Soothe My Worries About a “Public Option” Boondoggle. Please.

An interesting thread developed last night here on TMV, in which several people who are not ideologically sitting behind a firewall (“Public plan or nothing!” or “If the government touches it, it’s Socialism!”) tried to find areas of common ground on health care reform. We found several areas of agreement. However, we also heard from folks who think there are irreconcilable ideologies at work.

I concede the possibility, but I’m not ready to accept it as a foregone conclusion.

I’ve been accused of dishonesty because I’ve failed to acknowledge that I’m completely unwilling to accept anything that includes a public option. That’s false — but I do have very serious reservations.

They’re not rooted in irrational fears of socialism or “death panels” or disdain for the poor or racism or that we’ll be providing abortions to all or insurance to illegal immigrants. At the highest level, my reservations primarily stem from a desire to maintain as much authority as possible at the state / local levels, and from my strong feeling that on a national scale, public health care for all would become a boondoggle beyond anything ever seen before.

The first of those requires careful appraisal and a constant balancing act. Yes, we’ve grown enormously and society has changed. Yes, we have common national interests. No, we should not therefore should toss the baby with the bathwater every time we’re discussing complex issues and national policy. Aside from constitutional considerations, there are very good reasons why it makes excellent sense to keep decisions and delivery mechanisms at the state and local level.

Meanwhile, the Wall Street Journal’s description of the program in Maine hits right on my worries about a boondoggle today.

In 2003, the state to great fanfare enacted its own version of universal health care. Democratic Governor John Baldacci signed the plan into law with a bevy of familiar promises. By 2009, it would cover all of Maine’s approximately 128,000 uninsured citizens. System-wide controls on hospital and physician costs would hold down insurance premiums. There would be no tax increases. The program was going to provide insurance for everyone and save businesses and patients money at the same time. [...snip]

Here’s how the program was supposed to work. Two government programs would cover the uninsured. First the legislature greatly expanded MaineCare, the state’s Medicaid program. Today Maine families with incomes of up to $44,000 a year are eligible; 22% of the population is now in Medicaid, roughly twice the national average.

Then the state created a “public option” known as DirigoChoice. (Dirigo is the state motto, meaning “I Lead.”) This plan would compete with private plans such as Blue Cross. To entice lower income Mainers to enroll, it offered taxpayer-subsidized premiums. [...snip]

After five years, fiscal realities as brutal as the waves that crash along Maine’s famous coastline have hit the insurance plan. The system that was supposed to save money has cost taxpayers $155 million and is still rising.

A program that was supposed to save money by reducing health-care waste and inefficiencies has seen a 74% increase in premiums. But even those inflated payments can’t keep the program out of the red.

Please — read it all. The article isn’t full of hysteria or fear-mongering. It doesn’t hinge on partisanship. It’s talking about cause and effect, and describing how a specific plan has worked (or has not worked) — a plan that sounds (to me) VERY much like what’s being proposed.

So I have a question for the folks who have drawn a “public option” line in the sand: How do you feel about the Maine plan? Are you sure that what you’re pushing for won’t end up being a magnified version of their problems? Using this example, help me understand why you think things would work differently (i.e. better) when expanded to a national scale.

I’m not looking for impassioned arguments involving moral imperatives or Brother’s Keepers. I’m not trying to argue Federalism or Socialism in this post. I’m asking about cause and effect, and fiscal impact. I want to avoid a boondoggle.

If your answer is that we’ll tax the the top 1%, then — assuming that narrow population could manage it (and I don’t think they can) — what will you do when that non-static funding source dries up as the extremely high earners move into their retirement years? Or as their wealth fluctuates? Have you thought this all the way through?

You may feel that you’ve already explained this ad nauseum. If so, then I hope you’ll forgive me but it’s gotten lost in all the shouting.

I’m asking in good faith. Help me see why your insistence on the “public option” won’t break the system beyond any hope of functionality or recovery. Because I’m honestly worried that it will.

Author: POLIMOM

73 Comments

  1. You've missed the more fundamental flaw in the public option as currently envisioned: It's not sustainable. The reason it's unsustainable is that the cost of providing the benefits for the program will rise much faster than the revenue streams that will fund it. That is the flaw the CBO identified. In ten years or less it will be in the red and we'll have to face the tough choices of benefit cuts, tax increases, or more borrowing to keep it afloat for a few more years. To support a such a flawed plan is, IMO, irresponsible.

    That flaw is not unique to the current public option plan. Any plan which does not have radical cost control as a central component is similarly unsustainable regardless of party or ideology. There won't be any difference with Co-ops or any of the other schemes designed to expand coverage. We simply have no revenue streams (whether they are revenue increases or benefit cuts) that can keep up with the ever-increasing cost of health care, which is rising 2-3 times the rate of inflation and GDP growth.

    To find a solution we must first properly identify the problem. For health care, the uninsured, people who are uninsurable and the expense of quality care all share the same fundamental problem: Health care is too expensive, and that expense is growing every year. Plans and programs narrowly designed to address those categories are, therefore, treating symptoms and not root problem, which is cost. What we need to do is make health care cheaper and get cost growth under control. To do that requires more radical, more fundamental systemic reform, which the Democratic and GoP plans do not have.

    Personally, I'm pessimistic. Our politicians are too worried about the next election and too tied to ideology to do what is necessary to make our health care system (public and private) sustainable over the long term.

