A "Conservative" Healthcare Market

by Ugh

Since the ACA has come up in so many threads lately I thought I'd ask what a functioning, "conservative" market in health care in the United States looks like?  It's not clear to me from comments what such a thing would be or how it would operate.

Do we all have insurance?  Do we treat it like any other market and do fee for service/good?  What role (if any) does the government have to play?  Is the current system just fine?  

I'm genuinely interested.  Thanks!

Update:  Other questions:  What is wrong with the current U.S. health care system, if anything?  How do we move from the current system to whatever is the preferred conservative alternative?

Comments

[Countme-In]

"I'd ask what a functioning, "conservative" market in health care in the United States looks like?"

Picture chickens and/or other poultry (obviously suburbanites living under codes strictly limiting the raising of barn animals would be at a disadvantage in this scheme) being exchanged by would-be patients for medical services and procedures.

Hers's some help with the picturing:

http://www.photographyblogger.net/19-great-pictures-of-chickens/

Further picture medical practitioners saving up whatever number of chickens would be required to purchase MRI machines and such.

Imagine ambulance crews inquiring whether the elderly woman bleeding to death while balancing the chicken on her head would like to trade her chicken for a ride to the emergency room and her responding: "No, I need the eggs."

[cleek]

i'll guess:

Dr. graduates Dr. school, leases a space in a strip mall, hires a cute receptionist, starts taking patients.

Dr charges what the market will bear.

Dr will perform whatever procedures people can afford to pay: maybe takes credit for trusted patients. otherwise, Dr is a death panel of one.

and through the magic of non-regulation Dr can't be sued for more than some fraction of Dr's annual income if, by negligence or malpractice, a patient dies.

[russell]

Here's Ryan's Patient's Choice Act, from 2009.

Don't know if this is still the state of the art for conservative thinking or not.

[russell]

An analysis of Ryan's plan.

It's not fundamentally different from ACA. I don't see anything about a federal exchange - there are exchanges, but they're at the state level, so it has that nice federalism aroma - and instead of an individual mandate, you get auto-enrolled in a state exchange.

Some other stuff is different.

But it's not fundamentally different from the ACA.

So, I guess I'm confused about what the fuss is all about.

[russell]

or maybe this is one of those things where it's something proposed by a conservative but it's not really conservative.

I'm at a loss.

Sorry for the serial posts.

[bobbyp]

Douthat's recent column is getting a lot of play on this issue.

[Pete Gaughan]

I've read recently that veterinary care is the closest thing to the right-wing ideal for health care. Transactions are between the buyer and the provider directly and only, and there's plenty of competition. Buyers are the sole decider when multiple treatments are offered, and make their own judgment of cost vs. benefit. Insurance policies are rare.

Of course, many patients simply die due to lack of treatment or are even euthanized. It's a separate debate as to whether, for conservatives, that would be a feature or a bug.

[CharlesWT]

Elective medical care, like lasik eye surgery and cosmetic surgery, have seen a steady decrease in prices and improvements in service.

[Countme-In]

The conservative plan would work like this: after going into a diabetic swoon at the President's speech, you'd be sent to Dr. Kristol Dr. Barnes, Dr Podhoretz, and they'd diagnose that you were faking your illness and refer you Nurse Death Panel for some rehabilitative ridicule:

http://www.usgovernmentportal.com/karmel-allison-obamas-staged-fainting-g769272578?language=en

[Obdurodon]

The conservative health care market would be completely deregulated. Insurers could charge whatever they want, and turn away anybody they want. Any disagreements about whether they should have paid for something would be settled in court, with multiple high-powered attorneys on the insurer's side and probably quite a bit less firepower on the other. Insurers would also never use their monopoly/monopsony position to extract rent from either subscribers or providers.

Anybody who was denied insurance and couldn't pay for care out of pocket would go to a charitable hospital. Those would be well financed from private donations and would provide excellent care. They would never place religiously based limitations on who they accept or what care they provide, so they'd still be tax exempt (and donors would get an exemption too).

It's all a complete fiction, of course, but that's what the hypothetical conservative plan would look like. I can describe what a unicorn looks like too, even though they don't exist either.

[russell]

Elective medical care, like lasik eye surgery and cosmetic surgery, have seen a steady decrease in prices and improvements in service.

One reason they are elective is that you won't die if you don't get them.

That, among several other reasons, makes them a more suitable commodity for market price setting than, frex, a cardio stent, or surgery radio or chemo for cancer.

[Laura Koerbeer]

I know elective means you don't die without it, but something like lasek can make the difference between functional, able to hold a job, and not. Before I had lesek I had no effective vision in one eye. That screwed up my depth perception to the point that I could not drive safely. I could not judge distance!

[liberal japonicus]

This comment may seem a bit more combative than I intend it to be, so take it with the requisite amount of salt, but after the discussion about how the Heritage plan does not represent conservative values, I'm hesitant to look at any actual plan as a representative of conservative values. Conservatives complain that a system like that moves us to where the government tells people what to eat, but there are just too many ways a private company can find to cut corners. In that sense, the conservative ideal is whatever screws up the liberal plan. I mean, after reading the background, the Heritage plan was simply a proposal to try and and undercut the Clinton proposal, so it seems like a conservative proposal on health is simply one designed to undermine a liberal proposal, which is that anything that gets closer to a single-payer system.

[Countme-In]

Russell, your link to Ryan's perfectly reasonable healthcare policy proposals from 2009 is enlightening.

Considering what has transpired since, I can only conclude that Ryan has supported the marauding, nihilistic vandals of the Tea Party to make his "absurd" (good term, I forget who suggested it here recently, but if folks like it better than "vermin-like", I'm happy to go with the flow) dalliance with Ayn Rand appear like various deep worldly philosophers dropping their pants in Times Square and calling it a worldview, in other words a youthful mistake carried into adulthood, and maybe his staff should listen to "Sgt Pepper" instead of reading "Atlas Shrugged".

But it also reveals that discussions about "what is conservative and what is not" are pointless in this confederate pre-1963 Dallas period of time and what really matters is the extent to which Ryan and the Republican Party hate one man and will go to any lengths to destroy his works even if it means burning down their own houses.

I say this with due respect to legitimate conservatives, disagree with them as I do.

[DaveC]

I'd begin with "free" immunizations as an initial effort to have government-supported healthcare services that could save money.

[Brett Bellmore]

Well, I've proposed that the current tax status of employer provided health insurance be extended to health insurance purchased through anybody: Personally, through a credit union or bank, the NRA or ACLU, Kroger's, special organizations formed for the purpose.

Ideally employers would pay you in money, and not have to shop for health insurance or other benefits just to help with your taxes. And you would get your health insurance through some organization of your own choice, large enough to have negotiating power, and of the sort you didn't have to quit if you changed jobs.

Most distortions of the health insurance market are due to this business of buying your health insurance through your employer, which is driven by tax laws. It can be fixed by tax laws, too.

Give insurers large, stable groups to insure, and they have much more motive to support preventive care, (Because they're likely to still be insuring the person getting it when the benefits arrive.) and much less motive to cause trouble over "pre-existing conditions", because mostly there wouldn't be such a thing.

Expand HSAs, and don't mandate that health insurance include things that aren't actually insurance, and you'd solve most of the problems.

Mind, you could achieve many of these benefits by simply ending the favorable tax status for benefits. My objection to this is that it would be a massive tax increase for most people. But perhaps a one time adjustment could be arranged, to get the government entirely out of caring about what you're spending your money on.

[sanbikinoraion]

Brett - one question: in your scheme, how do people who cannot afford health insurance get health care?

[Brett Bellmore]

How do people who can't afford food get food? I notice it's not by forcing grocery stores to give food away, and forcing people who aren't poor to buy food at inflated prices.

Have you considered "health insurance stamps"?

[cleek]

Give insurers large, stable groups to insure

they already have that.

[Laura Koerbeer]

Actually the ACA exchanges could be conceived of a health insurance stamps since they provide all or part pay for insurance.

No doubt another aspect of the conservative paradise would be the middle class paying substantial subsidies through their taxes to the wealthy for various large businesses while the wealthy bitched and moaned about confiscation and tried to cut the insurance stamp funding and reduce their employees' pay.

[bobbyp]

And you would get your health insurance through some organization of your own choice, large enough to have negotiating power, and of the sort you didn't have to quit if you changed jobs.

I pick 'the federal government'. 'Citizen' is a very large group, and would have massive bargaining power with providers. Why, we could even bypass insurance companies altogether and deal direct. This is known in some circles as "cutting out the middle man" or "buying wholesale"....sorta' like Costco.

