Those Forked Tongue Democrats: How Many Uninsured?

Snake.jpgOne of the perpetual bones of contention in the ongoing health care reform debate is the precise number of people in serious need of help in this area. All too frequently we encounter various, exaggerated estimates, including some fact challenged quotes right here at TMV, which put the number as high as 50 million. Well, that’s certainly a troubling statistic for anyone to contemplate. In fact, the New York Times had a heartfelt opinion piece this weekend which recognizes a number of serious problems with the math on these figures, but then essentially bats them away, saying we shouldn’t dwell on the numbers.

But how many Americans are we really talking about here? And what mitigating factors need to be considered? A good place to start would be the most recent edition of the U.S. Census Bureau’s report on Income, Poverty and Health Insurance Coverage in the United States. (Follow the link, please, for the full PDF of the report.) It’s the same one cited in the Times piece. Turning to page 27 we find that the total number of people put in the category of not having health insurance during the previous year starts at 45.7 million (not fifty) which is down from 47 million in the previous reporting period. But that’s still a lot of people, isn’t it? We’ll need to do some more digging, obviously, and we will.

But first, here’s one more item which generally goes unmentioned when it comes to the Census Bureau’s Current Population Survey results, linked above. If you turn to appendix C, buried back on page 67, you will find that the Bureau doesn’t even have faith in its own numbers on this score.

National surveys and health insurance coverage

Health insurance coverage is likely to be underreported on the Current Population Survey (CPS). While underreporting affects most, if not all, surveys, underreporting of health insurance coverage in the Annual Social and Economic Supplement (ASEC) appears to be a larger problem than in other national surveys that ask about insurance. Some reasons for the disparity may include the fact that income, not health insurance, is the main focus of the ASEC questionnaire. In addition, the ASEC collects health insurance information by asking in February through April about the previous year’s coverage… Compared with other national surveys, the CPS estimate of the number of people without health insurance more closely approximates the number of people who are uninsured at a specific point in time during the year than the number of people uninsured for the entire year.

The report then refers you to the CBO’s report on How Many People are Uninsured and for How Long. This fascinating report informs us that, of the large numbers cited, roughly 45% of the people included in that statistic are not the chronically uninsured, but rather people who are in transition between jobs and are likely to have health insurance again within 120 days.

Next, we need to go back to the Census Bureau report and turn to page 31 where we are informed that their total number includes the category of those who are listed as “non-citizens” (which are carefully broken out from naturalized citizens vs. native born citizens.) The non-citizen rate of uninsured individuals clocked in at 43.8%, or roughly 9.4 million non-Americans. Since these people are not here legally and not paying into the system, that portion of the crisis is better addressed in a debate on immigration issues, but taxpaying Americans don’t need to be on the hook for that segment of the total.

While the number continues to drop, it’s also worth noting that we’re not talking exclusively about the abject poor who can’t afford insurance. As this Business and Media report informs us, that same Census Bureau summary includes the following:

But according to the same Census report, there are 8.3 million uninsured people who make between $50,000 and $74,999 per year and 8.74 million who make more than $75,000 a year. That’s roughly 17 million people who ought to be able to “afford” health insurance because they make substantially more than the median household income of $46,326.

Once you do some fairly basic math, you come up with the same figure that the Kaiser Family Foundation arrived at.

The liberal Kaiser Family Foundation puts the number of uninsured Americans who don’t qualify for government programs and make less than $50,000 a year between 8.2 million and 13.9 million.

Let’s say we take the high end figure and round up to 14 million. Yes, that’s still a lot of people in need of help, but the figure is becoming manageable at this point. If you look at the GOP’s health care bill, currently buried in Ways and Means, you realize that we could approve means testing for people in that category and issue them advancements and/or vouchers for five thousand dollars in coverage and you’d have accomplished the largest goal which most ObamaCare proponents claim to want to achieve. The price tag would not be chicken feed, coming in at 70 billion dollars, (and that figure assumes that every single person in that category would sign up) but after staring H.R. 3200 in the face at a cost of either 800 billion or two trillion (depending which CBO scoring method you go by) I can assure you that you’d have members from both parties doing back flips in their eagerness to sign on. And you could do it without driving a major American private industry into the ground and overloading public programs which we still don’t know how we’re going to finance in years to come.

Obviously there are other problems and they should be addressed as well. Those transitional people mentioned above should be able to move on to their next job without getting hit with preexisting condition clauses or major increases in premiums. Constantly increasing health care costs should be intelligently driven down, mostly by allowing interstate competition between private companies. But these are things where I believe the Republicans and Democrats can already find common ground. First, we’ll need to get the big issues put to bed, and a good place to start would be by being honest about how many people we need to insure and how we can most reasonably, efficiently and economically do it.

Previous Coverage:
Those Forked Tongue Democrats: Keeping Your Plan
Those Forked Tongue Democrats: Long Term Costs

EDIT: Changed 60 billion to 70 billion in paragraph eleven.

77 Comments

  1. Actually, a bigger problem is underinsurance, not non-insurance. I'm sure a significant percentage of Americans technically have “health insurance.” But woe unto them if they try to use it, what with bankruptcy-inducing deductibles, extremely limited coverage, etc. Yes, much of this is a health care cost issue. But as we discussed in another thread, reducing health care costs over the long term is probably going to involve some sort of significant rationing, which the Palinites have already demagogued away.

  2. reducing health care costs over the long term is probably going to involve some sort of significant rationing

    Not advocating, supporting, or opposing anything with my question here, but I do have to ask something.

    I spent some time yesterday reading up on how other countries are handling things. Leave Canada and the UK out of the thought process (please!), and look at some others. They are bringing in costs per person in at ~half what we are. Is France rationing care? Or Japan? Reading about them (at a very high level), as well as Germany and Singapore, I don't get that impression.

    WaPo put some info online yesterday. (Link gleaned from another thread on tmv.)

    So I don't know that your statement is true, elrod. Unfortunately, I don't know what other, more successful models are doing, either…. but it doesn't seem to be 'rationing', in the way we've been debating it in the US.