  2. Polimom, I don't know what to say except to point out that our for-profit health system costs over twice as much as any other modern nation, and our health outcomes are worse. Those are the facts.

    Over and over I see the argument here that we can't afford national health care (can't afford something that costs half as much?) or the tired memes about “socialism” as you mentioned. I guess the forgone conclusion of the right is that WE can't trust our government (apparently they believe it's just more corrupt and inept than European, Asian and even African governments). And compared to these other nations, our government would bungle it, it would be a boondoggle and would end up costing even more than the obscene current level. For capable and competent governance, apparently we can't match the records of Canada, UK, France, Germany, Japan, Norway, Italy, Spain, etc – ALL our global allies and competitors – all of them pay less both per capita and as a % of GDP.

    The problem with the Maine and other state programs, and the problem with state level or regional “co-ops” is that they can't negotiate like a national program. As I've pointed out many times here, Medicare pays 19% less to doctors and 25% less to hospitals, compared with private insurance. Its overhead cost is AT LEAST 12% less (that's what the insurance industry admits. other estimates are higher). Obviously, the Maine program was not nearly powerful enough to touch these kinds of cost savings.

    Since the misinformation is fueled by millions in insurance company and pharma lobbying funds and professional PR efforts, We'll probably not get the health care reform we need. Inside 10 years, everyone's insurance rates will double (they have doubled in the last 9 years) and as I've also pointed out, the exponential function applies here. Doubling a doubled number means that if we do nothing, in the next ten years, private insurance will cost FOUR TIMES what it did 9 years ago. In another 10, it's EIGHT times. Only when we're truly on our knees with extreme health care costs will we get serious about making health care about HEALTH, not MONEY.

    By then, I'll be on Medicare, and you and your family will be reeling under a $25,000 a year private insurance burden, the result of your decision to buy what the insurance industry and its GOP lapdogs are selling.

    BTW, private insurance cost has risen at three times the rate of salaries, medical costs are the top cause of personal bankruptcy and employer provided coverage has crippled our business community's ability to compete with manufacturers in every other nation, where employee health costs are already covered.

    I believe our refusal to take control now will bring about the end of American prosperity, if it's not already cooked.

  3. Andy,
    Are you suggesting that the only plan to bring costs under control is a single-payer?

    Is there a reason health care in Europe costs so much less – even when the services provided are just as good as here? I'm thinking of Germany in particular. They have a combined employer-paid plan and a portable public plan.

    Or are the costs skyrocketing simply because of modern technology and a longer-living population?

    Remember, the “managed care revolution” of the 1990s helped control costs for a brief period. But then health care costs started to skyrocket again after 2001.

  4. Greendreams,

    Polimom, I don't know what to say except to point out that our for-profit health system costs over twice as much as any other modern nation, and our health outcomes are worse.

    Yes. Maybe you can explain how expanding coverage without any cost controls (ie. the current “public option” plans) will do anything except make costs go even higher. The Democratic plan is not even budget neutral, much less able to reduce costs in other parts of the system.

  5. Elrod,

    My personal opinion is that single payer could work if it went the “full monty” into nationalized health care. That is, however, simply not possible in this country, but I don't think it's the only option that can work.

  6. Over and over I see the argument here that we can't afford national health care (can't afford something that costs half as much?) or the tired memes about “socialism” as you mentioned. I guess the forgone conclusion of the right is that WE can't trust our government (apparently they believe it's just more corrupt and inept than European, Asian and even African governments). And compared to these other nations, our government would bungle it, it would be a boondoggle and would end up costing even more than the obscene current level. For capable and competent governance, apparently we can't match the records of Canada, UK, France, Germany, Japan, Norway, Italy, Spain, etc – ALL our global allies and competitors – all of them pay less both per capita and as a % of GDP.

    This is a point I've often thought about although I don't think I've ever expressed it. I actually do think that there are some differences (one, which PM already mentioned, is scale- the US is more along the size of the entire EU, and I think it's concievable that if they attempted to administer a healthcare system for the whole of the EU instead of country by country, that it would be a boondoggle too.) Also, although I don't know enough about European politics to say for sure (and I don't think that the European politicians are likely to be more virtuous than ours), but I have a sense that our system may be more inherently corruptible, so that a corporatist, govt/private collusion can easily take place without real accountability. Maybe I'm overly cynical, but to me it always seems like the liberal/progressive plans that involve expansion of the role of the federal govt tend to lead to that type of corruption, while the GOP tends to be guilty of collusion with large corporations in other ways.

  7. Andy wrote: “Any plan which does not have radical cost control as a central component is similarly unsustainable regardless of party or ideology.”

    Andy is absolutely right. Example: Medicare Part D is NOT on solid ground because the Republicans sold out to Big PHARMA and prohibited cost control via quantity purchasing insuring a) Record profits for Big PHARMA and b) any chance of sustainability for Part D and in doing so knowingly ripped the heart out of it.

  8. Polimom

    Thanks for this post. I hope the ensuing discussion can take a different tack than the usual philosophic debate.

    I would first ask a simple question from both sides of the aisle.
    Is there anyone prepared to say that the current system is NOT headed for economic collapse due to ever increasing cost? It's a matter of yes or no.

    If you answer yes, I ask each side a question”

    For the Right, what are your specific means to avoid this collapse without addressing the non-competitive aspects in the present system.

    For the Left, if a plan can be devised that truly insures every one and reduces cost, is the public option mandatory?