[Tony P.]

There are two things I agree with Brett about, and one of them is that health insurance ought not be coupled to employment. As those of us who are not tenured professors know, jobs are not permanent.

On the other hand, NOTHING is permanent, not even NRA membership necessarily. Would I want to feel captive to my membership in the ACLU "for the health insurance"?

If I decide to drop my affiliation with the club, church, or supermarket I'm buying insurance from, would the NRA or the ACLU be required to accept me as a member? Or would they be free to turn me away because of pre-existing conditions?

Note that I'm not even talking about "the poor" yet. Note also that I'm talking about the financial service called "insurance", not the medical service called "health care".

If health care were less expensive, the arguments over health insurance would be less bitter. The charming notion (held by Libs and Cons both) that proper jiggering of the insurance system would reduce the costs of medicine seems doubtful to me.

Whatever insurance system you adopt, the following has to be true because it is a mathematical definition: the average person, over a lifetime, must pay the average person's lifetime medical costs. If we take it for granted that nobody is exactly "average", then somebody must be paid to handle the money -- to "redistribute" it, if you prefer.

For my part, I'd prefer the "somebody" to be Uncle Sam, rather than John Hancock or even Wayne LaPierre. My affiliation with Uncle Sam is the one affiliation I consider permanent enough to rely on. Secessionists may feel differently.

--TP

[Snarki, child of Loki]

Well, first you have to set up a medical FUTURES exchange.

You know "coronary bypass january futures are up $5 in morning trading". Doctors would book appointments by selling on the futures market, and customers would have to buy a contract for delivery on a particular date.

I imagine that the 7-month maternity contracts will be especially popular.

The only problem is that brokers will charge extra if you buy heart-transplants in "odd lots" of less than 100, but hey, that's just the invisible hand at work.

[McKinneyTexas]

First, a conservative would try to meet the greatest needs first, which are the chronically ill. A conservative would probably look at analogous insuring programs at state levels such as assigned risk pools and state-created insurance associations. Premiums would be kept low by requiring--as assigned risk and state-created associations now do--admitted carriers to fund up to "X" amount of the cost of treatment. Any excess over X should, for administrative ease, also be born by the admitted carriers with an offsetting 100% tax credit, i.e. actually born by the feds, but it's easier just to give a credit and not mess with the administrative hassle.

Conservatives would be honest,hopefully, and tell people that we are not doing "all in/everything covered". Conservatives would continue to let the private sector fund most of the private insuring costs by lauding and not complaining that employees don't pay tax on their insurance premiums (how liberals square this with wanting to pay for the whole damn thing has always mystified me).

Conservatives would treat adults like grown ups and let them live with the consequences of their own bad decisions, whether that is buying health insurance, riding motorcycles or unprotected sex--have at it, it's your body.

And, for those whose employers don't/won't carry or who are self-employed, create quasi-private groups that purchase discounts in insurance through size. Either join or not, that's up to the citizen, but have that out there as the option for those with limited bargaining power.

Finally, the issue of pre-existing condition/otherwise un-insurable person. First, the two are not the same. For example, if you are over 40, you most likely have a pre-existing degenerative spine, hips and knees. It's the aging process. OTOH, you can be bedridden and unable to care for yourself. Somewhere between the two extremes you have the obvious gray area that will require some degree of judgment. On one side, the default is the assigned risk pool, on the other, the default is a max added premium of X percent.

This is just off the top of my head. I imagine someone could do better if they took a bit of time to think about it, and probably with less than 1500 pages of laws and ten times that in regs and a f'ed up website.

[Ufficio]

If I decide to drop my affiliation with the club, church, or supermarket I'm buying insurance from, would the NRA or the ACLU be required to accept me as a member?

Or if your insurance provider jacks up your rates or offers horrible service and you want to change providers. Or if they decide to terminate your policy. Or if the provider folds or gets out of the insurance business.

Decoupling insurance and employment does not eliminate the possibility of needing to change providers and being denied for pre-existing conditions.

[sanbikinoraion]

McKinneyTexas -- same question: how do the poor and the pre-existing cover the cost of their insurance? I don't really understand what an "assigned risk pool" is but from my cursory reading it suggests that a pool of known high-risk claimants has to be insured, but to what degree and by who? Presumably the premiums in these assigned risk pool cases are exorbitant...?

[cleek]

In that sense, the conservative ideal is whatever screws up the liberal plan.

a dynamic that appears quite often...

[rea]

A conservative health care market would look much like the ACA except a (white, male) Republican would be president.

[Carleton Wu]

Conservatives would continue to let the private sector fund most of the private insuring costs by lauding and not complaining that employees don't pay tax on their insurance premiums

This is kind of meta, but we've had several 'what is a real conservative' discussions lately here. And Im struck by how often the conservatives on the board draw lines around the word that I don't see in the world. eg
Here is a conservative advocating getting rid of that tax break bc it is "distorting the natural market for healthcare".

Not to blame McTex, I think the question suggested there was a single "preferred conservative alternative". Of course, I still think of the Heritage-inspired ACA as something of a 'conservative alternative'... :)

Now Im wondering why we don't see this kind of line-drawing with liberals on the board- something to do with the preponderance of liberals in most of the discussions? Something to do with the two(?) philosophies involved, or the trajectories of the two groups at this point in time?
Or maybe we do and I don't notice it.

[thompson]

Not really conservative, but I'll chip in anyway.

I'd like to agree with the sentiment upthread that employer-based isn't the way to go. I think it artificially restricts the free market. I, for example, have health insurance through my employer (which is good on paper) but I hate my HMO. Previously, I bought insurance from Kaiser, and liked it very much. It was super easy to, say, get my HepB titers checked and get a pertussis vaccine. My current HMO, it's a nightmare of calls and appts to get anything done. Anecdotal, and likely not representative of the nation as a whole, but I'd rather have my employer pay me more instead of taking a huge chunk of my costs (about 30% of my compensation is health insurance), be taxed at some rate, and find my own insurance.

I think exchanges are a great way to do this. I think exchanges, done well, are a good example of the government facilitating a free market. I think there can be some reasonable limits on participating in the insurance. A basic shall-issue plan at a set cost, similar to the Swiss system.

Insurance companies would then be free to offer various higher-end plans with minimal requirements. No termination of coverage without patient agreement. Noncoverage of any pre-existing conditions needs to be specifically noted at intake.

I have no objection to federally run insurance plan, as long as it is funded by premiums alone, and not general tax revenue. As long as people are free to NOT pay in (via taxes) and acquire insurance on their own. Any insurance company that can't compete with the federal government doesn't deserve to exist. More competition, more options are never bad.

Uninsured/underinsured poor should receive subsidies from the government to purchase insurance by the government, similar to SNAP.

I like to think, but I'm probably wrong, the free-rider problem would be largely avoided in this system. There is no ECONOMIC stop to poor people getting insurance...so I like to think the coverage would fairly high.

I think at that point, we have two options to deal with the people who are rich enough to not qualify for federal subsidy but choose not to afford insurance and the poor that for various reasons don't acquire the subsidy (destitute, homeless, etc).

(1) Callously turn people away without proof-of-payment. I don't think this works for a number of practical/moral reasons.

(2) Have the federal government cover their costs directly. Out of the general fund. At least we would have a good tracking of the free-rider problem. Additionally, any identified free-rider could be targeted by the IRS. If your wealthy and to irresponsible enough to not have insurance (and need it) the IRS garnishes your wages and/or seizes your property.

Anyway, my thoughts. But I'm not an expert on this so, feel free to explain why it won't work. Speaking of work, I have to head in to it, so if I'm unresponsive, I apologize.

[thompson]

Work right after a response to Carlton's excellent comment.

"Now Im wondering why we don't see this kind of line-drawing with liberals on the board- something to do with the preponderance of liberals in most of the discussions?"

I would think yes. I live in a fairly liberal area, and while I think I'm pretty moderate, I often end up being the "conservative" in talks with my friends. And since I'm "conservative" and frequently outnumbered in this conversations, I frequently find myself getting saddled with "conservative" opinions of some Fox talking head that was on the Daily Show last night. Sometimes the easiest way around that is to say "that's not 'conservative' for X reason" and move on.

It's because of stuff like that, that I really don't like labels, Dem vs. Rep, Lib vs Cons, etc etc. And even just in the US...are Cali conservatives the same as Montana conservatives? What about Mass liberals vs. Oregon liberals? What are the odds that two self-described Oregon liberals agree on all or most things?

