Americans: Damned if We Do, Don’t

You don't have to be clairvoyant to know it keeps going up.

George -- I think the questions/answers suggest extraordinary increases -- i.e., the sense that, with or without reform, no one has yet cracked the nut on mitigating out-of-control cost increases; that neither private nor public options will do much to slow down the higher-than-inflation curve.

Pete--

You don't need to be clairvoyant to know that what we have is unsustainable.

Here's another quote from that NYT article:

There is overwhelming support for a bipartisan agreement on health care, and here again, Mr. Obama appears in the stronger position: 59 percent said that he was making an effort to work with Congressional Republicans, while just 33 percent said Republicans were trying to work with him on the issue.

I don't see this as particularly surprising. People know the present system isn't effective at controlling costs but also realize the government isn't very good at controlling costs either, especially if the plan entails covering tens of millions more patients.

Pete, I think your last statement in your response to GS sums it up. People are definitely concerned with the status quo, but they don't believe the current proposals solve the problem.

George -- I'm not communicating well. Let me try again: I'm suggesting Americans might be "clairvoyant" because they do not believe any of the current options -- to reform or not to reform -- will change an unsustainable system into a sustainable one. What I'm picking up on in these apparently conflicting poll responses is a virtual (if not complete) resignation to the fear that whether or not Washington acts, the dysfunction will continue. I'm not saying I share that fear, but three-fourths of Americans apparently do share it – and if that shared fear is proven correct, those Americans would have been, in effect, clairvoyant. Of course, we could argue that this is not clairvoyance but justified cynicism. Our history is certainly not devoid of examples of Washington’s failure to fix problems -- even when it tries.

My take on the two polls is that Amercans are more confused than clairvoyant, and why wouldn't they be when so much of the reporting is political in nature rather than explanatory. Sure the information is out there, but rather than work to dig it up (time constraints, family, work, etc.) they mostly hope their trust in the party of their choice will make everything allright. Sounds like the Professor Harold Hill method to me.

Our history is certainly not devoid of examples of Washington’s failure to fix problems -- even when it tries.

Precisely, Pete, and that justifiable lack of trust is what is killing this initiative.

Two big mistakes: First, creating a comprehensive bill that promises to save money over the long haul even though the expenditures are obviously real and the savings are not quantifiable. On this, as I've said before, the political mistake is the same as the GOP made in trying to do comprehensive immigration reform. Then, the opponents said, 'Secure the border first, and then we'll talk about the rest', and on healthcare reform, the public is saying 'Show us the savings first, and then we'll talk about expanding coverage.' In both cases, it's not that theres no appetite for the latter things to happen, but there's no trust that the plans hatched in DC will address the problem that is more important to the majority of voters and which must happen for the overall plan to succeed.

The second mistake was Obama saying things that are provably false about the bill, and some promises that are half truths or which ignore legitimate concerns. He has squandered a lot of the goodwill that he enjoyed previously, and this will definitely hurt the prospects of this key piece of legislation passing in any form that the Dems really wanted. It may harm the rest of his presidency as well, or may force him into the same position as Bill Clinton in 1994.

Sure the information is out there,

What information are you referring to, JSpencer? From the context, I assume you mean that there's information to show how the public option plan will save money and reduce costs. Can you point me to such information?

CStanley--

Ironically enough, I was going to ask you to point me to information about what's "provably false" about the bill.

Thanks in advance.

"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."

*****

Lack of health care is disrupting domestic tranquility. Protection from and treatment for disease promotes the general Welfare of the people. The Preamble to the Constitution is the nutshelled embodiment of the forefather's intent for America. It's time for a new Amendment that reflects that intent with respect to the nation's greatest enemy that has caused the most casualties, the most disruption of domestic tranquility accrued case-by-case, more than any and all wars or terrorist actions combined, to citizens' lives: lack of accessible [affordable] health care.

There is nothing unamerican about the government establishing a defense for individual citizens' health care. In fact it keeps absolutely beautifully and perfectly with the intent of the most american document of all and of that document even the condensed statement of its overall intent in the very first few lines written in it.

... especially if the plan entails covering tens of millions more patients.

In a way that lowers costs over the long term.

The current system is not just "ineffective at controlling costs"; it's a disaster that has happened and is simply unsustainable.

@ George:
"If you like your current plan, you will be able to keep it"

"There are some places, like the Mayo Clinic -- many of you have heard of -- provides outstanding care, some of the best in the world. People fly in from everywhere to go to Mayo Clinic to get treatment. It turns out Mayo provides care much more cheaply than a lot of other health systems, even though it's better care." (Implying that this is the model on which the proposal is based, which Mayo obviously disputes.)

And some more from Factcheck.org:
Obama promised once again that a health care overhaul “will be paid for.” But congressional budget experts say the bills they’ve seen so far would add hundreds of billions of dollars to the deficit over the next decade.
He said the plan "that I put forward" would cover at least 97 percent of all Americans. Actually, the plan he campaigned on would cover far less than that, and only one of the bills now being considered in Congress would do that.
He said the "average American family is paying thousands" as part of their premiums to cover uncompensated care for the uninsured, implying that expanded coverage will slash insurance costs. But the nonpartisan Kaiser Family Foundation puts the cost per family figure at $200.
Obama claimed his budget "reduced federal spending over the next 10 years by $2.2 trillion" compared with where it was headed before. Not true. Even figures from his own budget experts don’t support that. The Congressional Budget Office projects a $2.7 trillion increase, not a $2.2 trillion cut.
The president said that the United States spends $6,000 more on average than other countries on health care. Actually, U.S. per capita spending is about $2,500 more than the next highest-spending country. Obama’s figure was a White House-calculated per-family estimate.

There are more, too, especially if you go back to his campaign promises like when he said that his plan would reduce the average family's premiums by $2000 a year, and that no one making under $250,000 a year would see their taxes go up (I include this one since inevitably the high cost of this plan is leading Congress to consider ideas like taxing employer based health benefits- a proposal Obama harshly criticized as part of McCain's plan,.)

Oh, and then aside from making misstatements about the plan itself, there are misrepresentations of the status quo like his bizarre claim that doctors remove kids' tonsils in order to make more money. Here's the response by a group representing the nation's ENTs about how those decisions are actually made.

In a way that lowers costs over the long term.

Kathy- JSpencer hasn't responded yet to my question of where the evidence is for this cost savings. Do you wish to give it a shot?

People are getting microscopic with this debate and of course this is the intent of the health insurance and pharmaceutical industries right from the get go. The last thing they want the public to do is look at the issue from a standpoint of national security. That yanks the baby right out of their hands and places it squarely in a position where we can act quickly and effectively to right the situation.

The issue of health care is an issue of national security because the issue of unaffordable health care is breaking our system of productivity to such a degree that we are now on our knees before communist China begging for scraps and mercy because our GNP has shrunk so badly that we cannot compete effectively on the world market anymore to literally save our lives. This is because health care is sucking the system dry. Employers who cannot afford to provide it for their workers pull up stakes and funnel their profits overseas. We've been slowly bleeding from this puncture wound now for decades. The patient is getting faint, woozey, lightheaded and all because of health care issues.

You provide a public health system and impose strict tariffs on overseas production of US goods...and close all the loopholes, you'll see some really rich folk have to tighten their belts for a short period but then suddenly their quaility of life will again rise because a nation is more productive, rich and can afford the products they sell to get rich in the first place. So essentially we're all in a huge mess because of a health-monopoly and a group of super-rich who don't want to sacrafice even five years of their highball lifestyles to reinject life into the host they've sucked off of nearly to death.

That's the big picture that they don't want us focusing on.

*Silence Noteworthy*..

lol...

Literally if you look at the timing of posts they were coming every minute or less then this last one where I pointed out the macroscopic real issue hoped to be avoided and WHAM! Everything skidded to a halt. Now the hope will be that enough other articles will shove this puppy right off the front page of TMV and into oblivion.