  3. Elrod, rationing has to be part of the solution but I don't see any serious discussion coming from either side of the aisle. Indeed Obama continues to stress the government won't make medical decisions, won't come between you and your doctor, etc. There is a vague plan of a panel to decide on best practices but I wouldn't call that rationing.

    In order for health care reform to work there has to be some form of rationing of services, plus adequate resources (read:taxes) have to be committed to it. I don't think either party is willing to say that publicly.

  4. We already have rationing – if you don't have money you can't get health care.

    The issue is not just how many people don't have insurance (and for those who are just transitionally without insurance can run into headaches later of they develop medical conditions since the insurance company typically will set restrictions on treatments they will pay for if you were without insurance before starting their plan), but people who are underinsured and people who have to pay exhorbitant prices or go through an insurer of last resort just to get coverage at all.

  5. Polimom, the often left out aspect of that is that here in America we spread out and have to pay for the R&D end of things. Most all of the biggest innovation in medicine, machinery and all the tools that go into providing the level of care we receive all gets paid for someplace. Generally, that's from the health care community (doctors, hospitals, nurses, clinics, etc.) who use all of these innovative products and services. That cost has to be made up and it gets paid for by the consumer (and, of course, the evil insurance companies who write the checks for the majority of it.) Other countries not involved in that kind of development don't have to shoulder the cost of it.

    Anecdotal, obviously, and getting exact figures on Country A vs. Country B for this precise effect looks like it would be next to impossible, but it certainly seems accurate.

  6. Jazz — yes, the costs of R&D on new technology (as well as medications) is one area where there are differences. However, the WaPo article makes clear that the US hasn't cornered the innovations market by any means.

    In another source I read that at least one of these countries (France?) limits the amount of recoverable expense to bring a new product to market to 1.5x the cost. Along with that, they (whoever they are?) are amortizing the R&D costs.

    The WaPo article, btw, speaks directly to the innovative products question when it talks about Japan.

    In the United States, an MRI scan of the neck region costs about $1,500. In Japan, the identical scan costs $98. Under the pressure of cost controls, Japanese researchers found ways to perform the same diagnostic technique for one-fifteenth the American price. (And Japanese labs still make a profit.)

  7. A couple of things occur to me.
    1. Has anyone else noticed a trend toward young women saying something like this, “I had my baby and a week later, my husband was laid-off.” Is everyone out there so naive as to think that is coincidence? Am i the only one that knows that when an employee files a large claim or several employees file large claims, the insurance rates to the employer goes up considerably?

    2. As others have pointed out, under insurance is a huge problem. What other thing is purchased where what it actually is remains unknown? Yet, we are expected to shell out ~$500 a month for a pig in a poke. Until claims are filed, there is no way to know is covered, what isn't and by how much. Over the weekend, my neighbor found this out the hard way. He pays $400 a month and when he was checked into the hospital for divertivulitus, admissions called his insurance company, then informed him that he would owe $3,600 for the first day. Three days later, he was turned loose. He has no idea what his bill will look like.

    Image buying a car and not knowing if it had A/C in it until the weather got hot and you reach for the unlabeled knob, only to discover all it has is heat? Ridiculous, you bet.

  8. Losing your insurance when you lose your job is a big problem, even if they are “likely” (I wonder just how likely that is during our current recession) to get it again soon. People don't stop needing to see a doctor when they lose their jobs. They don't stop needing drugs to deal with diseases and injuries. They don't stop needing to provide the same to their families.

    And reform isn't just about covering the uninsured. It's also about helping the under-insured, people who pay for insurance that doesn't actually cover them in their time of greatest need (most people that file for medical related bankruptcy have or had insurance).

    It's also about trying to fix the rising cost of health care, which threatens the Federal budget through Medicare and is draining our own wages at a rate much higher than inflation.

    The reform bills in the house address all of these issues, even if they still need a lot tougher language to put a bigger dent in the cost problem.

  9. Jazz, the argument that we have to pay for the R&D doesn't make sense. Because at worst we should be paying the same amount as everyone else according to the law of purchasing parity. And at best the US should be reaping dividends by exporting the technology to other countries which should lower prices due to economies of scale. Yet the same drug costs less across our border in Canada than it does here. That means that the markets aren't perfectly competetive, which means we have a market failure, which means the government should step in.

    And I'm wondering when we're going to get posts titled “Those Forked Tongue Republicans”.

  10. Polimom,
    n the United States, an MRI scan of the neck region costs about $1,500. In Japan, the identical scan costs $98.

    I'll have to go google that up for you. I read something on it just last week. As in many other areas, both Japan and France subsidise the cost of high end medical equipment, which doesn't happen here. Somebody still pays for it… it just comes out of the pockets of everyone, which I suppose is the argument many people here are making. But given the cost of a new MRI machine, think how many people you're going to have to scan to make it up at 98 bucks a shot, minus the cost of paying the technician for doing the scan, the electricity to run it, the doctor's cut, etc. etc.etc.

  11. Jcavhs,

    And I'm wondering when we're going to get posts titled “Those Forked Tongue Republicans”.

    If you only read my entries, I suppose I could understand that sentiment. If you read the posts from a number of other writers here, Kathy Kattenberg in particular, you won't see “forked tongue.” You'll see far worse, just saying flat out “liars” “thieves” “panderers to the poor and uneducated bigots or whatever. I just get tired of that and now take an approach of what's good for the goose is good for the gander. There's no need for TMV to be one sided where all liberal ideas must be treated with kid gloves but any conservative point of view can be openly insulted to the general cheers of the masses.

  12. “But given the cost of a new MRI machine'

    If it is so expensive and so unprofitable to own one, then why is their an MRI place almost on every street corner where I live? Almost as common as bank branches.

    BTW, I live in a place that charges Medicare much more on a per patient average than the national average, yet can show no better patient outcomes for all those MRI's and tests. Think there is a connection?

  13. If it is so expensive and so unprofitable to own one, then why is their an MRI place almost on every street corner where I live? Almost as common as bank branches.