They are so broad that they become meaningless. But they carry weight. A "conservative" becomes responsible for "conservative" views. A "liberal" becomes responsible for "liberal" views. I think it's an unfortunate result of the tribal nature of humans.

[russell]

I think it artificially restricts the free market.

Can I ask a stupid question?

Why is it preferable for either health insurance or health care to be acquired through a free market?

I don't know if it is or isn't better, there just seems to be an assumption that it *is*, and I'm curious to know where that comes from.

[wj]

it's not fundamentally different from the ACA.
So, I guess I'm confused about what the fuss is all about.

russell, the fuss over the ACA isn't over the ACA. It's over "Obamacare" -- and specifically the first 5 letters of "Obamacare." This is demonstrated by the fact that, if you poll about Obamacare, and about the ACA, changing absolutely nothing about what you ask other than the name, suddenly the numbers in favor go way up. (And that's before the favorable numbers that you get when you actually talk about what is involved in the ACA.) It's feally a tribute to a great marketting campaign.

We will continue to hear all kinds of comments about what is wrong with the ACA, especially the implementation so far. And lots about what might be done different and better And much of that will be well taken. But "all the fuss" is really not related to any of that. Just the name and the man associated with it.

[wj]

Here's one step towards a conservative health care plan. Provide information so that people are aware of how to get around the fact that an individual will get rejected for a "pre-existing condition." All you have to do is set up a group (LLC, typically). Even if it just has members of your family as members of the group. Then, you can buy group coverage. No check for pre-existing conditions. No basis for rates beyond age and gender. And all it costs is your state's annual license fee for registering your company/group.**

All the government has to do is make that information publicly available. No other action whatsoever. And suddenly, nobody is uninsurable.

It's not a complete conservative solution. But it is a big step in that direction.

** Obviously, I have been down exactly this path. And it is amazing how different a group, even of just two spouses, gets treated than an individual. Simply amazing.

[jeff]

I received great health insurance through my wife's (school teacher) policy at no cost to us but also a good policy from my employer. Was denied a request that my employer stop with the insurance and just pay me a little more money. So for about 15 years somebody (taxpayers?) was paying twice what I needed. Employer based heath care can be screwy.

[thompson]

Russell:

I don't think that's a stupid question. It's an assumption on my part. I freely admit I assume free markets have advantages and serve the consumer better. I'd be willing to be convinced otherwise...but I think that's a really hard thing to know.

I want to be clear, that doesn't mean I think lack of regulation is always the right choice. A completely unregulated market frequently leads to monopoly. That isn't a free market. (I know, the ideal free market doesn't exist, grant me a little leeway on phrasing).

If I have only one option for healthcare, or anything, that option doesn't have to optimize for my needs. If I have many options, (a) I can choose the best choice for me and (b) options that are poor for everybody will face market pressure to improve or fail.

Those are assumptions I'm making, I'll admit. But I don't think they are crazy ones. (a) at least I have direct experience with. If my employer gave me the money they spend on my benefits, even after taxes, I'd be able to afford a plan I prefer from Kaiser, a provider I like more than my current HMO. And have some money left over. Even in the shambles that is the US health care system, not in some ideal-libertarian-free-market-that-will-totally-reduce costs-someday.

I also assume it would have the effect of reducing costs due to these market pressures...but that's a lot hazier.

[thompson]

Following wj's comment re: information. Something that always bothered me is due to the free-rider/insurance system we have, providers don't have a fixed price schedule.

I know they have a price schedule, because that's how accounting works. I'd really like mandatory publishing of a provider's price schedule. Yeah, I know it's not simple $10K for a hernia surgery. But the breakdown in terms of meds cost this much, surgery theaters cost this much per hour, emergency surgery teams cost X much per hour, interpreting radiographs cost X much /15 min. Etc.

I was in the middle of a negotiation between a hospital (emergency appendectomy) and my insurance. Initial cost: $29K. Insurance wanted to pay 15K (I think). There was a settling ~20K and I had to foot 2K or so. Not the biggest problem in the health care field, but one I always found frustrating.

Similarly, I had friend w/o insurance who broke/sprained her ankle. Couldn't get any information about how expensive an xray was from local hospitals. Was willing to pay but really wanted to know roughly how much it would cost (not to fix it, just get an xray). No-one would tell her. Ended up going to a free clinic. Not an efficient system.

[McKinneyTexas]

But "all the fuss" is really not related to any of that. Just the name and the man associated with it.

Not to pick on WJ, but is this considered insightful on the left, "They don't like ACA because it's Obama's program", the subtext being, "they are all racists"?

Jesus.

Why is it preferable for either health insurance or health care to be acquired through a free market?

Because every element of healthcare, from the provider to the MRI machine to the rubber glove I've come to know too well has a real cost driven by unavoidable market factors and when someone imposes costs or limits prices, you get something like what you see in Venezuela if it goes far enough.

Or, because no one has found out yet how to consistently deliver an infinite stream of acceptable quality goods and services for less than the cost of said goods and services.

You can artificially hold down prices for a time, or you can subsidize goods/services, but it can't last--people are involved and they want to be paid. Manufacturers, new product and drug inventors, they want their efforts rewarded. Doctors, they want some return on the time they spent in school and the difficulty of the work they do. Eliminate risk/greater reward or deferred gratification/greater reward and they will pursue other paths. Not next year or the year after, but in the long run.

[cleek]

"They don't like ACA because it's Obama's program", the subtext being, "they are all racists"?

that subtext might be all up in your imagination. i certainly didn't see anything in wj's post to suggest it. and polling says that he's right. "ACA" polls better than "Obamacare":

A recent CBS poll showed that 46 percent oppose "Obamacare" and 29 percent support it, whereas 37 percent oppose the "Affordable Care Act" with just 22 percent supporting it. Basically, people either really love or really hate "Obamacare" when it's labeled as such.

unskew that poll.

[cleek]

Eliminate risk/greater reward or deferred gratification/greater reward and they will pursue other paths. Not next year or the year after, but in the long run.

fnck em. relax the onerous immigrant doctor requirements and let the market run. there are thousands of doctors from other countries who would be happy to take the place of all those Galtian brats.

[Tony P.]

McKinney,

The question was about "either health insurance or health care". Health insurance is a financial service. How much more innovation can we stand in financial services? How do private-sector health insurance companies, innovating all over the place, motivate "manufacturers, new product and drug inventors", etc, thus keeping us from becoming Venezuela?

--TP

[thompson]

Tony:

Those things aren't always separate. HMOs, for example, are involved both in the financing and the execution of health care. Kaiser Permanente has been held as an example of how to reduce costs due to better managed care (http://www.nytimes.com/2004/10/31/business/yourmoney/31hmo.html?_r=0).

Of course, that's not "new drugs" but a lot of things go into improving patient care and reducing costs.

Not exactly what you were talking about, but maybe related. Or maybe completely unrelated. shrug.

[wj]

Thanks, cleek.

McTex, No doubt some people do hate Obama because they are racists. Equally without doubt, some people simply hate Obama for reasons unrelated to race.

But when "Obamacare" gets signifcantly worse polling than "ACA," with zero other information offered about what either consists of, it is hard to argue convincingly that this isn't about Obama.

[McKinneyTexas]

But when "Obamacare" gets signifcantly worse polling than "ACA," with zero other information offered about what either consists of, it is hard to argue convincingly that this isn't about Obama.

You are assuming that everyone knows that ACA = Obamacare. ACA is widely known as Obamacare. It is not so widely known as ACA. That's how I unskew that poll.

How do private-sector health insurance companies, innovating all over the place, motivate "manufacturers, new product and drug inventors", etc, thus keeping us from becoming Venezuela?

We can be well above Venezuela and still have a much crappier system than we currently do. But, to answer the question: health insurance companies negotiate fee contracts with provider groups that fix costs for a stated period--by agreement, not by fiat--that in turn permits better actuarial and thus better pricing analysis by the insurer.

fnck em. relax the onerous immigrant doctor requirements and let the market run. there are thousands of doctors from other countries who would be happy to take the place of all those Galtian brats.

As long as you, the Congress, the Senate and the President are required to use exclusively those overseas trained and licensed physicians, fine. I like the much higher end, US trained physicians. Particularly board certified specialists. So, thanks, but I'll pay more for domestically trained docs.

[liberal japonicus]

Not to pick on WJ, but is this considered insightful on the left

Not to pick on you, but if I'm not mistaken, wj is a self identified small c conservative who feels the Republican party has left him. I realize that the whole conversation about racism and conservatism is fraught, but trying to put it in a drawer labeled 'left' is not going to make it disappear.