Those damed cats just keep jumping out of the bag..

The CBO reports show that there will be no cost savings. People need to stop arguing that the bill will save us money.

CStanley--

The links to Investor's Business Daily and the Mayo Clinic blog are opinion pieces, right?

As to FactCheck, everybody already know about the problems with CBO numbers. The current struggle to further reduce costs is ongoing.

You haven't proved anything false.

All you've proved is that there's controversy.

The IBD piece was an opinion piece which contains facts. Do you dispute the facts, or the analysis of them?

The Mayo piece too is opinion but the point there isn't whether that opinion is agreed upon or not- the factual error Obama made is in using Mayo as an example of what this bill does. If Mayo disputes that, aren't they ultimately the ones who would know whether or not the plan uses their own methods of cost reduction?

Oh, and the CBO- please. I assume you also felt that the CBO numbers were faulty whenever they were used to argue against Bush policies?

You haven't proved anything false.
It is definitely false that everyone will be able to keep their current plan.
It is definitely false that the proposal uses cost saving measures based on the Mayo model.
It is definitely false that doctors choose to perform tonsillectomies based on greed rather than efficacy basis.
It is definitely false that there are verifiable net cost savings in the bill- according to the gold standard of fiscal analysis that has ALWAYS been used to score bills. Not to mention that obviously if the bill was going to be a net cost saving one, the Dems wouldn't be hung up on trying to figure out a politically tenable solution for how to pay for it.

Saying I haven't proven anything is the equivalent of putting your fingers in your ears and yelling 'Lalalala'. Controversy? There's nothing controversial about the facts I've presented, and you haven't given a single valid reason that would make those facts consistent with Obama's rhetoric.

Oh my yes...microanalysis necessary. Let's not look at the bigger costs of not having public-funded health care! Weigh all of the costs including those to industry..then we see a net gain on the side of public health care in spades...lol..

No! No!...keep focusing on micro issues of public vs private! DON'T let them include larger costs to our nation in the equation at all costs!!

lol...

The private health ripoffs have GUTTED our economy in just the ways I pointed out before the hour-long pause in this conversation. The costs of not having public health care are ASTRONOMICAL and may even mean the death of capitalism totally when our nation can no longer compete on the world market.

Talk about the dragon eating its own tail. Republicans and the masters they serve are slow, overfed, dull-witted and just plain dumb even to save themselves..

George, a lot of your posts come across like an eight-year-old endlessly repeating "Oh yeah? Prove it!" no matter what anyone else says.

I'd love to see you weigh in more with your own opinions backed by your own citations

In fact, it wouldn't even surprise me if health industry bots would start a siderail argument between each other at the first hint of THE BIGGER PICTURE being exposed..lol...if an hour-long pause and hopes of thread disappearance doesn't work. Or is pointed out..lol..

Anything but argue the bigger picture. Anything but that!

BTW what are the numbers reflecting in costs of loss to industry and productivity by forcing companies overseas to escape escalating private health care costs? Should we add those to the equation? No?....lol... No No No No NO NO NO! [please, not THAT!]

Silhouette, if you want someone to respond to your arguments, they sort of have to make sense. What you wrote makes you seem like a liberal version of Archie Bunker, and trying to argue with him is rather like hitting one's head against the wall.

On your latest bit- what macroanalysis shows that overall costs of a public system would be lower than costs of healthcare as currently funded? If your saying the costs would be shifted away from corporations and onto other payers, sure. But are there reallly enough billionaires in the country to pay for all of the healthcare needs of the entire population? The question is, do costs really go down if the govt is the payer- and no one has been able to prove that that would be the case. When the govt negotiates lower prices for the portions of care that is provided under the current public systems, the providers shift costs to private payers. What happens when there are no more private payers?

Now the bigger picture they don't want us to see "doesn't make sense". I don't want a response from you or your fellow bots. So my feelings aren't hurt...lol..

This is a matter of national security. Private insurers screwed us over as a nation. Time to screw them over. They can compete with Uncle Sam from now on. And if Uncle Sam is this big unwieldy expensive prospect then why do they fight it so? Answer: they fear that competition because they factually know it will be less expensive and therefore they will have to drop their rates to compete. Bottom line is less profit for them.

The very fact that they're fighting this proves they themselves know it to be a success in the making..

CStanley--

Proof is proof. Opinion is opinion.

Name-calling is name-calling.

I'll say it again:

They [the private insurers] can compete with Uncle Sam from now on. And if Uncle Sam is this big unwieldy expensive prospect they are saying, then why do they fight it so? Answer: they fear that competition because they factually know it will be less expensive and therefore they will have to drop their rates to compete. Bottom line is less profit for them.

The very fact that they're fighting this proves they themselves know it to be a success in the making.. And the amount of fight they put into this is inversely proportional to how much their experts have crunched the numbers to find it will actually cost tax payers. ie: how much they'll have to lower their rates to reflect actual costs. You see, Uncle Sam doesn't have the overhead they do. No advertising, no gimmicks, no fatcats and strings of yachts to support at the expense of the sick and dying. That's competition they don't want. And that's why they're fighting a good system that will work.

It must, we won't survive as a first world nation without it..

Well, George, as DrJ pointed out, you could try presenting some evidence for your opinion if you think you can support the opposing view better than I supported mine.

What name calling?

And if Uncle Sam is this big unwieldy expensive prospect they are saying, then why do they fight it so?

Um, because it's a big unwieldy expensive prospect that can legally subsidize itself at taxpayer expense, until such time as the taxpayers revolt or the funds dry up, at which point the only choice is to cap the services that are paid for.

Now the bigger picture they don't want us to see "doesn't make sense". I don't want a response from you or your fellow bots. So my feelings aren't hurt...lol..
Didn't think your feelings were hurt, I was just presenting what I think is the more accurate reason that no one responded to your earlier comment. Considering that liberal commenters here greatly outnumber the conservative ones, I don't see other liberals agreeing with you either or even addressing a lot of your remarks so I think the issue is that they're sometimes rather off the wall in reasoning.

"Bots"...WTH?

CStanley--

I am, in fact, currently writing a reply to Dr J.

I think that whole finger-in-the-ears-la-la-la thing qualifies as name-calling.

I think that whole finger-in-the-ears-la-la-la thing qualifies as name-calling.

I was only trying to describe my frustration at presenting evidence to back an opinion and then having you respond by claiming that I didn't. I mean, really- are you that sensitive that your feelings were hurt? If so, I apologize. I still stand by my characterization of your reaction, and if I could think of a way to describe it without what you'd consider 'name calling', I'd do so but I can't.

The point remains, that if you don't think someone's evidence is strong enough, then you should present your own evidence to support the opposing view or at least take apart the analysis the other person presented and show where you think the dots aren't connected properly.

Eg....Was the IBD piece inaccurate in reporting the stipulations in the bill which will force people out of their current plans? Was Obama accurate in asserting that he's trying to implement cost savings the way Mayo does? Was he accurate in portraying the way doctors make decisions about tonsillectomies?

Dr J--

The US spends more per capita on health care than other nations, even though we don't get more services. Most of those other countries that spend less and get more have national health plans, right?

The Commonwealth Fund produced a study, complete with charts, that points a way to what they call a high-performance health system. There are other studies with reasonably similar conclusions.

Not everyone likes what's being proposed. Some of that is reasonable, like Pete Able's questions about costs. Some of it is just political, like Republican Senator DeMint's expressed argument that opposition to health care reform can be used to break Obama (link will also show some of the problems DeMint's constituents face while he plays politics), and like Republican Senator Inhofe's expressed argument that opposition to health care reform will be beneficial to his party in the 2010 elections. And some of it is just plain insane, like Republican Representative Louie Gohmert claiming the health care reforms will kill senior citizens.