    Hey, if you want to sit down and have a conversation about whether or not the actual health care providers (read doctors, hospitals, clinics) are using too much equipment and investing in too many expensive aspects of medical technology and running up costs, feel free. But that doesn't really fit in very well with the whole “evil insurance companies are gobbling up all the money and everything would be just peachy without them” meme. Insurance companies and Medicare both have bills delivered to them from the actual health care providers, and the consumers, either through insurance policy premiums or tax dollars for Medicare have to pay those bills. You want to bring the bills down without cutting the quality of health care through innovative technology? I think that's great. Lay out your plan and if it's feasible you'll see me getting on board.

  14. “You want to bring the bills down without cutting the quality of health care through innovative technology?”

    You can cut down on bills by changing the fee structure which practically forces doctors to run needless tests. More care does not equal quality care.

    By the way, with your GOP plan, how do you cut costs in health care so in 3 years that $5 thousand voucher doesn't need to be $10 thousand?

  15. Jazz — I found an interview from Frontline in 2007 about Japan. Very, VERY different system. Link

  16. Losing your insurance when you lose your job is a big problem, even if they are “likely” (I wonder just how likely that is during our current recession) to get it again soon. People don't stop needing to see a doctor when they lose their jobs. They don't stop needing drugs to deal with diseases and injuries. They don't stop needing to provide the same to their families.

    That's all very true, Chris, but the nature of the problem is very different. What you're describing there is a problem due to high unemployment rates, not directly due to healthcare costs or insurance availability. And, there's already been a partial remedy for unemployed people to get temporarily insured- the stimulus bill allows for payment of 2/3 the costs of COBRA coverage, with phaseouts according to your prior year's income.

    That may not be enough for all unemployed people, since even paying 1/3 might be too much for people who didn't have sufficient savings to get them through a period of unemployment- but again, it is a direct way to address that portion of the uninsured and it differs from the way we need to address the problems of the chronically uninsured population.

  17. “That's all very true, Chris, but the nature of the problem is very different. What you're describing there is a problem due to high unemployment rates, not directly due to healthcare costs or insurance availability”

    It's the nature of one of many problems I addressed in my comment. Jazz and the other nay-sayers have a tendency to pick out little bits and pieces of reform they don't like and criticize that. Then they move on and criticize some other little part, even if their complaints are contradictory.

    For example, there has been a lot of conservative hand wringing over the cost of health care reform, $1 trillion is too much and so forth. Yet they don't acknowledge that the cost of doing nothing is even higher, and the cost of weakened reform is even higher still. But then they don't want stronger reform, because it inevitably means more government intervention.

  18. Yet they don't acknowledge that the cost of doing nothing is even higher, and the cost of weakened reform is even higher still

    Who is this “they”, Chris? Can you give me a few examples of conservatives who argue against the current Dem reform plans without acknowledging that the current system is economically unsustainable?

  19. Hmm, I don't know about that MRI bit in that discussion.

    … The price of that MRI is so much cheaper in Japan. Doesn't he have to pay the same price, $5,000, for an MRI machine like the man in America?

    Well, it depends on what kind of image density the radiologist wants. And the MRIs that are available in Japan are much less expensive than those that are typically found in the United States.

    So the imaging machine is cheaper? … To me that's another advantage of negotiating low prices: Then the supplying industry has to cut its prices, and the MRI makers met this need.

    Right. And MRIs have now become very big in [the] export industry.

    So the health ministry set a low price, the MRI makers make cheaper machines to help the doctors meet that price, and now Japan is exporting these around the world?

    Right. … This is a situation where the market does work in health care. …

    The interviewer and the interviewee blew right past it, but it seems to me that they're making the point for critics, that such price fixing leads to a form of rationing or at least stifling of innovation.

    The guy acknowledges that prices for MRI machines vary according to “what kind of image density the radiologist wants” but then they completely ignore that for the rest of the discussion, as though the cheaper MRI machines are the same quality as the more expensive ones that are being made in the US. Image density is an extremely important factor in the usefulness of an imaging technology. Now, maybe we do have to accept limits for how far the tech advances will go, and keep using one level of technology for a longer period before it becomes obsolete as a newer advance replaces the old. But you can't ignore that as though the govt just waves a magic wand of price negotiation and suddenly we can keep manufacturing higher quality imaging machines for a much lower price.

  20. The interviewer and the interviewee blew right past it, but it seems to me that they're making the point for critics, that such price fixing leads to a form of rationing or at least stifling of innovation.

    I don't think that's the point they're making. What the interviewee didn't answer was what an MRI machine costs there for comparable image density. Dunno if that's a dodge, or a function of the direction the interview was moving. I did think, though, that the fact that they're exporting their MRI machines indicates a less expensive development of some kind.

    This was, btw, the first time I'd read how the Japanese are controlling costs. Fascinating.

  21. CStanley,
    Read Jazz above. Vouchers will help the uninsured, but won't fix the risings costs.

  22. What the interviewee didn't answer was what an MRI machine costs there for comparable image density.

    You're right, that they just didn't address the question of whether or not the cheaper machines are cutting edge quality, or if they represented a compromise for lower cost. Instead, the direction that the interview took (to me at least, and maybe I am reading between the lines a bit) suggested that they thought this was all peachy because the price controls worked in bringing down the actual cost of comparable equipment.

  23. Chris, later in the post Jazz wrote:
    Constantly increasing health care costs should be intelligently driven down, mostly by allowing interstate competition between private companies.

    You may not agree with that, but it's inaccurate to say that he doesn't address rising costs.

  24. CStanley — that was just the first link I found. Illuminating in a number of ways, but you're right that there could be more underlying the MRI question. OTOH, maybe not.

    However, I am curious what you think about Japan's approach, generally, to cost containment. The government's setting of prices, and then leaving the underlying states / employers / people to handle the coverage and delivery mechanisms, is radically different from anything currently under discussion. What is your opinion of the Japanese solution?

  25. Constantly increasing health care costs should be intelligently driven down, mostly by allowing interstate competition between private companies.

    You may not agree with that, but it's inaccurate to say that he doesn't address rising costs.

    Addressed in the most cursory way imaginable. How will competition increase when there are still relatively few large insurers? How will we be able to pick our plans if we're still practically forced to get insurance through our employers? How will a bunch of insurance companies force doctors and drug companies to change their cost/fee structure?