[sapient]

McKinney: Finally, the issue of pre-existing condition/otherwise un-insurable person. First, the two are not the same. For example, if you are over 40, you most likely have a pre-existing degenerative spine, hips and knees. It's the aging process. OTOH, you can be bedridden and unable to care for yourself. Somewhere between the two extremes you have the obvious gray area that will require some degree of judgment. On one side, the default is the assigned risk pool, on the other, the default is a max added premium of X percent.

I don't understand what your solution is here, McKinney. The fact is that over 80% of people support non-denial of coverage for people with pre-existing conditions. That has to be paid for with more than philosophizing about "the two extremes". There are people all over the actuarial map with pre-existing conditions. That's the whole point of the mandate, etc.

And I still don't get your obsession with legislation that consists of a lot of pages. If you work with the legislative system at all (state and federal), you know that those kinds of acts exist in every legislative session.

[wj]

You are assuming that everyone knows that ACA = Obamacare.

Actually, I'm assuming exactly the opposite. People have a negative opinion of Obamacare, without really knowing anything about it. And they have a less negative opinion of the ACA, not because they know more about it, but just because it doesn't have Obama's name attached.

And I unskew the fact that views are even more positive when people discover what the ACA/Obamacare actually includes this way. The things that they think that they hate about it are things which simply are not true. In short, there has been some great (negative) marketing done here. But trying to say that people hate what the ACA actually includes will only work by ignoring reality.

LJ, I take some amusement at McTex (or anyone else) assuming I'm on the left. I suppose I should introduce them to some of the folks I know who really are on the left. (Although I suppose it says something that their reaction when I point out that I'm a conservative has been "Oh, but you're a tolerant conservative!" Like that's almost a contradiction in terms.)

[Carleton Wu]

Not to pick on WJ, but is this considered insightful on the left, "They don't like ACA because it's Obama's program", the subtext being, "they are all racists"?

Not to pick on McTex, but is it considered insightful on the right to invoke racism and then claim that the other guy is playing the race card?

when someone imposes costs or limits prices, you get something like what you see in Venezuela if it goes far enough

Let's observe that a defender of free market versus government intervention in healtcare probably does not want to go offshore looking for examples. It's a bad precedent for your position. Yes, there are some &$^#ed up countries that have &$*#ed up economies. And then there's basically every other advanced industrialized country in the world, providing excellent healthcare at much lower rates than we do.
Shorter: let's not go that far, let's just go far enough to get a healthcare system like Germany or Sweden or France...

Or, because no one has found out yet how to consistently deliver an infinite stream of acceptable quality goods and services for less than the cost of said goods and services.

However, we have found a way to deliver those goods and services at a much higher cost than other countries. This is called "market failure".
btw, not sure why the stream has to be 'infinite', even a finite set of goods and services has a cost. I think you're getting overexcited.

You are assuming that everyone knows that ACA = Obamacare.

I am not sure how to logically process this- if we assume this is true, then there is no reason for the poll numbers to diverge. Right?

[Tony P.]

McTx: "... health insurance companies negotiate fee contracts with provider groups that fix costs for a stated period--by agreement, not by fiat--that in turn permits better actuarial and thus better pricing analysis by the insurer."

"Better pricing analysis" means what, exactly?

Do insurance companies compete with each other by negotiating LOWER prices with doctors and hospitals? Or HIGHER ones? And which of those leads to more new drugs, better devices, or smarter techniques? And how?

--TP

[Laura Koerbeer]

I don't assume that the discrepancy between those who like the ACA but dislike Obamacare is caused by racism. It's caused by people being exposed to dishonest Republican sources that tell them lies about death panels, socialism and "big government" misusing their private information.

In other words, the individuals who are scared by the lies, like the exchanges, like access to insurance for people with pre-existing conditions, and like people being able to keep their students on insurance through college.

Remember the article about Kentuckycare that was posted here a while back? That same phenomenon is happening all over, which is exactly why the Republicans in Congress did the government shut down.

In another five years so Obamacare will be established and popular. That's the big threat.

[bobbyp]

I like the much higher end, US trained physicians.

Pure 100% crap. An untruth. A lie. US physicians are a classic guild that, under any other circumstance, McKinney would be howling and flinging poo against the walls for "restricting the supply of labor" (cf. hatred of unions). If McKinney truly believed in a 'free market' he would promote policies to allow any qualified foreign doctor to practice in the US----or would allow US citizens to participate in other countries health care plans. Free trade, right? Liberty!!!!

They support restricting the power of the largest buyer of medical services to negotiate prices with the private sector (Bush Medicare drug benefit), a clear violation of free market principles.

Tex, and his conservative brethren, do not advocate remedies for these clear violations of their professed free market ideals. They support their constituencies collecting economic rents. They assert the guild setup of the AMA is just dandy. They like restricting free trade in medical care. They support granting infinite patents (a government granted monopoly) for minimal innovation. They like insurance companies skimming dollars off the top of the healthcare market so they, not the government, can be 'death panels' and allocate scarce resources in such a manner as to satisfy the insatiable greed of their shareholders vs. satisfying the needs of We The People.

THEY LOVE SUCKING OFF THE HATED GOVERNMENT TEAT.

They are shameless in their greed. They know what they want. They want f#cking everything.

[Laura Koerbeer]

I don't think McTex is a greedy person. I think he's a bit doctrinaire (but so are most people) and it's a doctrine that tends to reward greed, but I don't think that's the as being personally greedy.

[bobbyp]

Laura,

I agree. I have not idea how greedy Tex is. But he does play golf.... ;)

However when it comes to labor markets, many conservatives and their glibertarian brethren vehemently assert that "if you don't like the job, go get another one."

They throw this line in the face of collective bargaining supporters always. They call this "Liberty!". They tend to get rather red faced an angry about it.

Yet, when it comes to doctors, why, suddenly everything changes....these poor, poor creatures. Why, if Medicare keeps squeezing them, they will simply close up shop and go away...then what will we do? Pity those poor physicians.

They never said this about good factory jobs. Never.

The convenient disregard of their espoused free market principles when it suits their political interests is well neigh total.

[bobbyp]

Lit up as I am on the evil bourbon, I'm also pretty god damned tired reading stupid tirades about 'Obamacare' being 1,500 pages long.

Do you know how long the Defense Appropriations Act of 2013 (H.R. 4310) is, Tex? It's 681 'effing pages long, and it doesn't change a whole lot of policy...just allocates dough.

I'm sure every GOP Congresscritter has read each and every page, right?

Christ on a stick. Give it a #$#$@%ing break already.

[bobbyp]

McKinney: Doctors, they want some return on the time they spent in school and the difficulty of the work they do.

It should be noted that this claim is essentially a classic regurgitation of Marx's Labor Theory of Value, a concept that has been fairly well demolished by the legion of Marx's critics.

Damned communists!

[jack lecou]

Damned communists!

Indeed. It's fun to imagine this quote with other professions:

School teachers, they want some return on the time they spent in school and the difficulty of the work they do.

Social workers, they want some return on the time they spent in school and the difficulty of the work they do.

Community organizers, they want some return on the time they spent in school and the difficulty of the work they do.

Nurses, they want some return on the time they spent in school and the difficulty of the work they do.

[russell]

no one has found out yet how to consistently deliver an infinite stream of acceptable quality goods and services for less than the cost of said goods and services.

That's true, but it doesn't answer who pays and how.

It also assumes that what we have now delivers the desirables for the lowest reasonable price, which I think is not in evidence.

Eliminate risk/greater reward or deferred gratification/greater reward and they will pursue other paths. Not next year or the year after, but in the long run.

Not everyone in the world is motivated exclusively by return on investment.

Look, here is a very short, off-the-top-of-my-head list of things that are delivered to me, and to most or nearly all of us, through channels where price-setting is not done exclusively, or even mostly, by market forces.

Gas (natural gas to the house, not gasoline)
Electricity
Water
Auto insurance

And yet, all of the people involved in getting all of those things to me make a living.

So, I'm puzzled as to why goods and services related to health care can only be provided via a 'free market'.

And the quotes are intentional, because quite a number of the goods and services that make up a health care market basket aren't really a good fit for market-based price setting.

It might be the case that market forces, allowed to operate without intervention, will provide something like (a) concierge medicine and (b) the ER.

Would that be an acceptable outcome?

If not, than do all of us who (a) can't afford concierge medicine and (b) would prefer to not go to the ER every time we have the flu get a voice in things?