As you can probably tell from my links, I don't have much trust in Republicans to solve what even you once agreed was a health care crisis in America. Meanwhile, Democrats are sweating over the CBO numbers.

In another comment you made here, you spoke pretty eloquently about the lack of honesty in general over the subject of costs:

If we could have such a dialog, the result might be give and take in a number of dimensions. They might involve raising taxes, or lowering expectations, or embracing more serious systemic reforms. We might even decide that our grandparents had it much worse than us in every dimension, our grandchildren will probably have it much better, and we really are going to stick them with a bunch of bills

I personally think we should suck it up and raise taxes--in a sensible, targeted way. But I certainly understand how politically untenable that is.

I favor the public option. But even I recognize that will cause problems. The main one I can think of doesn't get discussed much, though Kevin Drum once summed it up pretty well:

Well, for starters, the program could be limited just to the poor. But that wouldn't make it universal since there are plenty of non-poor who don't have health insurance and can't get it through the private market.

No, we'd have to simply offer it to anyone who was uninsured, subsidizing the poor and charging full price to everyone else. But what would happen then? Answer: employers would start dropping health coverage for their employees. Why wouldn't they, after all? Unlike the food example, where there are personal incentives against being lazy and living off the government dole, employers have no reason to hold back. As long as a decent alternative is available, their incentive is to get out of the healthcare business, hand over the money they save to their employees, and tell them to sign up for the government program. Before long, the government would be funding a huge portion of the private insurance market.

That will never fly, of course, so we'd need rules in place to prevent companies from dropping their healthcare plans. But that would put existing companies at a disadvantage if new companies didn't also have to provide healthcare. So we'd need rules that didn't just prohibit companies from dropping healthcare, but affirmatively required them to provide healthcare. But which companies? Lots of big companies don't offer healthcare right now, so this would be a brand new mandate

And so on and so on. The regulation required to make all interests happy is a hall of mirrors. And that lengthy quote buries the real problem: Your employer doesn't want to be in the health care business. Your employer will dump you the second he gets chance.

And in doing so, your employer will derive a competitive advantage. Which is a benefit the CBO doesn't score. Because the government will be on the hook for all that insurance that all those employers dump off their financial books. Just like the government is on the hook for road construction and maintenance, which is something that everyone benefits from. Health care is just another infrastructure problem, in my opinion.

We're running a huge deficit. That worries me. I'm as cynical as anyone. But I'd vote for the guy who wants to raise taxes to pay the deficit down. I'd vote for the guy who is ready for the honest conversation about costs and benefits. I'd vote for the guy who wants to solve real problems, and then I'd hold that guy accountable. If only everyone was ready for that kind of honesty!

Democrats are sweating the problems.

Republicans are sponsoring legislation about a birth certificate.

I'm for solving as much of this problem now, while serious people are running things.

(This was kind of a rush job, so sorry if there are grammatical errors or the links don't all work.)

God almighty, CStanley, I've been arguing with you here for five years. You should know better than anyone that I'm not sensitive about that kind of thing. Call me what you like.

But don't pretend differently.

@George- I wasn't pretending, I honestly was surprised that you'd consider that an example of name calling. It was just a way of expressing that you didn't really address my arguments, and actually claimed I didn't make them at all.

Anyway, am I correct in saying that your response to DrJ admits that people WILL in fact lose the coverage they currently have from their employers in many cases? And if so, isn't that an admission that I was right on at least one of the points where I said Obama isn't being truthful?

Gotta go out for a while but I'll check back later.

Rationing, having someone else decide what you can get for the money you've paid, strange bureaucrats making decisions over your head, not being able to choose your own doctor... That's what the US has today.

The employer limits physician alternatives, an opting out and getting your own doctor is very costly. There may be increased costs for some middle-class families, but in the new system they will not be struck with sudden huge costs that really destabilize their lives. A few hundred dollars more in taxes per year (not for all middle-class households, but let us be honest and state that some middle-class families will pay more) or risk getting bankrupted by a sudden whammy, costing all taxpayers more money in the end and consuming less.

The current system is a relic from a time of wage freezes, when employers had to attract employees some other way. I thought America was about meritocracy, state-of-the-art and adaptation, not ideological abused-spouse syndrome. Every disaster "Obamacare" would supposedly bring is already available in the status quo.

CStanley asks:

Anyway, am I correct in saying that your response to DrJ admits that people WILL in fact lose the coverage they currently have from their employers in many cases?

No. No. No.

Go back and read the quote from Kevin Drum. It's about how they have to write legislation that PREVENTS current employers from dropping their employees.

Sorry to shout, but you're not the only one who gets frustrated, CStanley.

EDIT to add the relevant quote from Drum:

That will never fly, of course, so we'd need rules in place to prevent companies from dropping their healthcare plans. But that would put existing companies at a disadvantage if new companies didn't also have to provide healthcare. So we'd need rules that didn't just prohibit companies from dropping healthcare, but affirmatively required them to provide healthcare. But which companies? Lots of big companies don't offer healthcare right now, so this would be a brand new mandate

Emphasis added!!

GS- As I said, I'm on my way out the door and probably skimmed too quickly- I'll take another look later.

Surely though you can at least see why people who currently have employer based insurance that they're satisfied with are concerned, and how many people don't feel reassured by some of the provisions of the bill?

CStanley--

Certainly some people don't feel reassured by some provisions of the bill.

Why should they, if they're being told Obama wants to kill them?

---The president said that the United States spends $6,000 more on average than other countries on health care. Actually, U.S. per capita spending is about $2,500 more than the next highest-spending country. Obama’s figure was a White House-calculated per-family estimate. ----

CS, the $6,000 figure jibes better with the data I've found, do you have a source for the $2,500 figure? Thanks!

George, thanks, tons of substance there.

Just to comment briefly on the Commonwealth paper, I'd characterize it as more a bunch of nice sounding ideas than a credible policy recommendation.

Paying for results rather than treatments sound terrific, as does letting you keep your current insurance and doctors. But once you get into the "how" questions, those two goals are sharply at odds. Virtually every insurance policy, hospital, doctor, and contract in the industry is geared around fee-for-service. How do you get all that machinery to re-orient around fee-for-value? And to the extent you manage, how can you expect existing arrangements to survive?

The conventional meaning of an exchange is a clearinghouse where commodities are bought and sold. That doesn't seem to be what Commonwealth proposes, so what do they really mean by the word? The way they describe it has a whiff of simply a big government-run industry, where private entities are so tightly constrained they aren't really private in anything but name.

I'm a little late to this party but I want to throw a few things out there:

* None of the bills in Congress are Obama's
* The different plans under negotiation each have their own pros/cons and price tag

Truth is, other countries provide better care, that's universally available, for substantially less than we pay now. The trouble is how do we replicate that here in America. It's possible, but we need to push Congress and the President in that direction.

As it stands, defenders of the status quo/insurance industry shills (both Republican and Democratic) are scaring Americans about reform. They're insisting it will be too expensive and it will cut benefits. So they are pushing to water down the proposed health plans. They won't mention that the status quo is also too expensive and will eventually lead to a cut in benefits and more Americans with no insurance at all. What we need is stronger reform with the power to actually change the costs of health care long term.

@@What we need is stronger reform with the power to actually change the costs of health care long term.

OK, I'll bite. Here are my top ten reasons healthcare costs are escalating in the United States. As I said yesterday, unless "public option" can possibly shift some back end ER into front end preventitive, there is not one single solitary thing "public option/single-payor/government sponsored" can or will do to make any bit of difference in these cost escalation factors.

Note my list does not have "insurance company profits" on it because in my view these are nominal dollars compared to the others listed. The five biggest health insurers—UnitedHealthCare, Wellpoint, Aetna, Humana, and Cigna—which cover 105 million members, last year had profits between them of $11.8 billion........ U.S. health care costs last year were in the area of $2.3 trillion.

However, if you think you have a more accurate list of the primary cost escalators, post that and explain which ones Demcare legislation will reduce.


