By Any Other Name
Ronald Bailey at Reason objects to Ezra Klein’s objection to Charles Krauthammer’s repetition of the rightist canard that government-funded health care will lead to rationing.
First, Ezra:
“Look at Canada,” says Charles Krauthammer. “Look at Britain. They got hooked; now they ration. So will we.”
So do we. This is not an arguable proposition. It is not a difference of opinion, or a conversation about semantics. We ration. We ration without discussion, remorse or concern. We ration health care the way we ration other goods: We make it too expensive for everyone to afford.
Ezra should have stuck the adverb “reasonably” before “arguable.” Because despite the name of the publication he writes for, Bailey does argue that market-imposed rationing is not rationing. The problem, Bailey condescendingly informs Klein, is that he is “confused” about the definition of rationing:
Like most left-leaning folks, Klein clearly doesn’t know the definition of rationing. Take this one from Britannica:
Government allocation of scarce resources and consumer goods, usually adopted during wars, famines, or other national emergencies.
Klein evidently thinks that market outcomes that he dislikes mean that government should step in and impose outcomes that he does like. All right, let’s admit it; the health insurance market and the rest of health care are royally screwed up as a result of decades of government interventions and mandates. Consequently we don’t actually find the usual benefits of falling prices and improving products and services that we experience in normally operating markets where robust competition and choice reign.
Huh. Bailey apparently thinks that “market outcomes” happen by chance, or by natural law, or the laws of physics. He apparently believes that when insurance companies jack up their premiums, or force people to choose between sky-high deductibles and Cadillac coverage or lower deductibles and Edsel coverage, that is not the result of deliberate policy decisions. He also seems to have fallen hard for the notion that health care is just like any other consumer good — that when your child is up in the middle of the night with appendicitis-like symptoms, you can go out and comparison shop for doctors and hospitals the way you would if you were in the market for a new car, or a washing machine, or a graduation present for your nephew.
If these were not life-or-death, wellness or illness issues we are dealing with here, I would find it amusing that the same market ideologues who so passionately defend the profit motive will simultaneously defend the proposition that the medical and insurance industries will forgo their profits if their customers can’t afford the price. Of course, no one would expect an appliance store to give away a washing machine or drastically lower the price to accommodate a customer who really, really needed a new washer but couldn’t afford to buy one. By the same token, no one, we are told, should expect a doctor to provide free treatment to a woman who has breast cancer and will die without the treatment, or an insurance company to cover her medical expenses, even if she doesn’t have the money to cover them herself. Doctors and insurance companies have a right to be paid for the hard work they do and the expertise they provide.
And they do. Of course they do. Truly, they do. And yet, a washing machine still seems to me to be less essential than the life of a woman with breast cancer. But if it’s true that a public health care option is absolutely unthinkable in any way, shape, or form, because it will unfairly compete with private insurance companies and take away their profits and force them to go out of business, then we are left with what we have now — the private insurance industry, which has the right to be profitable and has no obligation to be a charitable enterprise or put compassion above making money.
That’s why I, in my leftie foolishness and naiveté, believe that health care should not be bought and sold like any other commodity, product, or service, because it is substantively, morally, ethically, and essentially different from any other commodity, product, or service. This is not to say that there is no place for the private insurance industry. But they cannot be the only game in town. Because that breast cancer victim could be me, or my daughter, or a close friend, or another congregant in my synagogue, or my next-door neighbor. Whoever she is, I know this much: She is not a washing machine.
opinions powered by SendLove.to
34 Responses to “By Any Other Name”
[...] More: By Any Other Name [...]
Condescension has its place. In this case, it is totally misplaced. Klein is right. Money and power are fine with me. I would love a little. But we have to live in the world. You cannot ration an argument that can't be won. But Bailey has a point. If you look up 'ration' in a dictionary you can make a semantic point. But reason? Not a chance.
“when your child is up in the middle of the night with appendicitis-like symptoms, you can['t] go out and comparison shop for doctors and hospitals the way you would if you were in the market for a new car, or a washing machine, or a graduation present for your nephew.”