[Laura Koerbeer]

I think it is a definite indication of greed that corporations like Walmart expect the taxpayers to help pay their employees via Food Stamps. And I think it is a definite sigh of self-induced stupidity though excessive doctrinaire thinking that some many people on the political right are knee-jerk hypersensitive about some slob who doesn't deserve Food Stamps, but unsupportive of labor unions that fight for a living wage and tolerant of corporations that suck up more in undeserved subsidies than any welfare recipient ever dreamed of. One of the reasons I never finished medical assistant school was my discovery that many med assists don't have health insurance!

But on the subject of keeping the doctor's money in his/her pocket: single payer is the way to go for that. With a single payer system the doctor could layoff the med assists who spend their days bird-dogging insurance claims. Do you all have any idea how long it takes doctors to collect? And how much they have to write off because of insurance carriers deliberately lallygag on payment, hoping the doctor's office will give up on collection?
I took a whole class in bill collecting for doctors. Insurance companies hate to pay their bills, except for Medicare and Medicaid.

So single payer, easier more efficient bill collecting, less staff, more money for the doctor. How about that as a conservative idea?

[Countme-In]

The full text of the ACA. I don't know how I found the thing, secret as it is. Be the first to read it:

http://www.hhs.gov/healthcare/rights/law/

If Lincoln were a boy, he'd be sitting against a stump in a meadow reading it to prep for Civil War and his surround-sound theater-going experiences:

The full text of Obamacare:

http://www.hhs.gov/healthcare/rights/law/

Ha ha! Both the same, but which one did y'all click on?

Anyway, for those whose Food Stamps have been cut to 88 cents per meal by the literal bean counters, the full text of the law, eaten at a rate of two pages per day, will supply one's daily requirement of roughage and residual sausage scraps.

The savings for the food stamp recipient, over time, will permit purchase of a rice cooker, at which point Paul Ryan will find a passage in "Atlas Shrugged" warning darkly and verbosely of efforts to get around bean-counting for the poor by substituting rice.

Just noodling (another substitute starch) around: here's something about the historical rates of doctors per capita in the United States going back through the last century:

http://www.washingtonpost.com/blogs/wonkblog/post/we-have-more-doctors-per-capita-than-ever-before/2011/12/16/gIQAKIfByO_blog.html

The up slope in doctors per capita, after declining for decades looks like it started in the early 1960s and has gone on since. Let me see, what happened in the 1960s that could have had something to do with that?

You'd think the AMA would have sent out a memo at the time suggesting different career paths for would-be doctors. Come to think of it, they did.

Now, of course the geographic distribution of doctors is out of kilter now, and we seem to have a shortage of GPs and a surfeit of specialists -- I have a separate doctor for each finger, two audiologists (one for either ear), and an entire committee of specialists whose only job seems to me to be to tell me "No" when I request an MRI.

I insure with Kaiser and have for 35 years. I'm completely happy with it -- but I've been healthy pretty much, with the exception of knee surgery over the years.

Laura wrote:

"Insurance companies hate to pay their bills, except for Medicare and Medicaid."

I have a feeling the exception of the two M's here is considered a flaw/bug by conservative thinking, not a feature.

In fact, the current dysfunction of the ACA federal website (which will be fixed, just as the trot out of Medicare Part whatever under the Bush Administration went so unswimmingly that John Boehner himself had to stand a microphone at the time and give reporters a pep talk about how the kinks would be ironed out) is viewed with barely disguised glee by Republican members of Congress and they are wondering how they can import the crash feature into other Federal and State websites, like medicare, SS, unemployment insurance, food stamps, and agricultural subsidies (except for their brothers'-in-law)

Russell mentioned:

"will provide something like (a) concierge medicine and (b) the ER."

If I was poor (I am by some standards) and had to go to the hospital emergency room for my care, I think while I was biding my time reading the March 2007 issue of
Medicare Capitation Weekly (the Enema Issue), and if were ambulatory, which I must be because I would walk there to save money, I'd stand near the door with my cap in hand and show folks to their gurneys and fluff their pillows for them concierge-style, and hope for tips.

Laura also wrote:

"I think it is a definite indication of greed that corporations like Walmart expect the taxpayers to help pay their employees via Food Stamps."

What you do is have a connection on the loading dock and skim needed food items, or shoplift. To stay under the 88 cents per meal Food Stamp allowance for propriety's sake, I'd stick with oatmeal, eggs, and the ramen substitute with edible packaging.

Leave work with a fake limp.

[Doctor Science]

A "conservative" healthcare market would be promoted on FoxNews and the Wall Street Journal.

That's it. The ACA is a fundamentally conservative approach to health care reform, because it relies so much on private insurance companies. Obamacare was basically developed by conservatives, it was their baby.

But conservatives (really "conservatives, these days -- most are much more reactionary than conservatives) are owned by the Republican Party, and the Republican Party is owned by FoxNews. FoxNews doesn't want policy agreements and negotiations, because they make for bad TV. FoxNews wants the fire of battle, stalwart opposition and heroic fights, failure is not an option! -- Because that makes for exciting TV.

FoxNews' ratings (and profits) have never been higher. You have always been at war with Obamacare.

[Brett Bellmore]

"because it relies so much on private insurance companies."

In the sense of the government treating them like finger puppets, instead of shutting them down, anyway. Dictating the exact details of what they must sell, to who, for how much.

The DMV is almost as "private" as health insurance companies are under the ACA.

[Tony P.]

Dictating the exact details of what they must sell, to who, for how much.

Seriously, Brett:

The ACA sets prices on health insurance policies? Really?? Cite please.

The ACA does require insurance companies to sell a policy to anyone who's willing to pay their premiums. They don't get to turn you down because you had cancer or a bad back or a hangnail. But it also gives them millions of new customers.

The ACA dictates a minimum level of coverage, not "the exact details of what they must sell". You talk as if requiring cars to have seat belts and brake lights is the same thing as designing auto makers' cars for them.

Try harder next time.

--TP

[Countme-In]

"The DMV is almost as "private" as health insurance companies are under the ACA."

And the DMV works.

Everyone in the country who wants and tests (meaning just about everyone) for a driver's license and tags has both.

The websites work well too and conveniently, as will the ACA's, unless the give-up caucus shoves a spaniel in the works, the worms.

This resort to comparing all government programs ad nauseum to the DMV is a tired conservative oasis with a dry waterhole.

Move your humpless camels on to wind and solar power. Oh, yeah, those work too, in their niche.

The only times is my state that the DMV falls down on the job is during republican administrations when they cut the DMV's budget and staff to prove some verminous, scum point that a starved government doesn't work, the filth.

And, no, I don't need a Starbucks or ESPN on the cable feed or fries at my DMV.

Read a book, whiners.

[Laura Koerbeer]

BTW the exchanges are working fine in my Democratic state.

I'm seriously worried about the effect that over heated Republican lies have had on some people, though. One of my Facebook friends posted a pic of a grave stone with dates and the slogan "United States Killed by Obama". She followed that with a pic of a quote about the necessity of fighting back (the quote meant literally fighting) when an evil is being done that necessitates a violent response. My Facebook friend isn't going to shoot anyone or blow anyone up, but she has male relatives that could go that far.

The lies from the Republican party are beyond irresponsible. It's one thing to discuss a policy as a policy and to disagree even strongly. It's something else altogether to engage in the-end-of-America type of rhetoric. And that kind of rhetoric has been typical of Republican politicians for years now on Obamacare and other issues. This is why I don't have much respect for the party leadership or its politicians. Bunch of nasty dishonest irresponsible rabble-rousers.

[Brett Bellmore]

"The ACA sets prices on health insurance policies? Really?? Cite please."

Sure. First, by having price controls at the level of the exchanges, and secondly, by mandating that prices not increase more than three fold between ages.

Obamacare And Price Controls

[Tony P.]

Brett, I can read your Jan 2011 Forbes article, but I can't read your mind.
WTF are you talking about?

--TP

[Laura Koerbeer]

I can't get through the link to the article,

[Brett Bellmore]

Apparently you can't read my second paragraph, either.

Obamacare sets prices in two ways: First, if they don't like your prices you can get kicked off the exchange, and getting your insurance no longer averts a fine. It's not so much that that the prices aren't controlled, as that they aren't explicitly controlled. The Forbes link went into this.

Second, they have set a limit on the price differential between policies. You can read about THAT here.

I assume you're already familiar with the mandate to take people with existing conditions, and the controls over what will be actually covered, since you didn't take exception to that.

So, who you have to sell to is controlled.

Who must buy from you is controlled.

The price you can charge is controlled.

The product you must sell is controlled.