1. Nobody shops for value.
2. Medical innovations are usually more expensive, not less.
3. Health care is a "luxury good".
4. We don't pay for what we consume.
5. Baumol's disease.
6. The old.
7. The uninsured.
8. The fat and lazy.
9. Because death is sometimes the low-cost option
10. Malpractice/defensive medicine.

Public option is a transfer payment mechanism, pure and simple, it will not reduce costs in any of these categories but one (maybe) way.

Further, I submit 2,3,5,8, 9 and 10 are significantly more preponderant in the US than any other country....yielding the false comparison of healthcare costs of the US to other countries with the baloney liberal premise that nationalized healthcare is the same but cheaper in other countries.........unless you are prepared to announce to the United States that Barack Obama is going to change the demographics and usage/access patterns of US citizens to conform themselves to other countries.

Dr J--

I often ask you for the sources of your ideas because I'm interested in what you say. I agree with your complaints about the absence of price transparency. But I don't really have much sense of where you're coming from. If there's a report like the Commonwealth Fund report that ballparks it for you, please provide a link.

For that matter, feel free to explain it in your own words like I did.

As for re-orienting the machinery, if there weren't huge problems there wouldn't be such an overwhelming need for reform. You once provided a link to a long New Yorker article about health care delivery in McAllen, Texas. Having a payment structure around fee-for-service causes an obvious problem: Performing more services earns providers more fees. The incentives are out of whack. That's a pretty big problem, in my opinion.

And as for the Commonwealth report, anyone could nitpick it. (Including me.) As a practical blueprint, it has a lot of political problems. But I think it's a reasonable outline for useful reform.

Casualobserver--

I think that's a fantastic list.

I might move Baumol up to number one. What you're calling "Nobody Shops for Value", I'd probably call "Lack of Price Transparency". And today's somewhat expensive innovation is tomorrow's simple, effective solution, so I think in a more rational system innovation ends up paying for itself.

And I think you're kidding yourself about #4. Somebody pays. Every time. That's just the way it is. And that's a huge part of the problem.

As for #9, burial in potter's field is probably cheaper than a ride in an ambulance. I'm pretty sure you're making a different point, but I'm not quite sure what it is.

I gather you think there is no solution. Fair enough.

Lurxst- those figures were part of the Factcheck.org stuff on Obama's healthcare townhall statements. You should be able to find their sources at the link.

Lurxst--

Thanks for pointing out the problems with FactCheck as a source of checkable facts.

JSpencer hasn't responded yet to my question of where the evidence is for this cost savings. Do you wish to give it a shot?

If I can go to the doctor when I'm sick or don't feel well, instead of waiting until my condition is so bad that I have to go to the emergency room, that saves all Americans money.

If I can get regular preventive check-ups, potentially life-threatening diseases and medical conditions can be diagnosed, or I can find out I'm at risk, before the problem is so severe that I have to go to the emergency room or have to have really expensive life-saving treatment. That saves all Americans money.

If I do not have to rely for my health care on a private, for-profit insurance company that spends millions of dollars a year on lobbyists to make sure any public health care option is killed and never enacted, and in general to make sure all health-related legislation is written so that its profits are not adversely affected, even if that means shafting the people who need health care, then administrative costs that are built in to the cost of private health insurance policies will not exist, and that will save all Americans a lot of money.

This is just for starters -- just what I could come up with myself, from my own self-education, reading, listening, native intelligence, and common sense.

Which means you could have come up with these answers, too.

I think casualobserver's list is a good place to look at what our expectations are for a good law and fiscally effective system.

1. Nobody shops for value.
I think HSA users are an example of who is more prone to shop for value, but its true that much medicine seems to come from a "how much can you pay?" tradition. This might also concern #5. Baumol's.

2. Medical innovations are usually more expensive, not less. I agree here. But insurance companies don't make the innovations in anything except cost control. Much R&D is performed by teaching hospitals, universities and in the field outside of big pharma or health plan initatives.

3. Health care is a "luxury good".
This is closely tied with 7 and 8. Some of the innovations and changes in nations with national health systems have a lot to do with a overall public health. People do get hopeless about the costs of healthcare and their lives are affected accordingly. Without access to regular care, and I'm not referencing the usual talking point of "You can always get care, look an Emergency Room!" but instead I mean a culture that rewards good health and people can easily get regular checkups, teeth fixed, major medical problems addressed early. Then they can have a shot at contributing as a taxpayer and are less likely to end up a public charge at much weightier costs. There will always be some outliers but overall you look at Mortality rate data and those NHS nations have a longer lived, healthier populace. I wish I knew more about the history of other national health plans, in terms of how long this took, 2 generations, 3?, to see the slow change. Right now a regular workers costs (me for example) are so prohibitive that many are forced onto public plans after they go broke from lack of work while healing and massive copays and deductibles. You can burn through $8,000 of your HSA money in a blink. When that happens many end up on public systems. And to imagine a low wage earner being able to easily save up $8,000 each year..its gets pretty hopeless. So best to just adopt an attitude of detached concern about that ugly mole or that bad cut you got over the weekend.

4. We don't pay for what we consume. I think george nailed it. Someone always pays.

5. Baumol's disease. Getting adequate medical services into some areas of the country and communities is amazingly difficult, so there will have to be some attention given to the different costs. So far the health insurance biz only partially address this, the feds are already hip deep in subsidizing these services.

6. The old. I think end of life care is a real area to debate and look for the best options. Even with better overall health outcomes, people still have to die eventually.

7. The uninsured. They will have insurance.

8. The fat and lazy.
9. Because death is sometimes the low-cost option
10. Malpractice/defensive medicine. I think there should always be some way to file grievances and address real malpractice. Could there be a national malpractice indemnity pool?

Thanks for the list, good talking points.

The CBO reports show that there will be no cost savings. People need to stop arguing that the bill will save us money.

This statement is almost a parody of itself.

"But I don't really have much sense of where you're coming from. If there's a report like the Commonwealth Fund report that ballparks it for you, please provide a link. For that matter, feel free to explain it in your own words like I did."

George, I've followed you past those primroses before. I laid out my ideas, again, and you wanted proof the implementation wouldn't take too long. I responded it would take changing one tax law, and you dismissed that as impractical. Then you wanted proof that someone else is advocating these ideas too. I gave you a link, which you dismissed as just a blog post. In fact I pointed out an entire country already using a similar system, but you required more proof than that. At no point did you engage the substance of the ideas. So I'm afraid I'm having trouble believing your claim to be interested in what I say.

As for the Commonwealth report, its problem is not in the nits, its problem is it says almost nothing. It's clear that there should be rainbows and lollipops, and then the specifics get vague and contradictory as the couple examples I cited illustrate. A "reasonable outline for useful reform" should identify the basic tradeoffs we're facing and propose a path through them. The Commonwealth doc doesn't even do the first.

"What information are you referring to, JSpencer? From the context, I assume you mean that there's information to show how the public option plan will save money and reduce costs." - CStanley

Just getting back here, sorry bout the delay - lots of running around today. I think you may have misunderstood the context. As I said: "...when so much of the reporting is political in nature rather than explanatory." I was referring to reporting in general. Good information is available on most any subject (including healthcare) but if people wait for the MSM to give them worthwhile info, they might be waiting a long time.

"If I can go to the doctor when I'm sick or don't feel well, instead of waiting until my condition is so bad that I have to go to the emergency room, that saves all Americans money."

Kathy, you're right that that transaction would be cheaper. If an ER visit costs $1000, an office visit $200, you got the same result either way, and you didn't make four other office visits about problems that would have gotten better on their own, the system saves money.

But the question that needs to be answered is what happens to costs through the whole system? The cheaper you make office visits, the more people will make. How big is that effect, and does it cancel out the other savings?