    I'm jumping in here simply to ask if a mutual discussion of coverage and cost can be held without the usual rock fight or philosophic hyperbola.

    IMHO

  9. Are healthcare prices truly accurate? I mean, the market is out of whack with the for-profit system and hospitals and doctors charging large fees for which they are paid a fraction of by the insurance companies and Medicare. So are costs judged by what's charged, or what is paid? I'm truly confused about this issue. Also, I think we know a large percentage of healthcare costs are devoted to the byzantine medical billing system, which should be a ripe target for reform. But I guess to do that, insurance companies would have to be brought to their knees instead of making secret deals inside the White House.

    But to be fair, Polimom, will you do a “Soothe my worries about Co-ops” article? Because bringing in a failed health plan from the 1930s seems like a waste of money as well.

  10. “But to be fair, Polimom, will you do a “Soothe my worries about Co-ops” article?”

    Lit3 — If I run another one of these, it's far more likely to be along the lines of, “Soothe my worries about no reform at all”. I started here because it's the line in the sand I encounter here most often. (and also to continue explaining where I'm coming from with my own worries).

    HemmD — you're welcome. I hope this approach moves us somewhere. I'm not picky about where, but I'm disturbed by the increasing rigidity.

  11. Polimom -

    This thought isn't about “public option.” As Andy points out, without serious cost containment, both the current system and a “public option” system will cause great economic dislocation over time.

    One cost factor to consider, whether public or private, is the cost of state/local control. That is, having to be responsive to 50 + regulatory schemes adds to cost in the current system. A federal system, at least one that is properly administered, can reduce those costs, as well as opening doors to interstate coverage, again saving costs and allowing additional portability.

    To those who suggest that everything the federal government touches is, by definition, not properly administered, seems more a partisan rant than reality. We, as a nation, actually do many things better than we believe, or at least better than some would have us believe.

    The affection for state/local regulation of health care seems, to me, more wedded to the romantic ideology of a more pastoral time in America than the real need to effectively reform, with cost savings, our health care system.

  12. elrod

    “Or are the costs skyrocketing simply because of modern technology and a longer-living population?”

    I would ask if the skyrocketing profits in the private health care and big pharma industries is not also a factor to this question?
    Drug costs would certainly drop if we got them from canada. They generally pay 50% less even though those drugs are made in the US. funny how that works.

  13. Polimom, a very similar argument was made recently about Massachusetts' health care system, and it was thoroughly debunked. Opponents of the public option claimed that the Mass plan had gone way over budget and cost Mass residents millions more than it was supposed to. All of those claims were false. The program had actually come in under budget and is a big success story.

    Are you sure that the same thing isn't true of this latest attack on Maine's plan?

  14. Thoroughly debunked, Kathy? As I remember that discussion, you quoted a Boston Globe article that completely misstated the numbers (it wasn't even possible that they were stating the dollar costs accurately because there was information right in their article that contradicted itself.) One commenter (Adelinesdad, I believe) questioned how those numbers could be possible and then I linked to another article which explained where the Globe had screwed up.

  15. Polimom: You're like most normal people, who _of_course_ have reservations about this effort, _especially_ since it's the worst of a _pattern_ of bad legislation and bad conduct by the Dems.

    Even some well to the left, at Huffington Post, have expressed such misgivings about such obvious causes for concern.

    Oh, well, Some will remain incapable of understanding, incompetent, or have dark motives for not doing so.

  16. Yeah, I might be with you on that one. Obama looks over his head. Full moon, empty suit…

  17. “Are you sure that the same thing isn't true of this latest attack on Maine's plan?”

    I don't know that you're correct with your choice of the word “attack” there, but the answer to your question about whether the claims are or are not false is, no I'm not sure. And as CStanley says, the debunking doesn't sound particularly thorough.

    OTOH, I don't think you want to use the Mass plan as your example, since they aren't using a public option. It was, however, one of the places some people came together in last night's thread.

  18. “The affection for state/local regulation of health care seems, to me, more wedded to the romantic ideology of a more pastoral time in America.”

    That isn't what is happening. Most of the time it's faithful to the correct _mindset_ as well as to the _mechanics_ of our correct, constitutional federal system of government: Washington should be _last_ on our minds, not _first_, as the government to whom to go for intervention. As much as possible should be done at or retained by the states and the local (county and municipal) governments. Almost all the rest of the time it's actually opposition to Washington, period, but couched or phrased as an appeal to those who prefer to be truly American (and thuse to avoid Washington as much as possible).

    That this may be impractical or cumbersome is not disputed. (I've lived all over the USA, in so many different places, since I left California, and continue to do this as long as it's easy for me to do it. While I enjoy collecting additional license plates to be displayed as a collection someday when I stop moving around, do you think I enjoy re-registering my vehicles or getting a new driver's license? No.) That the issue, as I wrote elsewhere today, of the states, specifically, as entities of note and of state citizenship and state sovereignty, which is routinely seen as quaint and irrelevent if it is considered at all nowadays, is largely a Moot Point in modern life in favor of Washington being as large and incorporative as possible, is not really seriously questioned.

    But it doesn't support the mistaken assumption or belief that centralizing everything in Washington constitutes “streamlining” or that this will solve all one's problems and result in the complex being made simple and easy to live with.

    That assumption is false.