This isn't keeping a market. It's turning insurance companies into the government's finger puppets. It's pretending to keep a market, it's a 'market' consisting of companies which have had all their important decisions made for them.

That is nothing that a conservative would recognize as "relying on private companies". Its closer to taking over private companies, its one step short of nationalization.

[Laura Koerbeer]

I don't buy your theory that the exchanges are one step short of nationalization (seems like a way, way, overstatement), but if we pretend for a moment that they are--so what? This is my sticking point. I don't get how people can assume that some idea in their head is a Divinely Inspired Objective Truth That is so Indisputably True That it Must be the Basis of Policy.

Doctrinaire thinking isn't thinking. It's believing. Faith-based, like a religion.

Granted everyone starts from their assumptions. My assumption is that the government does have a responsibility to make up the gap between those who are trying to help themselves and what is realistically achievable by that person. I don't believe that a working person should be forced to go without insurance due to not being able to afford it. It's a pretty widespread religiously-based assumption that we are supposed to give a shit about each other and not live like piranhas fighting over a piece of meat. Or be indifferent. My assumption is that we are a "we", not a bunch of separate individuals who all live in one nation, divided, with liberty and justice only for those who are winners in the Social Darwinist competition.

So I definitely have assumptions.

But I'm open to all kinds of ways to achieve the goal of affordable insurance. To me, the issue is how to do it most efficiently and practically and fairly, within the framework of the Constitution, of course.

But the response I read or hear from the rightwing (the responses that aren't mere mouth-frothing such as one hears from Cruz) is the recitation of doctrine. It has to be done this way because of a doctrine or it can't be done at all because of a doctrine.

That's a much narrower way of thinking about the problem of unaffordable insurance. It's not a way of thinking that precludes the acknowledgment of the problem, but it is one that in the minds of some people precludes any solution at all, or precludes any solution that doesn't fit within the doctrine. So it's a narrower way of thinking.

The doctrine dictates the choices. Practicality is subordinate to doctrine. The doctrine is treated like something immutable that exists outside of human experience or belief, independent of cultural values which change over time.

This thread is supposed to be about a conservative approach and I'm getting the impression that that IS the conservative approach: recite the doctrine. It doesn't matter if the doctrine works when applied to the real world or not. It doesn't matter if a non-doctrine approach solves the problem--if the solution is non-doctrine, then the solution is wrong!

[bobbyp]

Who must buy from you is controlled.
The price you can charge is controlled.
The product you must sell is controlled.

The crocodiles cry.

The standard issue conservative response is this: Nobody forced you into the insurance game. Take that capital and invest it elsewhere. Don't let the door hit you in the ass on the way out.

[russell]

This isn't keeping a market. It's turning insurance companies into the government's finger puppets. It's pretending to keep a market, it's a 'market' consisting of companies which have had all their important decisions made for them.

And yet, the private companies will be cashing the checks and making money.

That is nothing that a conservative would recognize as "relying on private companies". Its closer to taking over private companies, its one step short of nationalization.

Disagree on the "nationalization" part, I would say it is many steps short of nationalization.

"Nationalization" means the public OWNS it, which means when the checks get cashed, the money flows to public coffers.

What is true here, and where I think we sort of agree, is that this is not a market, in the economic sense of the word.

We are, by law, delivering a big crop of new consumers to the insurance companies. We are placing requirements on what they sell, and imposing boundaries on what they can charge. We are imposing requirements on who they can NOT sell to.

In short, we are regulating almost every aspect of the private transaction between the buyer and seller of health insurance.

Which moves health insurance, and probably some aspects of health care delivery, further into the category of goods and services that are seen as being sufficiently important that we prefer to not rely on an unregulated market to make them available.

That category includes (in most places) things like water, natural gas, electricity. In some places it also includes things like trash collection and transportation.

What most of these things have in common besides being pretty much essential is that they are not particularly good matches for being delivered via purely market forces. The things that are essential for an efficient market don't apply to them. Either the capital costs present a very high barrier to entry, or the infrastructure required makes them naturally monopolistic, or some other inherent aspect of the good or service makes them poor candidates for provisioning via unregulated markets.

There are lots of things like that, most of them aren't essential, so we sort of leave them alone. Others are more essential, so we tend to intervene at the public level.

There are some essential things - food for instance - that ARE by nature good candidates for delivery via unregulated markets, so there is less public intervention.

What I observe in the health insurance market leading up to the ACA is that, in an environment where everyone over 65, everyone who is truly poor, everyone in the military - in short, many of the highest risk demographics - were handled completely on the public dime, private insurers were unable to deliver an insurance product AT ALL to about 15% of the population, and only a limited product to lots of other folks, and still found it necessary to engage in crap like recission and refusal to issue to people with pre-existing conditions.

Maybe that's because what we had leading up to the ACA was already so bollixed up with regulations that it screwed up what would have been a perfectly acceptable private market. I can't tell you, because absent traveling down some alternative-universe wormhole, there's no way to know.

It's speculation.

What is obvious is that, in fact, the private market under the existing regulatory scheme DID NOT deliver the goods.

I am not a conservative, or really a doctrinaire anything at all, so it does not bother me at all for the public sector to intervene in order to make important things happen. I'm absolutely fine if the necessary thing happens without public intervention, but I have no problem with public intervention if not.

But I can see why conservatives object to the ACA, because the conservative position is generally that regulations on private commercial transactions are an infringement on freedom.

But what I'm not seeing in any of the conservative proposals in this thread or anywhere is an explanation of how an unregulated market in health insurance and / or health care goods and services address the existing failure of the private sector to actually deliver the goods.

The reply tends to be that if an unregulated market doesn't make it happen, then it shouldn't happen. And I find that answer unacceptable.

Sorry for the rambling reply. It just seems like the answers on offer to the question of "what does a conservative health care system look like" seem to describe a system that is congenial to conservative preferences, as opposed to a system that ADDRESSES THE SALIENT PROBLEM.

Can anyone describe a proposal that is both congenial to conservative preferences, and gets us to affordable near-universal coverage?

Because IMO if it doesn't get us there, it's not a solution.

I don't see access to health care as being like buying a car, I see it as more like access to water or electricity. Perhaps the disagreement is at that point.

[russell]

in an environment where everyone over 65, everyone who is truly poor, everyone in the military - in short, many of the highest risk demographics - were handled completely on the public dime, private insurers were unable to deliver an insurance product AT ALL to about 15% of the population, and only a limited product to lots of other folks, and still found it necessary to engage in crap like recission and refusal to issue to people with pre-existing conditions.

Just to expand on my already over-long comment:

The reason for the above - the reason that the private offerings were not getting the job done - is that the COST OF HEALTH CARE is, and has been, rising faster than inflation.

Not the cost of the insurance, the cost of the actual goods and services.

If that trend continues, it doesn't matter who is paying for what, or how, or under what regulatory scheme if any.

Health care will become unaffordable for many if not most people. It'll be concierge medicine, and the ER.

This single item is also the biggest threat to the ongoing solvency of the US, period. The real difficulty in controlling spending is in the so-called entitlements, and the the problem child in entitlements is health care.

If there is a conservative plan that addresses the increase in the cost of health care, plain and simple, that would be of interest. To me, anyway.

The insurance stuff is kind of a sideshow, it seems to me, other than the degree to which the insurance regime is driving costs up.

[cleek]

i believe that the conservative response to the problem of ever-increasing health care cost is that markets cannot fail, but they can be crippled by outside forces. and in this case, if the govt simply removed all regulations in and around health care and insurance, the market would be free to work as it should.

oh sure, that would require getting rid of Medicare, Medicaid, the VA, all safety and pricing regulations. if would also require (but they'll never admit it) getting rid of limits on malpractice lawsuits.

but, once the market was unfettered, a thousand ponies would bloom.

go ahead, conservatives, have all your candidates propose that.

[sapient]

Brett: That is nothing that a conservative would recognize as "relying on private companies". Its closer to taking over private companies, its one step short of nationalization.

Not to change the subject to a horse that's been beaten before, but the term "private companies," if Brett is referring to incorporated entities, is an oxymoron. Corporations exist because of government. They are protected because of government. Unless they're willing to assume the risks of private partnerships, it should be a given they need to act under the terms that government requires.

The concept of "privatization" needs to be reevaluated. The financial reward system of our economy isn't so simple as "private" versus "public."

[russell]

Unless they're willing to assume the risks of private partnerships

Even private partnerships are enmeshed in public laws and policies, and are able to exist because of them.

Who you take to the prom and who you invite to dinner on Thursday are private matters.