  26. Addressed in the most cursory way imaginable.

    Chris, surely you can agree that someone can express an opinion that is critical of one plan in one article, mention that there are other ways of achieving the mutually agreed upon goals, and not flesh out the arguments in support of one of those other potential means within the confines of the one article? I would think you would agree, because unless I've missed it I haven't seen you complaining about authors here who've written posts that were critical of the GOP without also going into detail about what the alternatives to their policies should have been.

    To answer one of your questions though, competition across state lines would help because some states allow a more competitive market. I've mentioned it before, but my state of GA is apparently one such state- I get offers in the mail all the time and hear radio ads for some very affordable healthcare plans. From what I've been able to gather, it seems that a lot of states regulate against these kinds of plans because they don't meet minimum requirements- and such requirements sometimes are absurd, like disallowing any plans that don't pay for everything from chiropractic care to IVF.

    I'd love to find the data but haven't yet, on which states have the highest increases in uninsured people over the last few years or last decade- and see how that matches up to increased mandates on how comprehensive the healthcare plans need to be.

  27. “If you only read my entries, I suppose I could understand that sentiment. If you read the posts from a number of other writers here, Kathy Kattenberg in particular, you won't see “forked tongue.” You'll see far worse, just saying flat out “liars” “thieves” “panderers to the poor and uneducated bigots or whatever. I just get tired of that and now take an approach of what's good for the goose is good for the gander. There's no need for TMV to be one sided where all liberal ideas must be treated with kid gloves but any conservative point of view can be openly insulted to the general cheers of the masses.”

    Nice to see you lowering yourself to her standards. Stay classy TMV.

  28. The government's setting of prices, and then leaving the underlying states / employers / people to handle the coverage and delivery mechanisms, is radically different from anything currently under discussion. What is your opinion of the Japanese solution?

    I'd have to know more, but my general opinion is that top down, centralized price fixing never seems to work in the long run. I suppose what they're doing seeks to avoid some of the micromanagement problems associated with allocation of resources from the top, but I don't see how that can work in the long term either. How do they arrive at the general numbers for rate of increase in pricing in each sector or facet of healthcare delivery?

    It would seem to me that the problems in such a system might take several years- maybe even decades- to begin to show through. That's my impression of other countries that have a centralized approach- that people are quite happy at first since their access and choice doesn't change for a while, but if insufficient money is allocated toward R&D, or training of medical providers, or any other facet of the supply side, then over time the rationing problems become apparent. That seemed to be what the discussion did address a bit when they talked about potentially 'underspending'.

  29. “because unless I've missed it I haven't seen you complaining about authors here who've written posts that were critical of the GOP without also going into detail about what the alternatives to their policies should have been.”
    In a lot of cases the implicit alternative was do nothing. That was true of the tax cuts, social security reform, the war in Iraq, torture and warrantless spying.

    But from what I can tell, that's not what Jazz is saying here, or at least he's hedging.

    ****
    The state regulations you mention are a definite problem. Rather than “a rising tide lifts all boats” it's a mechanism that enforces near monopoly status and that's why I think you'll see significant opposition to that idea from insurance companies. Of course that's not a reason for not doing it, just means it will be tough. I do think for the Public Plan to work, it will need to be free of those state regulations, otherwise the administrative efficiencies wont be as great.

    Do you know off the top of your head if the proposed Health care Exchanges would be exempt from the state regulations? That seems like a smart move IMO.

  30. Do you know off the top of your head if the proposed Health care Exchanges would be exempt from the state regulations? That seems like a smart move IMO.

    No, that's another thing I've realized I need to read up on. Somehow I find it hard to believe that they'll adopt the least restrictive state mandates since the more onerous ones are typically from heavily Democratic states like NJ, CA, NY, so there is a lot of political pressure on the Dems who wrote or will vote for the bill to have the exchanges promote that kind of all-inclusive coverage.

  31. Chris: This summary of HR 3200 seems to confirm that scaled down benefits packages will be disallowed in the exchanges (though this seemingly isn't as bad as some of the state mandates that really go overboard):

    Essential benefits. A new independent Advisory Committee with practicing providers and other health care experts, chaired by the Surgeon General, will recommend a benefit package based on standards set in the law. This new essential benefit package will serve as the basic benefit package
    for coverage in the Exchange and over time will become the minimum quality standard for employer plans. The basic package will include preventive services with no cost?sharing, mental health services, oral health and vision for children, and caps the amount of money a person or family spends on covered services in a year.

  32. The wiser public has long tired of, and yawns at or is annoyed by, continued parroting of the number of the uninsured. Nearly everyone knows reform is appropriate, and in fact, desireable. But that's not the same as the childish people who insist on rushing hurriedly to enact bad legislation with consequences to match, much less make silly (and in the following examples, revealing immaturity) arguments in favor of rushing to enact bad legislation, such as “we cannot afford _not_ to do something quickly,” and “we need health care reform, NOW!” The continued remarks about the number of uninsured, which are tainted by sensationalism and “outbidding” among numerous parties remarking about this number, neglect the fact that so many uninsured have placed themselves in that position, particularly the young — who constitute the true poster people for the uninsured most of the time, rather than the currently unemployed who can't afford COBRA.

    About the only thing we have yet to encounter is deliberately manipulated, revised-upward figures, that redefine “uninsured” in the most broad, biggest-number sense possible, such as defining first what can be called “underinsured” (particularly by people who irresponsibly demand comprehentive, “Cadillac” health care or “insurance” for everyone, as opposed to catastrophic-care true insurance). This would aid the hyping of figures, which don't impress anyone but the most emotional, and generate a backlash if anything among the intelligent. But it's not necessary for activists to do this; current hype already serves this purpose.

    We know there's a desire and even a need for health care (not only insurance) reform (for what so many are viewing is not insurance, but health care). It would have been better from the beginning, but is not a surprise that it hasn't been this way given who is at the controls, not only at the forefront, of the current health care effort, had the silliness, hype, and irrationality been replaced by direct, honest, reform efforts.

  33. “Somehow I find it hard to believe that they'll adopt the least restrictive state mandates since the more onerous ones are typically from heavily Democratic states like NJ, CA, NY, so there is a lot of political pressure on the Dems who wrote or will vote for the bill to have the exchanges promote that kind of all-inclusive coverage.”