    Even if you replace fifty different governments with one as your agent of choice (the same is true with replacing several health insurers [health care payers] with the federal government, incidentally), you will not escape complexity or bureaucracy. At the very least, and if you want to do a good mental exercise, assume the result you will get with Washington is something like the square root of the sum of all fifty state bureaucracies. Relatively and absolutely _smaller_, yes, at least in theory. Absolutely _small_, no.

  19. “That this may be impractical or cumbersome is not disputed. (I've lived all over the USA [...])”

    Or _outmoded_, in our age of frequent relocation as well as of modern transportation and communications.

    Sometimes uniformity or standardization (the oft-rightly-maligned “one size fits all”) makes sense.

    We have a common, single currency, after all.

    But even if the current system is bad and alternatives appear good, they aren't always so.

  20. I would ask if the skyrocketing profits in the private health care and big pharma industries is not also a factor to this question?

    Sure, but like the right's darling, tort reform, those are small potatoes. Eliminate all profit and you're still left with unsustainable cost growth…

    Are healthcare prices truly accurate? I mean, the market is out of whack with the for-profit system and hospitals and doctors charging large fees for which they are paid a fraction of by the insurance companies and Medicare. So are costs judged by what's charged, or what is paid? I'm truly confused about this issue.

    You're not the only one! That's an important point because it's difficult to figure out if you're paying too much if you have no idea what it actually costs and where the money goes. Greater transparency will have to be a key part of any reform. How much does a surgery cost? The answer is there isn't any set price, which is a problem.

  21. “the Mass plan as your example, since they aren't using a public option”

    Well, it _is_ a model for intervention by (state) government to try to get everyone compulsorily insured, etc.

    And it is also something for review (again?) if the Dems really came to their senses and restarted things.

  22. ” How much does a surgery cost? The answer is there isn't any set price, which is a problem.”

    Well, in theory there shouldn't be a set price for this or anything else in this world.

    That's not to say there won't eventually be such a thing; you can reasonably expect it from Washington.

    And I originally wanted to respond to note aloud that we should make the distinction (not normally made, as the two words are used synonymously when discussing health care, if you haven't noticed) between (true) costs and charges (prices you or your insurer or other payer are asked to pay).

    Costs are not the same as charges (which are larger unless you're non-profit).

  23. @Steve- you did hear, didn't you, that Obama recently made the same deal with Big Pharma?

    And that goes to my point- the system itself is too corruptible and voters who believe in good faith attempts by our politicians are naive. Both Dems and GOP collude with large industries because that's what they have to do to finance their reelection. For some reason though, it often seems that Dem voters turn a blind eye to it when their guys make these deals. It's one reason I really get ticked off by the lack of discussion about those examples of Democratic malfeasance here on a moderate website. If the moderates who read this blog don't also access more conservative or balanced sources, they have reinforcment of the narrative that the GOP is corrupt and in bed with corporate America, while the Dems are just tryin' real hard to look out for the little guy.

  24. @Steve- you did hear, didn't you, that Obama recently made the same deal with Big Pharma?

    And that goes to my point- the system itself is too corruptible and voters who believe in good faith attempts by our politicians are naive. Both Dems and GOP collude with large industries because that's what they have to do to finance their reelection. For some reason though, it often seems that Dem voters turn a blind eye to it when their guys make these deals. It's one reason I really get ticked off by the lack of discussion about those examples of Democratic malfeasance here on a moderate website. If the moderates who read this blog don't also access more conservative or balanced sources, they have reinforcment of the narrative that the GOP is corrupt and in bed with corporate America, while the Dems are just tryin' real hard to look out for the little guy.

  25. @Steve- you did hear, didn't you, that Obama recently made the same deal with Big Pharma?

    And that goes to my point- the system itself is too corruptible and voters who believe in good faith attempts by our politicians are naive. Both Dems and GOP collude with large industries because that's what they have to do to finance their reelection. For some reason though, it often seems that Dem voters turn a blind eye to it when their guys make these deals. It's one reason I really get ticked off by the lack of discussion about those examples of Democratic malfeasance here on a moderate website. If the moderates who read this blog don't also access more conservative or balanced sources, they have reinforcment of the narrative that the GOP is corrupt and in bed with corporate America, while the Dems are just tryin' real hard to look out for the little guy.

  26. @ CStanley– This is why I'm coming down on the side of not doing anything and Obama's presidency be damned. He promised bring change and greater transparency and he did neither. Our political system is fundamentally broken in favor of corporations.

  27. @DLS–

    This is why I thought a public option might be good to contain costs, despite the inevitable bloat. Gov't tax writeoffs and subsidiaries prop up numerous industries and help to artificially set costs. Why not health care where costs are outpacing inflation by large margins?

  28. CStanley wrote: @Steve- you did hear, didn't you, that Obama recently made the same deal with Big Pharma?

    CStanley, I have heard rumors to that affect. Hopefully rumor is all it is but just in case I gave BlueAmerica $50 and sent emails of protest to Mr. Obama, my Senators and my Representative in the House.

    If the United States government sells out to the health industry… again… Our grandchildren will not know what it was like to say they lived in a greatest, most powerful nation on earth.

  29. Andy: “Maybe you can explain how expanding coverage without any cost controls (ie. the current “public option” plans) will do anything except make costs go even higher. The Democratic plan is not even budget neutral, much less able to reduce costs in other parts of the system.”