A related train of questions: is it safe to assume that under a government-sponsored plan, more Americans will see doctors more often, and overall we will be consuming more doctor-hours than we are now? If so, where will these hours come from? Will the doctors we have work longer days? Will we lure more doctors from Canada or elsewhere by offering them pay raises? If so, how much will these raises add to our health care costs?

These are complex questions, and there are many more where they came from, but they're critical. Whether we end up seeing cost savings or cost increases depends on all these complex factors.

is it safe to assume that under a government-sponsored plan, more Americans will see doctors more often

Why, because it's fun to go to the doctor?

Seriously -- why would Americans go to the doctor more often under a public option that emphasized preventive care? People w/o health insurance put off going to the doctor because they can't afford it. If they don't have to worry about how they are going to pay doctors' bills, why would they wait to see a doctor? And why do you think that being able to see a doctor *before* you get sick so you *don't* get sick will *increase* doctor visits?

Whether we end up seeing cost savings or cost increases depends on all these complex factors.

Obviously, no one can say for sure how much cost savings we will see under *any* plan until it's been implemented. But what we *do* know is that if we either do nothing, or if we pass a bill that does not effectively and significantly address the factors that are driving up health care costs, we will see cost increases. The system we have now is driving up costs astronomically, as we speak. I honestly don't know how anyone who claims to be concerned about "cost increases" can be in favor of scrapping the Democrats' plan (in its general outlines, since we don't actually, really, have a plan yet because of all the obstructionism) with no feasible alternative to put in its place. I don't understand how anyone who claims to be concerned about "cost increases" can complain about the Democrats "rushing" things through when we have a crisis that's been building for decades, and I don't understand the lack of a sense of urgency among people who claim to be concerned with cost increases. Anyone who can say, Hey, let's take our time, what's the rush, let's start again in the fall and "do it right" is not as concerned about cost increases as they claim to be. Either that, or they simply don't understand that every week that goes by with the status quo still in place, thousands more Americans will lose their insurance, and cost-conscious conservatives' premiums will keep on going up and up and up.

I don't *think* that's what conservatives want, but honestly, sometimes I do wonder.

Dr J--

Changing one tax law is a revision of the tax code. If you say that'll be easy, great. Someone in Congress still needs to propose it, conference it, pass it. Let me know when that happens.

You inspired me to find out more about Regina Herzlinger's ideas and I found this short piece she wrote for the Atlantic's business, yes, blog. Her ideas are interesting. There are some problems (she seems to think everyone will suddenly become a fantastic haggler over their health costs), but every solution has problems. For me, a big problem is that there is no one pushing her ideas, as a practical measure. At least, no one I could find. I had some hope you could point me toward some organization in favor of them.

I've read about Switzerland as a model. Switzerland seems unique in the industrialized world in its approach, however, and there's nothing intuitively obvious to me about its superiority. In fact, I vaguely recall reading some stuff about their ad hoc approach leading to piecemeal treatment, but I can't remember where I read it (and Google's not coughing it up). Still, all solutions have their problems, and I don't know much about the Swiss model. It could be good in a non-rainbows and non-lollipops way. If there is a serious effort behind implementing a Swiss-type model here in the US, I'd like to know more.

I provided links on this thread to a couple of the comments you've made here at TMV. (One. Two.) People can go to those links, read the threads, and decide for themselves if I've engaged in the substance of your ideas.

And, yes, I am interested in how quickly we can get some reforms, under the practical political conditions. I am especially interested in increasing the number of people who are covered by health insurance. But I understand it's a process. In that comment you linked to, in the thread to a post called "Ripples", I also said a few things, including this, which ends by me saying, "Maybe the things you're proposing are best dealt with in the next round of reforms?"

I also said I don't live in Utopia. I don't have any interest in rainbows and lollipops. If you have something from Regina Herzlinger (or anyone else) that identifies the basic tradeoffs we're facing and proposes a path through them, please point it out. If you've shown that before and I, in my ignorance, missed it, please do it again. Links, quotes--you know how it works. Then you can bookmark it and trot it out as often as you like.

Thanks.

These are complex questions, and there are many more where they came from, but they're critical. Whether we end up seeing cost savings or cost increases depends on all these complex factors.

You're right - what these rose-colored glasses scenarios don't factor in is that when you improve access to care you will increase demand and therefore utilization and cost. If you make it cheaper to see a doctor people will see the doctor more often. That would counter balance or even exceed the savings from people not having to go to the ER. Of course since there is already a primary care shortage a lot of people will probably just go to the ER anyway.

The dirty secret of preventive care is it doesn't save a lot of money. It improves the length and quality of life. Yes you will catch an occasional early colon cancer by doing a bunch of colonoscopies but you will also pay for a lot of normal colonoscopies. Also by extending life you will increase the number of years people are utilizing the health care system. Don't get me wrong, I think preventive care is the way to go for many reasons but it should not be looked on as a major cost-saving feature.

What will save money is what insurance companies do and what the government is afraid to do, and that's to sometimes say no to what people want. Insurance companies regulate expensive testing and medications. You don't need an MRI because your neighbor had one. You don't need an expensive medicine for your blood pressure or reflux when there's a $4 med at Wal-mart that will work just as well. I am hearing talk about panels of doctors and experts deciding what treatments will be covered, but very little that is concrete.

Seriously -- why would Americans go to the doctor more often under a public option that emphasized preventive care? People w/o health insurance put off going to the doctor because they can't afford it. If they don't have to worry about how they are going to pay doctors' bills, why would they wait to see a doctor? And why do you think that being able to see a doctor *before* you get sick so you *don't* get sick will *increase* doctor visits?

I can't tell if that was a "yes" or a "no." Are you saying that in the system we have, the uninsured spend as much time in front of doctors as they would if they had insurance?

if we pass a bill that does not effectively and significantly address the factors that are driving up health care costs, we will see cost increases.

Well, yes, we told you so. My fellow fiscal conservatives and I have been saying for month after month after month that costs are the main problem we need to solve, while everyone on the left has refused to think seriously about them. Now we're further down the road, we have a bill that doesn't address cost control, and the cost problem has become so obvious that the CBO, the public, and centrist Democrats are starting to balk at it.

So, I'm sorry you're frustrated progress on the reform has slowed, but the left's intransigence--including your personal intransigence, Kathy--is a big contributing factor.

"There are some problems (she seems to think everyone will suddenly become a fantastic haggler over their health costs), but every solution has problems."

GreenDreams keeps making that claim too. And while it's true that few consumers in our culture haggle, haggling is not what matters.

The magic thing consumers do is shop. They analyze value for money, and if they don't think they're getting a good deal, they very quietly take their business elsewhere. Shopping is what keeps every other industry lean, efficient and responsive, and it's glaringly absent in health care.

I can't tell if that was a "yes" or a "no." Are you saying that in the system we have, the uninsured spend as much time in front of doctors as they would if they had insurance?

Her logic is confused. She's arguing against her own arguments.

Dr J--

There is no constituency for the reforms you want. That's a big problem if you expect anyone to think your proposed solutions are practical.

Changes to the tax code that would benefit some will damage others, like insurance companies. Those who'll be damaged will fight them, just like they're fighting right now.

Changes in price transparency that would benefit some will damage others, like insurance companies and some of those fee-for-service providers. Again, they'll fight against those changes.

You seem to be defending the current fee-for-service structure in spite of its obvious, built-in problems. The incentives are out of whack. Yet some of those fee-for-service providers will fight against changes in those incentives.

The lack of a constituency for the reforms you want seems to me like it's a big problem. And yet you continue to talk about them as if their "magic" (a word you used in the comment I'm responding to) is posed to quickly resolve the problems we have.

You're out here complaining about problems with current attempt to solve a real problem, which is fair enough. But it's also fair enough for me to point that you have no solution to this current problem, which you acknowledge is a crisis. What's your response to the crisis?