Commercial transactions, especially anything involving a contract or other formal agreement at all, are not private. The government may not be a direct party to them, but they are not private.

Nor have commercial transactions been immune to regulation by the public sector, ever, in the US. Nor in the various colonial era governments that preceded the US.

Nor in any other government I can think of, of any kind or flavor, ever.

Just to set the context.

[wj]

Who must buy from you is controlled.
The price you can charge is controlled.
The product you must sell is controlled.

Let's see. If, for example, you are a seatbelt manufacturer, every auto maker is required to buy from you. If you sell almost anything, you are forbidden to collude with others who sell the same thing to set the price. If you sell food, the product you sell is required not to contain poisons.

Oh yes, and if you own a lunch counter, you are required not to discriminate in who you sell to based on race, religion, etc.

Now Brett may be a purist libertatian, who thinks all of those are also intolerable infringements on freedom. But let's be clear that the same sorts of infringement occur everywhere in our economy, in one degree or another. Nothing particularly novel here in the ACA. So why the exceptional hysteria over this one? Really curious.

[thompson]

Russell:

"It's speculation. What is obvious is that, in fact, the private market under the existing regulatory scheme DID NOT deliver the goods."

Sure. The question I guess was the regulation getting in the way, not getting in the way? A mix of both? I think the question isn't where we are, it's how we get out.

"The reply tends to be that if an unregulated market doesn't make it happen, then it shouldn't happen. And I find that answer unacceptable."

I could have missed it, but I don't think any conservative on this thread has taken that position? I think there is a lot of faith in unregulated markets, perhaps too much, but I can't find a reference to, if loosening regulations on the market don't work, then throw up our hands and despair. Maybe they did.

"describe a system that is congenial to conservative preferences, as opposed to a system that ADDRESSES THE SALIENT PROBLEM."

I think the system I described would work. I would guess both McK and Brett feel their suggestions are valuable. And there's been discussion about the problems, which is good. But for myself at least (maybe not "conservative"), things that are "congenial" to my "preferences" are that way because I think they would work.

So let's talk about the salient problem, which you expanded upon in your next post. The cost of healthcare. Which the ACA does what for, exactly? http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/115xx/doc11544/presentation5-26-10.pdf. You also mention medicare/medicaid as working (and it certainly provides care) but the cost is continuing to increase (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/proj2010.pdf). We all recognize the problem. If we don't get a handle on healthcare costs, we will cripple the economy.

Now, this doesn't mean the ACA is bad. Not solving all problems isn't the same solving no problems. And the ACA at least according to the CBO, does help. Just not very much, and not enough to put us on a sustainable path. And there have been a few criticisms of the CBO analysis...I'm sure you can dig some up if you want to. But it's a good starting point I think.

I don't think Ds or Rs are sitting on a magic bullet, here. Rs, bluntly, haven't really brought much to the table. Healthcare cost control is going to be a crippling problem for our nation unless something changes. And right now, I don't think anybody has hard data (or at least I can't find any) on a solution.

I like competition. I think it breeds innovation. I think innovation is what we need. I think examples of this, even in the crappy market we have now, are places like Kaiser, which invests in preventive care and research. And this can keep costs down. Old article in the BMJ but I think still relevant (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC286244/).

I would also note, on the flip side, much of Kaiser's research funding comes from competitive grants from federal sources such as the NIH. I can't find a source for exactly how much, though. I support competitive government grants for research, which probably makes me a communist.

[thompson]

wj:

"But let's be clear that the same sorts of infringement occur everywhere in our economy, in one degree or another. Nothing particularly novel here in the ACA. So why the exceptional hysteria over this one? Really curious."

As someone who doesn't really like the ACA and thinks there are any number of reasons to change it...I think the answer is pretty clearly politics. Political point-scoring. Politically, I think the republicans have had any number of times to propose meaningful changes to the law...or propose a better one. And they haven't. They've voted to defund it dozens of times. As far as I can tell, none of those included a comprehensive package to replace it. To me, it's pure uncut black tar gamesmanship (everything I know about drugs I learned from tv!).

Hysteria helps them fundraise. For the moment. Those winds are changing. http://www.bloomberg.com/news/2013-10-18/republican-civil-war-erupts-business-groups-v-tea-party.html

[wj]

You know it's politics. I know it's politics. But the question in my mind was whether those who are objecting so vigorously would acknowledge that it was politics. Ot, if not (which I thought likely), what their alternate rationale would be.

[thompson]

Sorry! Didn't realize I was getting in the middle of your quest for truth and approximations thereof.

[bobbyp]

Just not very much, and not enough to put us on a sustainable path.

There is absolutely no evidence for this assertion beyond simple linear extrapolations of the past into the somewhat distant future.

As they say in the investment game, past performance is no guarantee of future results. Also please see the absolutely dismal CBO record of forecasting the bankruptcy of the Social Security disability fund. Kinda' leads one to believe that anything they put out is pure unadulterated BS.

Furthermore, the rate of increase in underlying health care costs seems to have slowed down significantly....now why is that?

[russell]

I could have missed it, but I don't think any conservative on this thread has taken that position?

not on this thread, but for example here.

[sapient]

Even private partnerships are enmeshed in public laws and policies, and are able to exist because of them.

Well, I'm not sure about "able to exist because of them". In a Libertarian Paradise, I might be able to freely gamble on people's health (which is what the insurance healthcare market is doing, in a highly regulated way). In a Libertarian Paradise, I would not be able to set up an Anthem Healthkeepers, which is highly regulated, but also highly protected.

In any case, i agree. In the United States, because of its Constitution (and therefore the Commerce Clause, the dedication to equality under the law, to due process, to protection of property, etc.) there are a whole lot of reasons that the "State" is involved with "private" conduct.

But corporations aren't private. They, as of their birthdays, just aren't. So Brett's discussion of a "private healthcare market" is lunacy if it has anything to do with corporations.

[thompson]

"There is absolutely no evidence for this assertion beyond simple linear extrapolations of the past into the somewhat distant future."

And I'm assuming you have better evidence that you're willing to share?

"Furthermore, the rate of increase in underlying health care costs seems to have slowed down significantly....now why is that?"

But the rate of increase is still positive (i.e. growing). Why? I don't know. Some people have attributed to structural changes from the ACA, the downturn, and a number of other things. Since I can't read your mind, perhaps you'd like to share what you think it is, and why?

[Tony P.]

thompson: If we don't get a handle on healthcare costs, we will cripple the economy.

This kind of talk is bad for my health. It makes me pull out my hair and throw things.

So, thompson: The Economy includes the "health care sector". What Americans spend on "health care" is not sent to Mars. It is income to other Americans -- just as what Americans spend on "litigation", or "entertainment", or "software" is income to other Americans. The "software industry" grows when Americans spend more money buying software. The "health care industry" grows when Americans spend more money buying "health care". The thing we call The Economy grows when Americans spend more money, period. When The Economy grows, people have more money to spend.

The only way your concern makes sense is this: if The Economy can only be a certain size because Americans only have a certain amount to spend, then all other industries must shrink in order for the "health care industry" to grow.

But you have to accept that "if". Do you?

If you do, ask yourself this: when cellphones became available, did The Economy shrink because Americans shifted some of their spending away from, say, food? Or did The Economy grow because Americans had something new to spend their money on, and something new to do for an income? Now ask yourself if there's any similarity between cellphones and pacemakers or hip replacements or MRI scans or cancer cures or even boner pills.

--TP

[thompson]

russell:

"in this thread or anywhere"

Sorry, I really should read more carefully. I have seen that video before, but I appreciate the link.

[bobbyp]

But the rate of increase is still positive (i.e. growing).

The rate of increase in many things is positive, population, GNP...just to name two. But for some reason many righties and so-called centerists are very selective as to which ones are "unsustainable".

To make the case for "unsustainability" you will have to do better.

And what Tony P. said.

[thompson]

"This kind of talk is bad for my health. It makes me pull out my hair and throw things."

Well, we certainly don't want that. It sounds painful, for you and those around you. I apologize, this concept of rising healthcare costs not being a problem is new to me, and my brief googling hasn't point me towards any enlightening literature. As long as you're throwing things, could you throw some in my general direction?

Because from the president on down, containing costs has been a talking point and an objective for both the left and the right. Russell even said it would be a problem for the solvency of the US upthread (parapharse, sorry if I'm mischaracterizing your statement, russell). If an insolvent US isn't a problem for the US economy, crap, I got nothing to say.

By the way, unsustainable isn't my word, it's Doug Elmendorf's and the CBO's. Which bobbyp doesn't like, but honestly, I kinda have to go with the team of economists, unless you have some contradicting analysis by another team of professionals?