    A discussion of needed cost controls is apparently too toxic to touch. Even with nothing of the sort in the bill, the GOP launched its “death panels” deception. How, exactly, will we ever be able to actually consider how much we can afford in end of life procedures? In a more general way though, there are several legitimate ways of assessing cost savings of a public option; first by looking at 50 years of comparative performance with all the health care plans in the world. Ours is by far the most expensive but yields tepid and worse results. So, evidence #1 is that public systems have not only been tried successfully elsewhere, we are the ONLY one who hasn't implemented one. So we get to compare our costs and outcomes against very different plans, all of which outperform ours, and always at dramatically lower cost. Evidence #2, Medicare is so efficient the insurance companies have pulled out all the stops to make sure they never have to compete with it.

    Also, your comment about profit being “small potatoes” is not accurate. Malpractice costs, including insurance is <2% of health care cost. Now let's look at private vs. Medicare. Medicare pays 19% less than private for doctors, 25% less to hospitals. Its overhead is at least 12% less than private (8% is profit, but the remaining 4% includes big salaries, cars and planes, etc). That's a 31% savings on doctor visits and 37% on hospitals. That, Andy, is HUGE potatoes.

  30. CS

    I believe some from the dreaded left hve actually brought up the fact that both sides of the aisle is hip deep in the money for votes system that currently drives our system. I have no problem calling out anyone who puts personal gain, political or profift, ahead of the responsibilities they were elected for.

    But again, the list of comments from the right side of the aisle in this thread consistently give us all the reasons why no plan from the left will work. jazz in the other thread touts a Republican based upon tax credits for funding. A tax credit isn't very helpful if peope don't make enough to begin with.

    For you on the right, i get you think we cant make use of the lefts ideas. Where's your solutions for reducing cost and covering people you and I currently pay for via emergency care?

  31. Polimom,

    Just to be clear, my use of the word “attack” was intended to refer to the WSJ piece you posted about, not to your post.

    The debunking of the Mass plan seemed thorough to me. Granted, I support the concept of universal coverage regardless of ability to pay. I'm not sure that CStanley supports that concept as a matter of principle, so she may be less willing to see the debunking of the Mass plan as credible.

  32. Polimom,

    Back to the thread topic, just let the government's past sucesses in running medical programs ease your fears……

    Joking aside, how can anyone expect the public to be supportive of a public option when existing government run programs are so terribly broken. If the Democrats really want to get support for a public option here is what they have to do first. Fix Medicare.

    They has control of all 3 branches of government, a filibuster proof majority, so there is nothing in their way. Fix Medicare and they will have a sucess to show they can be trusted with another government run healthcare program, until they can prove that, Conservatives, Moderates, and independents will rmain skepitcal and oppossed.

  33. HemmD — I still haven't seen anybody (other than GreenDreams) try to explain what would be different in a national plan that would be different from what's going in Maine.

    And with all due respect to GD — yes, I agree that the current system is unsustainable. I'm not advocating in any way to keep it as is. What I'm trying to understand is how moving to another unsustainable solution solves the problem. Kicking an expensive can down the road with some obvious problems will not only leave our kids with an even bigger version of today's issues to solve, but potentially some new, deep, systemic ones as well.

    I totally agree with this, from Andy:

    “My personal opinion is that single payer could work if it went the “full monty” into nationalized health care. That is, however, simply not possible in this country, but I don't think it's the only option that can work.”

    The 'public option'' is badly flawed. I really think that comes through very clearly in the WSJ article. I just don't know what the answer is. I freely admit it. But it is for this very reason that I keep trying to explore other avenues.

  34. For me the answer, at least for the time being is to institute those reforms where both sides might come together.

    Tort reform is one area, another is the ability to buy insurance across state lines, a third is working to fix medicare which is a single-payer system that is horribly broken right now.

  35. Fixing medicare means controlling medicare costs, which means telling seniors they can't have everything they want when they want it. They are a huge voting block and that will never happen.

  36. Leonidas — what about the pre-existing conditions exclusions?

  37. Fixing medicare means controlling medicare costs, which means telling seniors they can't have everything they want when they want it. They are a huge voting block and that will never happen.

    Ah. Well. There's one of the several elephants in the room.

  38. Greendreams,

    What do you mean we are the only country that hasn't implemented a public option? What is medicare, medicade, the VA, Tricare, etc.? About 50% of healthcare in the country is publicly funded and those areas are experiencing unsustainable cost growth too. So the problem is not confined to private sector health care. That means it's a systemic problem, which means that a “public option” that expands and/or alters coverage for one portion of the entire system isn't going to have much effect on the root systemic causes.

  39. Yup, the social saftety net makes up more than 1/2 of out federal spending between Social security 21.05%, Medicare 13.34%,, Medicaid and SCHIP 7.32% and Welfare/Unemployment 11.77%

  40. “Also, although I don't know enough about European politics to say for sure (and I don't think that the European politicians are likely to be more virtuous than ours), but I have a sense that our system may be more inherently corruptible”

    That reminds me of a post I read on Naked Capitalism about the Swedish Solution (nationalizing troubled banks, firing all the incompetents, cleaning them up and reprivatizing them). A Swedish official was over here describing it detail by detail and someone asked “well what do you do about the officials that will do things for the former corporate interests and show favoritism” and he just blinked and didn't understand the question. He said that of course the public officials wouldn't show favoritism, otherwise they wouldn't have entered public jobs! And why would they anyway, they don't have any reason to because once a public servant always a public servant.

    I haven no idea how true that is in practice (although the Nordic countries rank near the top with New Zealand and least corrupt nations) but in theory their ideas about governance do seem to be completely different.