    Of course.

    And don't neglect (if not now, then later) dental care, optical goods (eyeglasses and contact lenses), etc.

  34. “then over time the rationing problems become apparent”

    That's when there will be a desire for a “private option,” and this has been anticipated, for example, in the Conyers-Kucinich “Medicare for All” approach, which forbids private duplication of public, non-profit care guaranteed (?) to everyone.

    Also at issue, still badly neglected (the object of deception and dishonestly from the beginning of this effort, which immediately began to sink it among informed people), is how new federal care will be paid for. Even though we are in a slump (but Obama and the Dems want a vast cost increase on us with this issue, nevertheless, while wanting but failing to “stimulate” the economy in other ways, at vast cost to us, without suitable results), will there be a new consumption tax to be added to the income tax (which itself will not only likely see the end of the Bush tax cuts but face increases, and increased progressivity if the liberal Dems had their way)? It's possible, along with the imposition of new consumption taxes (this, despite a current slump and “need to stimulate” the economy out of it) such as the value-added tax that was discussed during the Clinton years. Simply taking $500 billion out of Medicare (a major reason why a lot of Medicare beneficiaries are alarmed) and threatening to “rationalize” costs away by imposing controls on provision of services based on what some bureaucrats may decide is “appopriate” or not, is not the answer, obviously. Curiously, though an up-front “cost savings” is sought by expropriation (changing private to public non-profit care, but not compensating for several years of subsequent lost profits), this issue was badly neglected in Conyers-Kucinich. The childish “magic” solution was sought, leaving the real effort to others in the future: That legislation would just make funding of health care by law “mandatory,” out of general revenue (the childish “magic wand” solution — “it _has_ to be paid for, by law. Poof!”), with the intention of highly progressive income taxes providing the revenue (in addition to things like taxes on stock and bond transactions, and possibly a wealth tax sometime in the future).

    These details should be kept in mind after Congress returns in September and may be revising things.

  35. “Nice to see you lowering yourself to her standards.”

    That's not what's happening. Some of us tire from nonsense and underlying misconduct and choose sometimes to push back, substantially (including what lies behind our positions, unlike theirs).

    It's not PC, and it generates whining and abuse, but too bad.

  36. “Vouchers will help the uninsured, but won't fix the [rising] costs.”

    Neither will replacing insurance companies or HMOs with government (typically, the federal government) as the intermediary. All that can be claimed here is that in theory government should be cheaper, if it is run on what essentially is a non-profit basis. It won't stop the cost growth, probably not even the slope of the graph of rising costs, just lower the Y-intercept (lower values all along the graph). Nor would extreme measures like expropriation in Conyers-Kucinich “Medicare for All” (forcibly converting private provision, including the “insurance” function, to public, without compensation for lost profits) achieve anything but an initial cost savings (not paying what they should, unless a court were to notice the unconstitutionality of this, and result in the costs being paid, after all, in addition to the punitive damages Washington should have to pay as well). Demography and continued medical advances (likely despite the repressive climate for them that a federal takeover would threaten and later, involve) will ensure that costs rise higher.

    Eventually there will be rationing and stunts like denial of care in the name of “futility” (especially in the case of elderly and very ill people, what we can start to see in some hospitals now), not to mention simply a limit to how much we can or will pay in taxes, in addition to cost-control measures such as a global cap or “ceiling” (part of the Clinton effort, “Managed care under a cap”). (That this is likely in all cases is obvious, along with the unseemly behavior associated with things like euthanasia, in addition to the things the liberal Dems have done so often for so long, which is why perceptive people have promptly had concerns, when not fears, of increased suffering or death not of one's own choosing, due to politics as well as financial problems in the future, when government takeover of health care here is at issue.)

  37. Jeeze DLS, spam much?

    No one is hurrying to enact bad legislation. We're trying to enact good legislation that people have been thinking seriously about for decades. It's only Republicans and nay-sayers like you who are late to the party.

    Also, there is no reason people shouldn't be provided dental and eye care. People gotta eat, people gotta see.

    Federal care will be paid for by redirecting what you pay for health care now to the government. Simple eh? Americans pay what, $12,000 a year for medical insurance if you include the funds diverted from your paycheck to insurance companies by your employer. If we were all paying $12,000 (if reform works it should be less) to the gov't instead, then there is plenty of money.

    And so what if it does end up costing $1 trillion over 10 years. Wouldn't that be better than what we're currently spending that kind of money on? Or as usual, are we only concerned with the well-being of our imperial subjects overseas and the mighty defense contractors?

    ****
    CStanley,
    Thanks for looking that up.

  38. “Eventually there will be rationing”

    There is rationing now. Don't even try to deny it.

    “All that can be claimed here is that in theory government should be cheaper, if it is run on what essentially is a non-profit basis.”
    Medicare is cheaper, government run insurance in other countries is cheaper. It's a fact, not a theory.

  39. Medicare is going to hell, Who here would want to wait as long as 28+ weeks for a knee replacement like in Canada instead of 5 weeks in the US.

  40. Leonidas,
    Then why are seniors so happy with their Medicare coverage? Why are Republicans fearmongering that Democrats are going to take it away?

    And I'd bet folks like these would rather wait for coverage than have NONE AT ALL.

  41. @ DLS–

    “It's not PC, and it generates whining and abuse, but too bad.”

    Exactly, DLS! So liberals are free to push back on Jazz when he tries to make Obama look like Serpentor, right? Yet when we do it, we're “attacking” and “savaging” the poor moderate Jazz. When conservatives do it, they're “standing up for what they believe in” and being “moderate.”

  42. Also, there is no reason people shouldn't be provided dental and eye care. People gotta eat, people gotta see.

    But some, even many, people only need to spend minimal amounts on their vision and dental care and can easily afford it out of pocket. These people should have the option of doing so in order to purchase lower priced health insurance plans, instead of being forced to help pay for every other middle class person's eyeglasses and dental prophys.

  43. @-Leonidas-

    You're right Leonidas. We do have the best health care system in the world. Now we just need to figure out how to pay for it while covering everyone without insurance while still keeping our high quality of care and making record profits for the doctors, hospitals, and insurance and drug companies at the same time. Let's think about this.