[thompson]

Re-reading my comment, I'm worried it might come off as a little glib. I apologize if so, and I want to reiterate that I am serious about any analysis you can point me to about the growth of healthcare costs not being a problem. Seriously, it's not a concept I've come across before and I can't find anything on the net about it.

[CharlesWT]

Growing healthcare spending and growing healthcare cost are not necessarily the same thing.

[bobbyp]

I did not claim that increasing health care costs was not a problem. I merely point out that assuming that health care costs will continue to grow faster than the economy over the infinite future is meaningless. Throwing in terms such as "unsustainable" is just the cherry on top.

What is driving these costs is a dysfunctional private healthcare sector abetted by some ineffectual public policies. Here is an article with a lot of click through links that could be the basis of a meaningful conversation: http://www.washingtonpost.com/blogs/plum-line/wp/2013/10/21/washington-is-still-stuck-in-the-wrong-conversation/

See also Dean Baker on this topic.

[John Spragge]

CharlesWT has it right: the cost of health related services does not equal the price for health-related outcomes. Based on comparisons with other national economies, the actual cost for the health outcomes Americans obtain comes to about half the total health services outlay in the United States. As American conservatives remind me sometimes, Americans pay as much in taxes for health services as most people in OECD countries pay in total, for the same outcomes.

What's the conservative solution? Some blend of the system in Canada, France, or Switzerland: a system of private or community providers with strong government involvement or regulation. Conservatives in the Burkean sense understand that society consists of a huge tangle of messy and often inconsistent relationships, and government exists to mediate these relationships, not to apply some consistent and elegant ideological solution. To judge from their behaviour, doctors as a class do not want to operate in a rough and tumble entrepreneurial environment. They show some fairly strong evidence of valuing their sense of themselves as a profession, dedicated to quality public service. A (Burkean) conservative response would respect that while having governments or representatives of civil society with large scale purchasing power balance the economic monopoly power of the medical profession. Something like Canada. Or France. Or Britain. Or just about any OECD country with the exception of the US.

How would an ideologically motivated "free" market true believer address this problem? Milton Friedman proposed an approach: dismantle the medical monopoly, allow anyone to offer health care services with nothing but a ban on fraud and false advertising, and let the market work. So far, none of the states that have conservative legislators and governors (looking at North Carolina, Wisconsin, and Texas) have taken any stops in that direction that I can discern.

Right now, the United States has the worst of both worlds, and outside the Affordable Care Act the will to remedy the problem appears absent.

[Tony P.]

thompson,

Not to worry. Your comment was not glib at all, and I still have most of my hair.

Quite honestly, I cannot point you to anybody more authoritative than myself on the subject of "health care spending is GDP, after all". I'm not saying I am in the least authoritative, mind you. Neither am I saying that I, an amateur, have some brilliant insight that has escaped professional economists. All I'm saying is that the argument I laid out is not a rehash of something I read somewhere on the web.

It's true that many people talk about "unsustainable growth in health care spending" in various contexts. But they often do not make clear what the context is. For example, there is a difference between the federal budget (much of which is spent buying health care) and the national economy as a whole.

--TP

[russell]

Well, I'm not sure about "able to exist because of them".

I was referring to partnership as a form of corporate organization. So, C-corp, S-corp, partnership, sole proprietor.

My point being that even though ownership in partnerships and sole proprietorships (and most S-corps) is not "public" in the sense that it is in a C-corp, they are still creatures of the public sphere, because their existence is a function of law.

[Hartmut]

John Spragge, false advertising is protected free speech according to some SCOTUS decision iirc.

[John Spragge]

Tony P., actual improvements in health services delivery grow the economy. Rent-seeking by providers and financial services around health care does not. Since the United States has about the same health outcomes as most OECD countries but Americans pay twice as much, I'd have to say the evidence suggests that American health system has problems that rent seeking and inefficiencies generally.

[Countme-In]

I posted this on the "A Conservative Healthcare Market" thread as well.

I find debate with most of the conservatives at OBWI to be a far superior experience to debating the "conservative" memes (nice words for lying horsesh*t) wurlitzered by the right-wing media.

By which I mean nearly all of the conservatives here argue in pretty good faith, even if I do disagree with them in every detail for the most part, though their opinions of the way I present here may differ (I'm an acquired taste).

So, we are stuck with conservative opinions about what conservative healthcare marketplace might look like and real world examples of the conservative healthcare marketplace in action in our faces.

I give you Texas, which I'm using as the worst and most vocal example of a state run by conservatives who I gather aren't particularly viewed in a favorable light by the Texas conservatives who comment here.

You see the disconnect. It's one thing to consider decent conservatives' opinions about health insurance coverage and yet another to actually live with the crap that the "conservatives" who have taken over the Republican party in these latter days of the Republic provide on the ground.

What the Texas State Republican Party has wrought (with no little help from the Texas State Democratic Party):

http://www.window.state.tx.us/specialrpt/tif/healthcare.html

But look:

http://www.wfaa.com/news/health/Thousands-line-up-in-Dallas-for-health-insurance-info-229408491.html

[thompson]

Agh, so much good stuff and so little time to post. Bobbyp, the more I read your links the more I think we talk past each other some time. I agree with so much yet come to a completely different conclusion.

For the record, either the initial link or one of the click-throughs made the point that not getting a handle on costs is a problem. Which you seem to agree with, but think I'm being to extreme and/or to broad in my phrasing? Again, the phrasing came from the CBO, so I don't think I'm way out in left (right?) field.

There was a concentration of various clickthroughs to a thinkprogress link about the slowdown in health costs which you mentioned earlier. Here is an example of another analysis attributing it mostly (77%) to economic factors and not structural changes (http://kff.org/health-costs/issue-brief/assessing-the-effects-of-the-economy-on-the-recent-slowdown-in-health-spending-2/). I have a CMS report that comes to a slightly different number (I think 55% economy, some other factors) but I can't find it right now. Also, I think they ultimately pulled their numbers from the CBO (again, can't pull it up so I can't be sure).

I definitely don't want to say thinkprogress is "wrong" and KFF is "right" (indeed, the thinkprogress piece heavily cites KFF), but this is a complicated question with poor data at the moment. I'd like to directly quote the thinkprogress article:

"But certain structural changes in the health care system may also be at play, including the “less rapid development of new medical care treatments,” greater reliance on generic drugs and more efficient provider practices.

The Affordable Care Act will further encourage these reforms. In fact, a ThinkProgress analysis of the Kaiser data found that the rate of growth has slowed since the law’s passage in March of 2010, though it is impossible to directly attribute the cost trend to the new law."

That assertion (The ACA will continue reforms) is far from concrete and indeed, two sentences later they say it is "impossible to directly attribute" the slowdown to the ACA.

Forgive me if I'm not floored by the implications and immediately abandon CBO projections and verbiage as severely flawed. This is staggeringly complex, and even experts aren't expert enough. At the end of they day the data isn't complete and we're going to step into the unknown based on biases and assumptions.

But even so, I agree intemperate language is rarely helpful and besides I'd rather focus on where we agree. We agree healthcare spending is a problem? We agree that this is due to a dysfunctional industry operating in a dysfunctional regulatory environment?

My understanding of where we disagree is what to do about it?

[thompson]

Tony:

Thanks for the response, glad you have plenty of hair. I'm going bald myself and wouldn't wish to accelerate someone else down that path.

Yeah, healthcare spending is GNP, but that doesn't necessarily mean it's a good thing. Someone else touched on rent-seeking behavior and relative spending US vs. other OECD and I have little to add.

I will say I convolve national spending and government spending, perhaps improperly. I view them as pretty linked, at least for the time being...if health care costs go up, the government will spend more, and that will threaten solvency. I get the impression you disagree with that assessment and I'd be really interested to discuss why.

Finally, I'd say it's not just the growth of spending, it's the growth of spending as a proportion of GNP. Of course, maybe the trends will continue to decrease due to the ACA and this conversation will become irrelevant. I'm not rooting for failure, to be clear. I'm just not convinced the ACA has solved the problem.

[Tony P.]

thompson,

When you say "if health care costs go up, the government will spend more, and that will threaten solvency" I suppose you mean the federal government's solvency.

But I also want to be clear on what you mean by "health care costs go up". Maybe you mean prices go up, maybe you mean "more medical services are purchased". Those are two different things, though not mutually exclusive.

If we are to discuss this stuff coherently, and reach agreement on whether "ACA has solved the problem" or not, we need to be clear in our terms.

--TP