  41. Has any of you considered the Mayo clinic's approach? I believe their costs are about 20% less than the national average cost while improving quality. A 20% reduction in treatment costs is not a bad start.
    Additionally, I have no problem with tort reform as long as true malpractice is still addressed.
    Somebody said drug costs were small potatoes, add it to the list
    How about computerizing medical records?

    I don't expect a fully fleshed out answer to the current system, but there's sure a lot other places that could be discussed. Coverage and cost are the only issues that we agree bout. Let's start there.

  42. How will you “fix Medicare” without the death panels? I'm only partially kidding here – nobody really wants to contain costs in a system that has so little overhead already (2-3%).

    Tort reform has been tried at the state level – in Texas in particular. And malpractice premiums keep going up. Why? Because the med-mal insurance industry is completely unconnected to tort payouts. Med-mal premiums are based on investment losses, not tort payouts.

    As for opening up competition across state lines, isn't the Exchange set up to do precisely that? Of course, how are you going to price these cross-state plans when mandates are completely different in different states?

    There are two ways to cut costs: single-payer or reverting to 1950s medicine.

  43. Leonidas
    Great rebuttal if this was a debate.
    Any ways to save money you know of or is stating that the current system is broken all you have?

  44. elrod

    “There are two ways to cut costs: single-payer or reverting”

    I like my current insurance right now, do you think a single payer system will let me keep it?

  45. I propose a tax rebate of $5,000 for every American with a BMI under 26, or if above 26 if they can deadlift and benchpress their own bodyweight! Who's with me!!

    But yeah, Social Security and Medicare two big fat elephants. The fact that a pittance of Americans ever made it to the age to receive it back in the day should tell you something. Why aren't we discussing SS or Medicare reform? Oh yeah, like higher taxes, it's political suicide.

    We as a nation deserve each other.

  46. LB
    “The fact that a pittance of Americans ever made it to the age to receive it back in the day should tell you something. “

    Welcome to the wonderful world of mortality. You'll get used to it when you realize nobody gets out alive.

    Youth is wasted on the young.

  47. There is some discussion of medicare reform in the current healthcare reform bills. That is why seniors show the highest objections to it in polls. The cost of healthcare reform does really concern me. I have lukewarm support for it at best. However, the fact that the senior lobby is doing their level best to block adequate healthcare for the workers who are paying the senior's bills galls me to the extreme. It would be different if most seniors really had earned it. However the data shows differently.

    http://blog.american.com/?p=3990

  48. Elrod,

    that 2-3% overhead is a bit misleading medicare pays 95% of the bills they get without screening, yeah that cuts down on overhead but makes it ripe for fraud.

    A draft report by the inspector general of Health and Human Services in 2008 determined that Medicare may have paid $2.8 billion in improper or fake claims for medical equipment in 2006. That’s an error rate of 31.5%, just in that one area.

  49. A tax credit isn't very helpful if peope don't make enough to begin with.

    That depends entirely on the size of the tax credit. If it covers cost of a HDHP and funds a HSA for one year's worth of deductibles and reasonable copays, then the person's out of pocket liability for their own healthcare would be zilch. I tend to think that would go a bit too far, since Medicaid already exists to cover people who have no income at all, and those who are between 100% and 400% of poverty level can probably cover a few $20 copays and would have more ownership in the program if they pay at least a small amount (or put it on a sliding scale or something of that nature.)

  50. So again why not all of the free market reforms AND a public option? That is the middle ladies and gents and I am unsure why no one seems to like it. I know it makes each side gag but why not take joy in the other side gagging. On a side note Clinton tried to take on the Repubs the insurance lobby and Pharma and had their ass handed back to them. Obama chose to play nice with Pharma and a little nice to the insurance industry and fight the GOP. Dont get me wrong ending lobbying as we know it would have been a better start but the GOP still would have gone nuclear. Another note is that how many of you that do not want a public option would stand behind the dems to cut off the legal bribery in our system?? Of course pharma and the insurance lobby are being short sighted if we pass a bill the next targets when prices do not come down will be them but that is an easier fight then fighting everyone all at once. So who wants to double down on 100% publicly funded elections?

  51. @Andy: “About 50% of healthcare in the country is publicly funded and those areas are experiencing unsustainable cost growth too.”

    It's about half the increase of private insurance. So while private insurance will double in 10 years, Medicare cost will double in 20. Buys us a decade. Maybe we'll eventually have the nerve or the desperation to actually address the tough choices. Is there an age or health status at which we can't have organ replacement surgery (or we pay out of pocket)? I guess that's a nonstarter if anyone in the public sector talks about it (death panels?). So we'll let corporate goons make those decisions instead. sigh.

  52. Leonidas, figures can lie. The total fraud is 13% (300 billion paid, 40 billion fraud and “waste”). Yeah, it's wasteful and if we can just get it down to the fraud rate on private insurance…. Oops. they're doing no better.

  53. Hemm,

    ” Any ways to save money you know of or is stating that the current system is broken all you have?”

    here are a couple of ideas,

    1. Let the states have some say in Medicare, not every state population is the same, and each state could tailor their services to better represent their populations that are dependent on Medicare. Medicare users in Florida and those in North Dakota, might have quite different overall needs.