You've also complained that I won't engage in your ideas. So I wrote a long comment in an effort to engage your ideas. (Anyone can back up this thread and read it.) Your response is to cherry-pick one sentence out of that long comment and literally claim that I (and other critics) have missed the "magic" of your solutions.

Feel free to engage.

Dr J--

Also, in your discussion with Kathy, you've been complaining that the volume of provider visits will go up under the currently proposed reforms. That seems to me to be a main point of these reforms. And that's big reason why Democrats are sweating the CBO numbers. But since that is a main point of reform, won't the volume of provider visits also increase under any reforms you want?

What's your solution?

George, several times now I've seen you agree with a policy proposal (or at least agree that it sounds reasonable) that Dr. J or I puts forth but then you argue that there isn't a politician or a political party supporting that idea. But if we, as private citizens, believe that there are solutions that haven't been put on the table, or haven't been given enough attention, or have been killed by special interest lobbies- but are good, meaningful reforms, then isn't it up to us to help build the public support for those policies?

Otherwise what's the point of blogging at all?

Also, in your discussion with Kathy, you've been complaining that the volume of provider visits will go up under the currently proposed reforms. That seems to me to be a main point of these reforms. And that's big reason why Democrats are sweating the CBO numbers. But since that is a main point of reform, won't the volume of provider visits also increase under any reforms you want?

George, I think the problem here is that universal coverage really does ADD cost to the system, rather than subtract it. If you're going to go after the dual (and conflicting) goals of universal coverage and cost reduction, you have to get really serious about finding ways to decrease the amount of money that we're spending on healthcare. Part of that would involve some decrease in the utilization of healthcare services per capita (logically- if more people are added to the system, to keep even the same net cost overall you have to reduce expenditures per capita.)

Obama talks about this in handwavy manner when he refers to cutting out things like unnecessary medical tests (and those unnecessary tonsillectomies performed by greedy doctors!) But he never clearly defines how his plan, or the Congressional plans, could accomplish that.

Meanwhile, all the Dem plans are ignoring a couple of ideas from the conservative side of the aisle which really do have a chance of reducing these things. First, tort reform because that cuts down on defensive practice of medicine which leads to doctors practicing CYA by leaving a paper trail of lots of tests and procedures. Second, use of HSAs which combine with high deductible health insurance plans to increase the patient's price consciousness so that medical services aren't overutilized.

And worse yet (besides ignoring these good ideas), the current plans would further reduce individuals' incentive to make healthy lifestyle choices (the one part of 'prevention' that really does save money by reducing the NEED for healthcare services.) The plans cut out these incentives by making it impossible for insurance companies to reward people with price reductions for behavioral changes like quitting smoking or losing weight.

George, there's plenty of support for these ideas. What I've been saying, what CStanley, Jazz and other folks on here have been saying, and what Republicans have actually proposed all have a great deal of overlap. Though we may pick different bits to emphasize, we're all saying "harness the market" rather than demonizing it and hoping government on its own can wish costs down. Given how much arguing you've done with us, I'm surprised you haven't noticed.

Regarding volume of visits, I didn't complain volume will go up, I just asked Kathy whether it would or not. She said no. Or yes. Or something. I agree with you, enabling more consumption of health care seems to be the whole point of universal coverage, so I was surprised at her answer.

The question matters because it's not clear to me volume *can* go up much in the short to mid term, because it takes time to train doctors or build hospitals. If we are to make room for people priced out of the market, we must start using those resources smarter, by reducing defensive medicine and the other things CStanley describes. I haven't seen anything in the current plan that could bring this about.

Just to throw this in the mix regarding volume, and overutilization as it currently exists under our system- and as it will undoubtedly worsen with some of the proposed changes...

The classic study on utilization of healthcare services as it relates to patient cost sharing was done by RAND researchers in the 70s. The summary is that when people have to actually pay something out of pocket for each time they see a doctor tend to go to the doctor less frequently than those who have no copays, yet overall there was no adverse effect on the patients' health even though one group went to the doctor less frequently. It was also true though that there were some adverse effects among poorer people when they had a copay, so obviously the rationality of the decision to spend the money or not spend the money was affected by the amount of disposable income that the person had.

Addressing overutilization by structuring insurance plans with high copays (with some mechanism to help poor people with that cost- either have it on a sliding scale or give them tax credits for HSAs, which has the advantage of still keeping them accountable for costs but not requiring them to fund this expense out of their limited or nonexistent disposable income) would put the consumer of healthcare in the position of making more rational choices about seeking medical care, and this study showed that when people consider economic costs they do tend to make rational decisions and reduce overutilization as long as they can afford to do so.

And of course, structuring insurance this way would also require a variety of options for different consumers- with more usage of HSA/HDHP where the health insurance plan has a lower premium- otherwise there's no incentive for consumers to choose this type of plan, and the only other alternative would be to mandate it.

Dr J--

I'm not sure that Republicans have proposed much of anything.

Just last week, on July 23rd, Jazz complained that the Party of No Ideas wasn't doing anything to solve this crisis.

In the first comment to Jazz's post, CStanley said there was a bill but even she wondered why they weren't pushing it.

And a little further down that thread, you'll see me pointing out that Republicans didn't have any problem spending recklessly on health care when it was to their political advantage.

Currently, the Democrats are sweating the CBO numbers. Currently--I'm repeating myself here--the Republicans are pushing legislation about a birth certificate.

Further up this thread you'll find me quoting Republican Senators Inhofe and DeMint about how they are just playing politics.

I'm perfectly willing to stipulate that you, CStanley, and Jazz are nice people who think that something should be done about this problem.

But your assertion that Republicans have actually proposed something that will solve this?

No sale, Dr J.

George, the facts are what they are. The Republicans in fact proposed a bill along the lines I've been advocating. The Democrats in fact buried it in committee so it wouldn't distract from their own bill. Theirs doesn't do much to rein in costs, so you're right, they are having to sweat the CBO numbers.

Are you saying that in the system we have, the uninsured spend as much time in front of doctors as they would if they had insurance?

No, I'm saying they often don't go to the doctor until they are gravely ill -- and at that point they don't go to a doctor's office, they go to the emergency room of the nearest hospital, where medical care is astronomically more expensive.

I'm saying that if we had a system of preventive health care in this country to which all Americans had access, regardless of ability to pay, people would not have to wait until they were gravely ill, they would see a doctor at a much earlier stage, and they would have to visit that doctor less often, not more.

Though we may pick different bits to emphasize, we're all saying "harness the market" rather than demonizing it and hoping government on its own can wish costs down.

Dr_J, what you have written above fits the famous definition for insanity, which I won't repeat because I'm sure you've heard it.

I think the problem here is that universal coverage really does ADD cost to the system, rather than subtract it.

And your support for this argument is.... what?

To be fair though, GS, the minority party almost never does push their own legislation. The way our system works, it's almost always politically savvy to give the other party enough rope to hang itself, and then let the public decide to give your party more power to actually take part in the legislative process. I've thought about my previous comment, wondering why the party leaders haven't been talking up Ryan's bill- but really if they did that now, it would create a very confusing debate on the pros and cons on their plan at the same time that the public is trying to sort out the Dems plan. I don't think there's enough oxygen in the room to debate both approaches at the same time, so it probably does make more sense to let the disenchantment with the Dems sink in first and hope to get a bigger seat at the table next year.

Now, I'm perfectly willing to concede that I wouldn't put it past the current GOP to still blow it and miss the significant groundswell of desire to fix healthcare which could translate into a more market based reform once the public sees the problems with the govt run approach. I've been one who has been frustrated for a decade or more that the GOP hasn't embraced conservative approaches to a number of problems that the public clearly does care about, from the environment to healthcare to deficits, and I'm not confident that they've gotten the message yet aside from a few of them like Ryan and Coburn and a handful of others. We'll see I guess.