  44. No one is hurrying to enact bad legislation. We're trying to enact good legislation that people have been thinking seriously about for decades.

    Good legislation stands up to scrutiny; this plan does not. I don't know what went into the thought processes of the people who've been seriously thinking about this for decades, but my guess is that it's been more politically driven thought than a serious attempt to control costs and remove barriers to access to healthcare.

  45. CStanley,
    That type of cost sharing is already supposed to be happening with dental and eye insurance. My point is simply that eye and dental health is just as integral to overall healthiness and happiness as anything else, so it should all be covered in the same efficient way.

  46. Leonidas this is the second time you've tried to bend the truth regarding to wait times for knee replacement surgery.

    The New England Journal of Medicine did a study on this topic and if you'll follow this link http://content.nejm.org/cgi/content/full/331/16… you will see that the majority of knee replacements in Canada are done with less than a 8 week wait. You'll note also that 3 US and 7 Canadians had to wait 24+ weeks… it seems our system has it's drawbacks, too.

    Glen Beck is your source this time eh? I thought your PNAC link was funnier. Are you being paid for spreading this misinformation.

  47. Chris, my point is that many people do not NEED to spread out their risk of needing eyeglasses or dental cleanings or even fillings, sealants, etc. Why should everyone get subsidized for something they don't even need, which raises the cost of real healthcare insurance for everyone?

    What's odd is that you don't even seem to realize the inherent contradiction. Earlier, you were agreeing with me that the new Health Exchanges shouldn't adopt the mandates of some states which force all insurance providers to cover everything. Maybe you're just disagreeing with me on where to draw that line, but if so, what would you consider an excessive mandate for essential benefits?

  48. CStanley,
    Dental care can get crazy expensive, especially when we're talking about replacing teeth and whatnot (which is not even covered by most insurance). The same goes with eye care when you start going into various surgeries for injuries and genetic problems. Even glasses, if you don't buy them from $20 internet sites, are pretty damned expensive if you're on the poorer side of the scale.

    And yes, I still think we should get rid of the state mandates, I think this should be part of the Federal benefits package eventually.

  49. Chris- I'm talking about mandated coverage for basic dental cleanings and eye exams/glasses. I don't think there's anything wrong with subsidizing that for the poor, but when it's mandated that no one can buy a health insurance plan that doesn't cover those things, you're just driving up the costs of everyone's health insurance in that state and raising the entry level, which creates a whole new population of lower income individuals who can no longer afford to purchase health insurance at all.

    I still don't understand your stance on the state mandates- are you saying that at the Federal level, we should implement the most comprehensive level of the current state mandates, or are you saying that all of those mandates should be examined on their merits and the Federal plans should adopt some level that may not be at the maximum that it is in some states now? And if it's the latter, can you give an example of something that you think ought not be mandated to be covered? IVF? Chiropractic? Massage therapy?

  50. Late to the thread and haven't followed the debate here to this point but wanted to comment on something ChrisWWW posted

    Losing your insurance when you lose your job is a big problem, even if they are “likely” (I wonder just how likely that is during our current recession) to get it again soon. People don't stop needing to see a doctor when they lose their jobs. They don't stop needing drugs to deal with diseases and injuries. They don't stop needing to provide the same to their families.

    Fully agree with you here, this is a big problem and the reason why I support plans that place insurance through the individual and not the employer. Its one of the very strong points of the Paul Ryan bill in my opinon.

  51. CStanley,
    I know what you're saying, but I don't understand the big difference between mandating coverage for getting your teeth cleaned and seeing your primary care physician once a year. And since I'm talking about doing it through a government plan which would available to everyone, it wouldn't possibly price people out of coverage.

    Without examining the laws in all 50 states I cant say what I would or wouldn't choose to have as part of a Federal standard. My only point is that I think dental and vision should be covered.

  52. Chris, I'm actually not in favor of 'covering' a visit to the PCP once a year in the sense of having no out of pocket expense for most people. HR3200 is moving in the wrong direction in that sense, because apparently the new mandates of the exchanges would eliminate virtually all out of pocket expenses and make people even more unaware of the real costs of their medical care (and completely unaccountable for it if they overuse services.)

    I think there are ways to ensure that people who truly can't afford their checkups can get annual exams for free or a very small cost (scaled to income.) You don't have to ensure that every middle class family has no out of pocket expense for them.

  53. CStanley,
    People shouldn't be of the opinion that healthcare is free, that's why I'm not saying there shouldn't be co-pays and the like. And government health spending accounts (like those in Singapore) can help keep those from being too onerous for the poor.

    But even if costs are more transparent, that's still only part of the battle. People are going to want to follow the advice of their doctors regardless of the cost in most cases. So, how do we make sure the doctor's are also trying to be efficient without sacrificing care?

  54. Chris, the more that people are directly responsible for paying the bill (the doctor's bill, not the health insurance bill), the more pressure there is on the doctor to promote that kind of efficiency.

    I think I know what I'm speaking of here because I deal with it everyday in the practice of veterinary medicine. I don't know if you read that thread where Polimom talked about having her broken foot set in a boot cast instead of having surgery. That would be an example of the kind of medical decision based on cost consideration that you're speaking of, no?

    Well, in veterinary medicine we offer those kinds of options every single day, because we are the ones who have to sit face to face with clients and tell them how much the gold plated option costs. And we have to offer them a box of Kleenex when they tell us that they can't possibly afford that, and then we come up with plan B. Or, as often happens, we have to know when it's not really appropriate to offer Cadillacs when Chryslers will do just fine, so we avoid those tearful conversations altogether.

    Of course even though I'm proud of the level of medicine that we offer, I'm not suggesting that human medicine should be handled exactly the same way. We shouldn't have doctors telling poor folks that they'll have to settle for inferior treatments- but we should make doctors accountable for knowing which treatments aren't really inferior but can reduce costs.

  55. CStanley,
    I don't think we're disagreeing anymore… so bravo ;-)

    But before I go crazy without an argument, I want to go back to something you said earlier:
    “Good legislation stands up to scrutiny; this plan does not. I don't know what went into the thought processes of the people who've been seriously thinking about this for decades, but my guess is that it's been more politically driven thought than a serious attempt to control costs and remove barriers to access to healthcare.”