    2. Pay the patients not the doctors. Why should bad doctors get as much as good ones. By determining a fair pricing for different recieved treatments and giving that money directly to the patients , they will be encouraged to find the best treatment for the money and to not seek treatment beyond what they need. this would reduce the costs of lots of extra uneeded proceedures.To keep doctors from pricing themselves out of the medicare market, a limit on how much they can charge above the base rate would need to be set, based on experience and sucess rates. However, it should be required that the payments are spent on medical care, at least the majority of them to reduce fraud possibilities.

    3. Allow indeminity insurance, this would help correct mispricing by doctors.

    4. Allow for beneficiaries to hire doctors as advisors to their use of other doctors and the healthcare system, medicare forbids this now I think.

  54. By the way, the cost of Medicare, even though it's the highest risk population in the pool, is the same as private insurance does with low risk patients and relentless claims denial departments. THAT is waste. When the government can pay costs for an 80 yo grandma and it costs less than a fit young person, something is very wrong. No, wait. Something is very right when a public system can do what NO private insurance company can, or even wants to. It covers the worst of the worst at cheaper cost.

    MagicalSky I'm with you. Public *option* will be just fine. Those who want to continue to keep their ramoras, oh, sorry, their private insurance are welcome to do so.

  55. GreenDreams, with the lack of government commitment of reasourses to fraud prevention is it any wonder they haven't found more?

  56. @ Greendreams-

    I don't trust you. You're poor. Jazz the reasonable moderate said so.

  57. Leonidas

    I appreciate your ideas.

    I would say up front that the current bills don't really address Medicare, and I think that is a major failing. Health care today is divided into pools of good risk and bad risks. Older Americans run higher medical bills, and I don't see private insurance wanting to work that segment as their profits would be at risk. For the participants, private insurance rates who go ever higher just when their incomes decrease due to retirement.

    The current system could certainly gain by strong cost reduction incentives Part D is a great example. Import those drugs made in the US and exported to Canada. They cost 50% less up there. pharma profit is one thing, gouging is quite another.

  58. CS

    “That depends entirely on the size of the tax credit.” Sorry, but I'm a little dense here. How can a tax credit exceed the tax charged? The poor don't make much and the don't pay much in taxes. It seems to me that any medical charges exceeding those taxes would have to be provided by you and me.

    Isn't that what we don't want now? Like I said, I'm obviously missing how you see a credit would work.

  59. Polimom, of course it's an attack. The WSJ op-ed section is even less accurate and honest than Fox News. The same can be said of Investor's Business Daily. Every word and every number on any political or politicized subject in a WSJ editorial will be slanted to the Republican Party and its positions. I cannot think of one exception.

  60. For the Right, what are your specific means to avoid this collapse without addressing the non-competitive aspects in the present system.

    Hemm, it's a good question, but I'd first unpack a couple of its premises.

    First, who's against competition? Competition is precisely what will bring down costs. It's the only thing that ever does, and it has worked great in every other industry. We need dramatically more of it in health care.

    Second, “what specific measures will reduce costs?” implies the wrong thing. I can and have listed a bunch of inefficiencies that are begging to be corrected and will result in lower costs. But your question implies that there ought to be some central authority spotting inefficiencies and taking action to correct them, and that if conservatives can't sell you on a specific list, they're talking out of their hats.

    I dispute the premise. The main observation guiding fiscal conservatives' thinking is the central authority model doesn't work. The authority can only spot problems big enough to see from outer space, and even those it has limited ability to fix because they tend to be very political. It's not working yet again in Maine, which is no surprise.

    Look at a business model like record stores. Politically speaking no central authority could have decided to kill record stores, but they've been eroded from underneath by small degrees, and now they're being replaced by cheaper, more efficient distribution channels. Driving efficiency is a grass-roots activity that can ultimately bring huge changes in the landscape.

  61. Dr J
    “I dispute the premise. The main observation guiding fiscal conservatives' thinking is the central authority model doesn't work”

    Fine, costs are increasing beyond control under the current system which is private oriented. They clearly won't do anything on their own, so fiscal conservatives must not have an option.

    You don't trust the central authority, but year after year increases in the private sector clearly demonstrate they have no ability or willingness to bring down costs. That's the premise of yours that I reject. A scary central bogeyman authority or a runaway price rise via private industry only concerned in enlarging the amount that passes through their hands..

    What do you want to believe, your fear or your lying eyes :)

    Every idea we talked about the past few days should definitely be put on the “list.”

  62. Here's a question to the free marketeers. Why should the private sector be trusted? Over and over distrust of government is put forth by conservatives as their motivation. Government is a huge bureaucracy. It has too much red tape. Guess what. Corporations have bureaucracy. They have massive amounts of red tape. They also have something the government lacks. A desire for profit as motivation to deny the services they agreed to provide (See recission.). When it comes to corporate integrity we have many recent examples of corruption and dishonesty. Look at Enron and other energy traders who rigged the markets in California a few years back. Real estate and mortgage brokers who rigged paperwork. The entire basis of passing useless mortgages back up to investors because they wouldn't be hit when they failed is dishonest. The list goes on. Could we regulate them? Of course not. We could pass the laws, sure. But in the not too distant future we would just see what we've seen happen with the financial sector. The people with an economic stake would wait until they had the right people in office and then the rules aren't enforced or repealed. We had Glass-Steagall. Then came Phil Gramm, Republicans like him and Democrats dumb enough to not realize the damage they were doing in dealing with him. In healthcare there are multiple cases of recission that have made the news. There are cases of suppression of factual evidence of side effects of drugs when the pharmaceutical company involved needed their stock prices pumped up and couldn't “afford” bad news about a drug they wanted to hit the market.