The magic thing consumers do is shop. They analyze value for money, and if they don't think they're getting a good deal, they very quietly take their business elsewhere. Shopping is what keeps every other industry lean, efficient and responsive, and it's glaringly absent in health care.

Sick people are not "consumers" in the usual sense of that word, and they do not "shop" to get "value for money" when they need a doctor. They just don't. I have never, not once in my entire life, ever asked three different doctors to provide me with estimates for the cost of telling me why I'm tired all the time and have constant sore throats and muscle aches and joint pains (I don't have those symptoms, except for feeling tired all the time -- those are the symptoms of Chronic Fatigue Syndrome, which I just picked at random for an example). What I did, when I had health insurance, if I didn't have a doctor already, was go through the list of doctors my insurance company would let me see, pick one near me, and make an appointment. And that's what most people do.

People simply do not "comparison shop" for doctors except in regard to professional reputation.

No, I'm saying they often don't go to the doctor until they are gravely ill -- and at that point they don't go to a doctor's office, they go to the emergency room of the nearest hospital, where medical care is astronomically more expensive.

Except that you can't just compare that one ER visit to one visit to the GP. When the numbers have been analyzed, it turns out that the ER visits under the current system are so infrequent (and many of the nonreimbursed ones are due to trauma, not preventable illness, so we'd still be paying for those visits no matter what we do) compared to the total cost of all the preventative and minor illness visits that would happen if everyone had full coverage that it's more expensive to provide the wellness and minor illness care. There's still a moral argument to do it, but it simply doesn't save costs no matter how much you want to believe that it does.

Kathy- If patients were paying out of pocket, they would do more comparison shopping but more importantly, they'd sometimes skip going to the doctor when they really don't need to. That was the point of the RAND study I cited- that people are pretty rational when they're spending their own money but they tend to overuse things when there's no cost (or a fixed cost no matter how much they use a service.)

That's part of the waste that Obama talks about. He says that he doesn't want to ration care in a way that will make people less healthy, but he wants to cut out the overusage. The problem is that he doesn't explain how to do that (no politician will, most likely, because it involves telling people that they can have what they need but not always what they want.)

"People simply do not "comparison shop" for doctors except in regard to professional reputation."

Yes, Kathy, that's what I said. People don't shop for value-for-money in the conventional way because they have no incentive to; it's someone else's money they're spending. That's a major structural problem with our health care system.

In the system we have, though, people do make choices and providers court them--even providers you wouldn't expect to. St. Mary's Hospital here in San Francisco has ads all over town advertising emergency room care in 30 minutes or less. Apparently even in an emergency, people make choices about going to one ER versus another. It's great to see the hospitals competing on wait times; we'd be much better off if they competed on price too.

People don't shop for value-for-money in the conventional way because they have no incentive to; it's someone else's money they're spending. That's a major structural problem with our health care system.


Someone else's money, meaning the insurance companies? So are you saying you want to eliminate insurance companies?

St. Mary's Hospital here in San Francisco has ads all over town advertising emergency room care in 30 minutes or less. Apparently even in an emergency, people make choices about going to one ER versus another.

You mean, people will go 30 miles to a hospital that promises in and out within half an hour emergency care rather than the hospital that's five miles away when they're having a heart attack?

"So are you saying you want to eliminate insurance companies?"

From non-catastrophic transactions, yes. We shouldn't be looking to health insurance to pay for routine care, any more than we look to car insurance to pay for gas.

"people will go 30 miles to a hospital that promises in and out within half an hour emergency care rather than the hospital that's five miles away when they're having a heart attack?"

I doubt St. Mary's is advertising to reach heart-attack victims, but they are apparently convinced enough people make choices like that to make it worth their while to advertise.

Kathy, you do realize that even people with health insurance sometimes use ERs for things that can't wait till the doctor's office is open but aren't as urgent as heart attacks, don't you? Things like a bad stomach virus that's dehydrating you over the weekend, or getting a bad cut stitched up?

Considering that liberal commenters here greatly outnumber the conservative ones, I don't see other liberals agreeing with you either or even addressing a lot of your remarks so I think the issue is that they're sometimes rather off the wall in reasoning.

I don't think liberal commenters here greatly outnumber the conservative ones.

I think some of us who would identify as conservative or right leaning moderate or libertarian have been a bit more prolific lately but in terms of number of overall regular commenters who lean left vs. right, there's no contest. And my point to silhouette still remains- that liberal commenters don't seem to have a clue what he's talking about either because certainly no one jumps in to agree with him in most cases. He was implying that the lack of response to his comment meant that his ideological opponents didn't have a good rebuttal, and I presented a reality based alternative interpretation.

Kathy, you do realize that even people with health insurance sometimes use ERs for things that can't wait till the doctor's office is open but aren't as urgent as heart attacks, don't you? Things like a bad stomach virus that's dehydrating you over the weekend, or getting a bad cut stitched up?

Uh, yes, Christine, or like slipping on treacherous ice while walking your dog and badly hurting your knee, which is what happened to me back in November. Those are true emergencies -- things that cannot be foreseen or headed off by earlier care. But let's tweak that a little. If I, a woman in late middle age, am at risk for osteoporosis but don't get a bone density scan (as indeed, I have not) because it's extremely expensive and I don't have insurance to cover it, and *then* I break my leg falling on ice, and have to go to the emergency room, that is very expensive health care that could have been headed off if I had known I had osteoporosis and could have been treated for that at an earlier stage and maybe would not even have gone out on an icy day knowing the consequences of falling could be much worse for me.

And my point to silhouette still remains- that liberal commenters don't seem to have a clue what he's talking about either because certainly no one jumps in to agree with him in most cases.

I thought Silhouette was a woman, but I'm not sure why I think that, and I could be wrong.

And the reason I (speaking for myself) don't rush in to agree with Sil on health care is not because I don't agree with her. It's because I don't quite know how to talk to her on issues we seem to be alilgned on, since on one specific issue (marriage equality), she is so homophobic. There's a disconnect there that I don't understand, and I just prefer to handle it by not engaging with her at all.

From non-catastrophic transactions, yes. We shouldn't be looking to health insurance to pay for routine care, any more than we look to car insurance to pay for gas.

So you are saying that gas is to car crashes as a yearly checkup is to stage 3 cancer?

If patients were paying out of pocket, they would do more comparison shopping but more importantly, they'd sometimes skip going to the doctor when they really don't need to.

Christine, that is what's happening now, but "need to" becomes defined by ability to pay if you don't have comprehensive health insurance that pays for preventive care. That's why you see people in the ER for pneumonia or severe bronchitis after having ignored a persistent cough or a cold that lingered for too long.

Kathy- I was responding to your comment about heart attack victims not taking the time to comparison shop for an ER...just saying that there are a number of conditions that would put you in the position of needing an ER but having time to go to one with a shorter wait time.

Have you read any of my comments which explained the RAND study on usage variations based on copays, Kathy? I've addressed all of that, and what I think would optimize people's ability to seek care when they really need it without capriciously using healthcare services for things that would get better without a doctor visit or prescription meds.

I doubt St. Mary's is advertising to reach heart-attack victims, but they are apparently convinced enough people make choices like that to make it worth their while to advertise.

Let me ask you this: What kind of health care needs could be addressed in 30 minutes or less -- from the time you walk in the door to the time you walk out the door?

Dr_J--

Throw me a bone.

A link to the bill?

Tell me how it's going to solve the problem without increasing costs. Show me how it gets us to the Swiss model you support. Explain how it addresses the issues that matter to you.

You've struck me as being more Libertarian than Republican, so I'm surprised you're claiming them.

It's okay with me if all you really want to do is bash Democrats. But why pretend anything about the Republicans' interest in a solution? These threads are full of people who do the first without doing the second.

As to the question of volume, I'm concerned by the things you said. How close are we to capacity? Do you have any numbers on that?