    You're right that this is a politically driven process, but that's unavoidable. Politics is how we govern the country. What's unfortunate is not that this process is too political, but that this process is being unduly influenced by lies/smears and politicians in both parties that bow only to corporate interests.

  56. People shouldn't be of the opinion that healthcare is free, that's why I'm not saying there shouldn't be co-pays and the like.

    So, what happened to that concept when those smart people you mentioned spent a couple of decades thinking about the problem of healthcare costs? HR3200 will eliminate copays on all preventative care. ;-)

  57. Chris- my complaint with the politics involved in this particular policy debate is that I think that the political forces are moving us in the wrong direction- making real reform even harder to achieve. Some people are saying 'Well, this bill isn't perfect but it's a start' but to me that's like trying to drive from GA to NJ and starting out by heading down to FL.

  58. “So, what happened to that concept when those smart people you mentioned spent a couple of decades thinking about the problem of healthcare costs? HR3200 will eliminate copays on all preventative care. “

    Unfortunately, the smart people are only advising (directly and indirectly) the people writing the bill.

    “my complaint with the politics involved in this particular policy debate is that I think that the political forces are moving us in the wrong direction- making real reform even harder to achieve.”

    Possibly, but the last time health care reform was defeated, it took us 15 years to try again. In the mean time we got the managed care people were afraid of, but instead of it being blunted by humane public policy, we got the corporate version with fun things like pre-existing conditions, rescission, etc.

  59. Chris, during that 15 years, there were a few conservatives working toward the conservative vision of reform. But then, just as now, partisanship and ideology prevented the Dems in Congress from working with the GOP (and I'll concede also that there was not nearly enough push from the GOP leadership- it was only a small group of conservatives pushing for healthcare reform.) Plus, those few individuals apparently made a boneheaded choice to support the Medicare drug bill as a way of getting their HSA legislation in, since it wouldn't have been allowed to come to a vote on it's own (the Dems would have filibustered it.) I don't think that was a good tradeoff, because that unfunding expansion of the Medicare entitlement also moved us in the wrong direction.

    As far as recission and preexisting conditions- do you have any data on that? I see a lot of people questioning the conventional wisdom that this is a large part of the reason for people's uninsured status. It seems to me that a much larger issue is that a lot of people have just been priced out of the insurance market- not that they're being denied coverage.

  60. CStanley,
    Well, I don't have numbers on exactly the number of claims that get rejected because of preexisting conditions or are denied insurance or priced out of it on those grounds. But according to CAP, there are 73 million people who might face pre-existing condition discrimination if they lost their insurance. http://www.americanprogress.org/issues/2009/04/

    (Hardly a non-partisan source, but they took their numbers from the center for disease and control, and the census. Plus I haven't come across any others.)

  61. Bolt: You're not quite correct. As far as attacks on Jazz or others, I'll provide comment as I see fit, as well as with the much greater problem we're seeing with lefties attacking “righties” (using a grossly expanded definition, effective) falsely (in in poor ways) for all kinds of imaginary “reasons.” We're seeing it in particular right now with the Dems' most ambitious and most [self-]endangered effort this year, the health care effort. The desperation and the anguish (not only anxiety) among the few faithful who still are in support of this effort (or anything with “Dem” or “health care” stamped on it), and their behavior, has become remarkable and remarkably bad (though not surprising when you think of it).

  62. Hmm…I am skeptical because of the source as well as the word “might”, but I'll look at it.

    Back to this for a moment:
    Unfortunately, the smart people are only advising (directly and indirectly) the people writing the bill

    First, I'm not even sure that the smart advisors are as smart as some people think they are, nor as impartial as they should be.

    Second, even if it were true that some braniac think tankers have come up with the ultimate solutions and now those solutions are being watered down or made ineffective because of the politics involved in writing the actual bill, I still don't see how you then can say that we shouldn't really need to keep debating the bill. At the very least, even if a majority of people agreed with the solutions put forward by the 'thinkers', shouldn't people take time to examine the 1000 pages to see if it actually does what the 'thinkers' say we should do, based on their decades of thinking on the problems?

  63. “[... A]ccording to CAP, there are 73 million people who might face pre-existing condition discrimination if they lost their insurance. http://www.americanprogress.org/issues/2009/04/

    (Hardly a non-partisan source, but [...]“

    It suffices. We with pre-existing conditions are a “silent” or “invisible” group, for the most part — we deal with the problems as we can (pay more, move elsewhere, etc. (So often what you encounter are activists who are campaigning on these people's behalf rather than the occasional testimonals from such people themselves.)

    Knowing this, I wouldn't be surprised if the total (with or without including a related issue, recission) involved more than 100 million people. (On the other hand, is it really approaching or reaching approximately one-third of the entire population?) Certainly it's large enough that either one is one of these people or knows well one or more instances of such people, and knows this this is one of a number of problems with the insurance-based health care system today. (This is why so many activists for years have sought “community rating” in place of “experience rating” and underwriting. Universality of federal health care includes this appeal and related implementation details, though are other reasons that universality appeals to “Medicare for All” advocates.)

    * * *

    “We're trying to enact good legislation that people have been thinking seriously about for decades.”

    That is absolutely, demonstrably (every day) false about the current Dems' health care legislation.

    (That is also the truth about everything the Dems have been doing all year, worsening with time.)

  64. “shouldn't people take time to examine the 1000 pages to see if it actually does what the 'thinkers' say we should do”

    Especially those who will be voting whether or not to enacted what's in these 1000+ pages?

  65. “Hmm…I am skeptical because of the source as well as the word “might”, but I'll look at it.”

    That's fair. But any one of those people would be screwed if they lost their job, or decided to start their own business or whatever. Whatever the numbers, any discrimination on those lines is immoral and we should work to address that fact.

  66. “the last time health care reform was defeated, it took us 15 years to try again”

    That doesn't mean another 15 years will elapse before the issue is revisited this time.

    The last “reform” attempt was bad and wrong, as this one is; having to wait 15 years is no argument against passing this one now, anyway, irrationally.