    Those are some of my reasons for doubting the efficacy of any private sector solution to our health care problems at least as much as Polimom distrusts the government.

  63. “Fine, costs are increasing beyond control under the current system which is private oriented.”

    “Private-oriented” is to competitive market as “fruit-flavored” is to fruit or “creme filling” to cream. The health care market is laboring under huge distortions that inhibit competition, garble pricing signals, and squeeze out all accountability for value-for-dollar. The way the system works today, no one really cares how much 98% of the transactions end up costing. Of course costs are going through the roof and millions of people are simply priced out. We simply need to remove these distortions and let the market do what it does well in every other industry.

    By all means, keep a list. But like I said, the longer and shrewder your list is, the more trouble you'll have acting on it from above. Complex political systems like our cannot be changed that way, at least not much. If you want really meaningful change, you have to embrace the profit motive and unleash the entrepreneurs to subvert the old order from below.

  64. “Why should the private sector be trusted?

    At the macro level, because it has a much better track record. Countries that leverage their private sector enjoy much better economic growth than those that try to centrally manage their economies.

    At the micro level, because it's opt-in. If you don't trust company X to provide good value for your money, you keep it in your wallet.

  65. Health insurance is opt-in?

  66. It sure is. A good chunk of the uninsured are young, healthy people between jobs who don't think their risk is worth the premium and make a rational bet. According to the actuarial tables, odds are they will save money.

    Even people buying insurance will–in a functioning market–have a wide range of choices. If one company has a bad reputation, they can sign up with another one. Say it with me: “exactly the way competition works in every other industry.”

  67. @ HemmD

    ” “I dispute the premise. The main observation guiding fiscal conservatives' thinking is the central authority model doesn't work”

    Fine, costs are increasing beyond control under the current system which is private oriented. They clearly won't do anything on their own, so fiscal conservatives must not have an option. “

    and I dispute your implication that the federal government is not at present responsible for a good portion of the current rising costs. Laws allowing huge rewards in malpractice suits drive up doctor costs, regulations about where you can purchase healthcare insurance drive up insurance costs, level upon level of bureaucratic function drive up hospital and doctor costs, other insurance regulation that interposes itself and prevents usage of indeminity insurance increases the cost across the board.

  68. @Jim Sattefield

    “Those are some of my reasons for doubting the efficacy of any private sector solution to our health care problems at least as much as Polimom distrusts the government.”

    Fair enough your entitled to your own bias, but understand one very big difference. The Private sector can be monitored and disciplined by public watchdogs with the force of law behind their regulators and and criminal investigators, the government has no check on its power outside of itself. I'll make a guess (and it is a guess) that you are not a fan of George Bush (I'm not either), would you trust the Bush administration to run an honest healthcare system and be diligent in investigating violations if those violations forwarded his political agenda despite being illegal acts? I wouldn't. So why should I want this type of thing left in the hands of politicians and their appointees? Why should you want this?

  69. Sorry, but I'm a little dense here. How can a tax credit exceed the tax charged? The poor don't make much and the don't pay much in taxes.

    Wow, Hemm, I'm sorry but I didn't know that people were unaware of this. Tax credits have nothing to do with whether or not you have a net income tax liability. We pay out tax credits right now to people who pay nothing in income taxes (the EITC.)

    So, these proposed tax credits would work the same way- not refunding people an amount that they paid in income tax, but actually giving them a net positive amount of money above and beyond their earned income.

  70. Why should the private sector be trusted?

    The 'private sector' that I trust refers to private individuals, empowered to actually make choices (which we don't really have the ability to do now.)

  71. The deficit has now grown to over 9 trillion dollars under the leadership of President Obama and the Democrats. The irresponsible spending spree of the Democrats must end now. Health Care Reform will further increase an already ridiculously high deficit. Nor can people afford the new taxes and fees to pay for Health Care Reform that are on the table right now.

    Moreover the fear of government run “death panels” becomes very real when the House Bill includes over 500 billion cuts in Medicare despite the fact there will be a 30% increase in Medicare enrollment once the baby boomers hit 65. The real fear is once the government has more control over the health care dollar how will they go about reducing costs other than rationing which is par for the course in other Nations who have government run health care?

    If Congress is sincerely interested in lowering the costs of health care
    insurance and making it more available and affordable for everyone Congress could do it with a one page Bill by: (1) Allow insurance companies to compete across State lines, (2) Do tort reform and (3) lift all the government mandates that increase the cost of insurance so that insurance companies can tailor their plans based on the wants, needs and pocket books of the people. That is how costs can be lowered and free choice can reign.

    AGAIN, A 9 TRILLION DOLLAR DEFICIT IS UNSUSTAINABLE AND THE DEMOCRATS AND PRESIDENT OBAMA MUST FACE UP TO THE FACT THAT THE NATION CANNOT AFFORD ANOTHER HUGH GOVERNMENT PROGRAM LIKE MEDICARE, SOCIAL SECURITY AND MEDICAID THAT WILL BANKRUPT US ALL.

  72. I'd loke to add another item to your list tsuh1231
    (4) allow insured to tailor the components of the insurance..i.e. my wife and I are 61 and 62 respectively…we have NO NEED for an insurnace component that includes maternity, pre-natal, post-natal care….in NJ it is mandated in our private insurance….so I am advocating ala carte insurnace….with premium reflecting the actual insurance purchased.

    just my $0.02

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