17% of the non-elderly in the US will be uninsured and the deficit will be cut by $68 billion and there will be 50,000 deaths a year caused (yes caused) by lack of health insurance.

Under the Democratic plan, by 2019, 3% of the non-elderly in the US will be uninsured and the deficit will be cut by $104 billion and there will be 8,000 deaths a year caused by lack of health insurance.

Do people who support the Republican plan think "it sucks mightily" that there would be millions of people uninsured under that plan? Perhaps in the sense of "it sucks to be you if you're uninsured". But they are willing to pay higher taxes if it keeps those people from being insured. The Republican plan is objectively pro-death. And it is the opposite of fiscally conservative - supporters of the plan are willing to spend huge amounts of taxpayer money as long as that money is being used to help cause the deaths of poor and middle class people. That's ugly but reality is ugly.

I can see why people who support spending huge amounts of money to cause the premature deaths of 50,000 people a year don't like to admit that denying health care to sick people causes their deaths. It is a monstrous thing to do in a country as rich as the US. But refusing to treat sick people does cause their deaths, as surely as if Congress passed a law that said 50,000 people a year would be picked at random from the poor and middle class, taken out of their homes, and shot to death in the street.

The whole idea that there is some sort of decision to be made between two comparable plans is ludicrous. It's like if you went grocery shopping for your family and you saw that a gallon of fresh milk was $3 and a quart of spoiled milk laced with cyanide was $5 and you thought, "Aw geez, another tough decision".

It's insane.

220-215, bitches!

Happy day!

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