    Obviously the effort is failing and is inept (and incoherent) as well as having other problems; best would be for everyone to stop, then actually think about what they want (which they've shown in numerous ways to have failed to do, or do well), limit themselves to that (sensibility, please), then work to get it enacted.

    I shudder to think of the manned space program starting from scratch under “guidance” of these people.

  67. It seems to me that a much larger issue is that a lot of people have just been priced out of the insurance market- not that they're being denied coverage.

    CStanley — Because we're talking about “insurance” and “risk”, the problem is as you say. I've known people with serious preexisting conditions who had no health insurance. Coverage for one couple I knew would have run into the thousands per month. So I guess you could call that priced out rather than excluded, but it's kind of a semantics thing I think.

  68. That's fair. But any one of those people would be screwed if they lost their job, or decided to start their own business or whatever. Whatever the numbers, any discrimination on those lines is immoral and we should work to address that fact.

    It looks like all they're really doing is calculating the number of people who might be vulnerable because there is no state law to prevent denial on the basis of preexisting condition in their state.

    So why would the solution to that problem be to create a new govt run health insurance system rather than to make a federal mandate that gives the same protection to the people in those states that is currently protecting those in states with mandates?

    Or, figure out an alternate way to handle the patients who have increased risks, like high risk pools that some states have?

  69. “any discrimination on those lines is immoral “

    It's not immoral, given that what's sought is “insurance” if only nominally (it's comprehensive care).

    Dishonest recission or bogus identification of pre-existing conditions is immoral, but a separate issue, too.

    That it's unpleasant and may result in harsh consequences for the individuals of concern is obvious, and is one of the things that so many of Republicans (even) admit are a known problem with the health care system today. (Note that one person I heard comment on this said that the true hard-core population, the truly uninsureable, numbers about [only] ten million.)

    There are a number of things that the federal government could do to reform the insurance system we have.

    This has been neglected, and in fact intentionally avoided (sidestepped), insofar as anything definitive is part of the current health care effort, because the private insurers really aren't seen as meriting any other than a token position (for now, though not later) by those in charge of the current effort, whose principal goal is to augment federal provision (if only through payment) of health care, replacing the private sector.

  70. PM- actually what I meant was that a lot of other people on the lower income part of the scale are being priced out because of general rise in price of insurance. You're right that that's also another way of describing people who lose coverage and then can't pick up a new policy at an affordable price, but that wasn't what I meant in my earlier comment. I honestly just don't know how the numbers break down- there obviously are people like the couple you mentioned, but also some people who are generally healthy but feel that they can't afford insurance (esp in states where prices are particularly high, which is sometimes related to mandated minimal coverage which includes all sorts of things that some people really don't want or need, or would be willing and able to cover out of pocket if they had to.)

  71. “[Why not] make a federal mandate that gives the same protection to the people in those states that is currently protecting those in states with mandates?

    Or, figure out an alternate way to handle the patients who have increased risks, like high risk pools that some states have?”

    Or:

    * Community rating (with possible mandatory insurance purchases) state-wide, region-wide, nation-wide;

    * Inter-state and multi-state insurance (health care provision) and providers;

    * Uniform benefit packages (kept to the realistic minimum to keep the cost reasonable — _insurance_).

    This isn't hard. This never hasn't been hard, insofar as _reform_ of the current system is concerned.

    But that's not what the current people in charge of the health care effort want — which is “replacement, not reform” — (incremental, partial) replacement of private health care with public (government) health care.

  72. “So why would the solution to that problem be to create a new govt run health insurance system rather than to make a federal mandate that gives the same protection to the people in those states that is currently protecting those in states with mandates?”
    That is in fact part of the proposed solutions being written in the House and Senate. The government run system is primarily a way to address universal coverage and long term costs. It also provides a backstop against an insurance industry that finds innovative new ways to avoid paying for health care (like rescission).

  73. It's a separate issue (and something I've stressed for ages, as well as the recent subject of another thread), but one of the first things people need to do is to distinguish (and perhaps, to divorce) the concept of insurance from what is normally being viewed and meant instead, (comprehentive) health care.

    That's certainly on the minds of those who want any incrementalist federal takeover of health care, and if they were honest, they'd say so.

  74. The government run system, on the other hand, is primarily a way to address universal coverage and long term costs. It also provides a backstop against an insurance industry that finds innovative new ways to avoid paying for health care (like rescission).

    But the same thing could be accomplished without a govt health insurance provider by simply strengthening the regulation of the insurance industry WRT those practices, and passing legislation for the individual mandate to get health insurance with tax credits or vouchers for people who need financial help. Conservatives won't like that, of course, but at least by avoiding the additional step of expansion of public healthcare, the same goals are addressed in a manner that would represent more of a true compromise between the Dem/GOP stances on the issues. Instead, the Dems insist that they've already compromised by shifting from single payer to public option (and now perhaps to coops) but really all of those will probably involve a govt run health insurance entity (I say probably because the coops may or may not end up like that, depending on how they're structured.) Their 'compromise' is mostly semantic and still always insists that having a govt provider is necessary- and on top of everything else that conservatives will be forced to swallow, why should that be non-negotiable when the same goals can be addressed in a different manner?

  75. Jazz says

    “Polimom, the often left out aspect of that is that here in America we spread out and have to pay for the R&D end of things.”

    Jazz obviously didn't read the link or he wouldn't make such a fact free assertion.

    Or are you willing to confine your mother to a wheel chair should she need a knee or hip replacement?

    The more you pontificate on this subject the more I think you're being willfully obtuse or outright dishonest.

    Which might be acceptable if it were not for his snarky forked tongued references.

    I don't have time to go into it tonight but isn't it time we call Jazz's post what they are?

    Here in Texas it has an acronym you know.

    Why does Astrazeneca decide to locate one of it's major drug development labs in Canada?

    Why is Jazz ignoring this?

    You make the call.

  76. Signing off before posting comments which, while true, may be less than generous.

    Forked tongued indeed.

    I don't have time to truly cover this issue, but then, I'm not subsidized by other industries.

  77. “No one is hurrying to enact bad legislation.”

    And you *** dare *** make false accusations that others are Spamming?

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