This problem of trained personnel been acknowledged for years. In the medium-sized city where I live, they've doubled the size of nursing school classes. Several nursing homes are training their own practical nurses. There's a medical school that's increased its enrollment by 50%. One of the other local colleges started a Physicians' Assistant program five or six years ago.

Maybe one of the problems is that it takes so long to train a doctor. I understand the reason why it takes so long, but--and I'm just spitballing here--maybe some of the things doctors do could be handled by technicians? Maybe they could teach people to read X-rays--again, just spitballing--in two years? Even if it took four years, that would be faster.

Is it really that bad?

Um, I assumed that ad meant no more than a 30 minute wait time. Having been to ERs for dehydration, as I mentioned as an example earlier, I had to wait for four hours as they triaged other patients through. I can understand that, but if a hospital is able to find efficiencies or increase staffing or whatever to get you seen more quickly even when you're not about to die, I for one would opt for that hospital over another when I had the chance.

Christine,

I had not seen your prior references to the RAND study. I have now. After reading the study, these quotes are representative of the conclusions that stand out for me (emphasis added).

I might also add that, if I was mocked (not by you) for referring to a poll from a month ago that showed support for government-run health care, then what is to be said about relying on a study that is over 30 years old?

Thus, care could fall significantly without adverse health consequences for the average person.
[...]
The lesson from the health outcome results is clear. For individuals who were not already high-risk, there was little benefit to health from free care. For high-risk individuals, however, particularly if they were low income, there were important benefits to health from free care.

[...]
Of course, the HIE evidence is subject to at least three important limitations. First, this was only a short run study. ... Second, these effects only hold in a world of (often quite low) maximum limits to out-of-pocket medical exposure. There is now a large literature which consistently documents the enormous negative implications of being uninsured on health care outcomes. Uninsured individuals who face unlimited exposure to medical costs are no longer on the “flat of the curve”: they are clearly forgoing care which matters in a real way for health care. The HIE also varied out-of-pocket limits by income, a feature typically not found in private insurance policies today.
Finally, the nature of medical care in the era of the HIE was very different than it is today. The past 30 years have seen enormous advances in treatment effectiveness for a variety of conditions, ranging from heart attacks to depression. This may imply that the care that is reduced in today’s medical environment is more important for health outcomes than in the 1970s. At the same time, however, treatment in general has become much more expensive and intensive, so it could also be that the care that is reduced by cost sharing is still on the flat of the effectiveness curve. Thus, there is substantial uncertainty in extending the results of the RAND study to the 21st century.

CStanley--

I appreciate your admissions about the Republican strategy. I also appreciate your frustrations about their strategy.

Since you've been talking up that Ryan bill, I wonder if you've got a link to it. (I know you posted something last week, but it kept returning an error message when I tried to open it.) I'd also like to know how it goes about making functional changes without raising costs. I'm pretty sure Republicans think cost concerns are just for Democrats.

I think you are correct in your sense, not widely shared on your side, that Republicans are missing a significant opportunity to push alternative approaches on this and other issues. It seems to me that they are replaying the Harry Reid strategy of doing nothing but waiting for the other guy to lose the next election. If Harry Reid had spent 2007 and 2008 laying some foundation, health care reform (this is, of course, just my opinion) would already have passed in 2009.

You made a claim about about fairness to the minority party. I agree they cannot move any legislation forward. But I expect you to concede the willingness of Republicans to push legislation about a birth certificate and about the Gates case. Republicans are perfectly willing to push legislation that really matters to them. I don't see how anyone can deny it.

It's possible they can block health care reform. If so, maybe they'll break Obama and win big in 2010. But I don't think so. I could be wrong, of course, but I don't think Republicans really understand what hit them in 2008.

Republicans have forgotten about the war. They've forgotten how Katrina administered a coup de grace to the notion of Republican competence.

They've also forgotten about their own reckless expansion of Medicare during the Bush Administration and they've forgotten about their own financial industry bailout.

I don't love everything the Democrats have done. But government spending is the conventional wisdom response to recessions (so much so that even Bush and Cheney pushed it through at the end of their own term in office). And Democrats are sweating the CBO numbers while the Party of No strokes the prejudices of the birthers and claims the proposed health care reforms will kill seniors.

While I respect what the Democrats are doing to solve problems, it also seems inevitable that Obama is going to lose me over the wars.

If that happens, am I really supposed to vote for the party of Glenn Beck? You can't beat something with nothing.

CStanley--

George, several times now I've seen you agree with a policy proposal (or at least agree that it sounds reasonable) that Dr. J or I puts forth but then you argue that there isn't a politician or a political party supporting that idea.

As I've said here and on other threads, I think there's a crisis and I'm in favor of doing something soon that gives more people insurance coverage.

Soon. Soon. You know?

I think Dr J has said a bunch of interesting things. You may have noticed that I am putting up links to some things he supports in an effort to explain them. I think his complaint about lack of price transparency being a problem is 100% correct. (If you went to Walmart and they didn't have prices on their stuff, you'd go across the street to Target; on the other hand, you don't show up at Walmart in an ambulance.)

I have even agreed with you about some things. You may, for example, have noticed that I am rather more concerned about price than some of the other people on my side. I'm also not a big one for talk of universal human rights and such.

That's because it's obvious to me that these reforms would save money.

If your boss didn't have to pay for your insurance, he'd have more money to invest in new equipment, new software, and other improvements--plus he could buy that Mercedes he's always wanted. He might even have enough left over to give you a raise, CStanley. (You deserve one, right?)

Think of emergency rooms that charge a million individuals with a billion dollars, aggregated, in costs. What if, instead, they accepted $800 million because they are no longer saddled with the expenses of patients who can't pay. The economy just saved $200 million! And a bunch of those patients still have money in their pockets that they can spend on books or plasma tv's or beer. Maybe they'd even pay down their credit cards a little. (I can dream, right?)

The problem is the government is still on the hook for your health insurance and all those emergency room visits. Those expenses get included in the CBO score. (And fair enough--I'm for being honest about the costs as well as the benefits.) But the money saved by your boss and by all those people with broken arms doesn't get included in the CBO score. Plus, the guy who didn't break his arm didn't save any money at all.

Dr J has also been known to say we're not honest about what we pay for and what we get. Holy Moly, do I ever agree with that!!

I think this round of reforms, the round that (I hope) gets people covered by health insurance, won't and shouldn't be the end. I've told Dr J that some of his ideas would make a good basis for the next round of reforms. But if there's nobody working for them now, then they're not going to happen now, and the problems that now exist haven't gone away.

I'm willing to accept half a loaf to get some portion of the crisis solved now.

George, I'd say lack of price transparency is more of a symptom of the bigger problem: nobody cares what the price is. If they did, we'd have price transparency because people would demand it.

And the reason they don't care is because they're spending Somebody Else's Money. Get them spending their own money for most transactions, and price transparency will become the norm within a few years.

Advances in health care will make it more expensive, the more is adopted and then expected.

Meanwhile, we are an aging society. I've said many times, just wait another 10-20+ years...

Two big mistakes:

"First, creating a comprehensive bill that promises to save money over the long haul even though the expenditures are obviously real and the savings are not quantifiable.

The second mistake was Obama saying things that are provably false about the bill, and some promises
that are half truths or which ignore legitimate concerns."

In a general sense, this is a continuation of the behavior of the Dems to rush bad legislation that they simply have outdone themselves in attempting with their latest issue, here, health care.

Specifically, the deliberate avoidance initially of addressing the costs and how to pay for them, and then engaging in falsehood about costs (in addition to other facts about what they were trying to do) was what has primarily generated public concern about and opposition to this failed effort.

In this case, the Dems rushed to pass anything with "health care" stamped on it, rushed to the point of neglecting fundamental concerns with this (costs and payment), and even managed to fracture itself (the Dem contingent) while appearing this time momentarily to be almost as dysfunctional as the Republicans currently are commonly seen. (But compounded with dishonesty and poor appeals to the public, too.)