If the free market in the insurance market worked as it should, which it can't due to our employer-based system, you would do that sort of comparison shopping when you are looking for an insurance plan that suits you. One that offers a good bang-for-the-buck and has good customer satisfaction. Because our choices are limited, insurance companies' get away with more than they should in terms of both cost and quality.
But, I do agree with you that health care is not the same as washing machines. Would you say, then, that's it's in the same category as food? Yet the food market is mostly a free market system (yes, with some government involvement–it's hard to find an industry that doesn't have some of that these days), which has many choices, with the rich able to afford more than the poor, etc. There isn't much outrage, on the left or the right, on the market-based rationing that occurs in the market for food.
The reason for that, of course, is that food is relatively cheap. Most people can afford it, and for those who can't, we can provide programs like food stamps pretty cheaply. So, the difference between food and health care is that health care is very expensive, and so there is a greater percentage of the population that can't afford it, and it is also expensive for the government to provide it to those who can't afford it.
So, if our focus is bring down the cost of health care, both for individuals and for government, it seems to me that driving more people into that market, because of the public option as well as a government mandate, would only drive costs up as there is more demand and the same amount of supply. So if we want to increase access to health care (which I do want to do), we have to focus our attention equally, if not more, on controlling the cost.
So how do we reduce the cost? The public option would try to do this by eliminating the profit margin (which is actually not that much) and then using its bargaining power to pay lower rates, similar to how Medicare pays doctor's less than private insurers. Who pays for this cost control? Doctors, providers, and companies that produce medical products (yes, those evil drug companies). If they make less, they provide less (less doctors, less breakthrough drugs, etc) So, we have the predictable result of price controls–lower quality, less available, which requires even more rationing.
On the other hand, we could implement reforms that are based on free-market principles to increase consumer choice (not only the quantity of choices but the variety also). More choices would force insurers to find ways to attract and keep customers, both by lowering the cost as well as improving the service. The only way to do both is to find ways to keep people healthy, which is in the interest of both the insurer and the patient. And encouraging more healthy lifestyles is the only way to “bend the curve” in the long term.
I understand the free market is not perfect. It is a means to an end, and not a perfect means. However, we can't ignore its ability to lower costs and improve quality when it is allowed to function as it should. This effect has served us well over the past 200+ years (our current recession notwithstanding), even in areas that might be considered by some to be “rights”, like food and clothing. It does need regulation (specifically, I favor measures that prevent those with pre-existing conditions from being priced out of the market), but it does not need to be supplanted.
f the free market in the insurance market worked as it should, which it can't due to our employer-based system, you would do that sort of comparison shopping when you are looking for an insurance plan that suits you. One that offers a good bang-for-the-buck and has good customer satisfaction.
How would that work, in practice, given that you don't necessarily know in advance exactly what health care you're going to need over the course of your entire life? It's not like picking a camera, where you can pinpoint your needs fairly accurately over a time range, and you know the camera is not going to last forever anyway, so if it doesn't have a feature you decide later that you want, you can just wait until you have the money to buy a new one.
How would eliminating employer-based insurance lower costs? I don't get that. Insurance companies would still charge a king's ransom for policies that provided even decent coverage. Their goal would still be to eliminate competition from any source that could provide health care at lower cost and high quality. Their goal would still be to maximize profits, not to make sure their customers get the specific coverage they need, at a price they can afford. There are lots of things I would like to have that I can't afford right now, and probably indefinitely, but most of them don't harm me if I don't have them. I would love to have a car again, but I can't afford the cost of owning any car. That's okay. I can live without it. I really would like a laptop computer, and cable tv as well as Internet. Too much money, and it won't kill me to do without them.
I also need anti-depressant medication, since I suffer from major clinical depression. I can tell you with assurance that if I could not get my anti-depressant medication and went without it beyond a certain length of time, I would be in serious trouble. And I mean life-threatening trouble.
I realize that prescription meds are among the easiest health care needs to find ways to subsidize, but it's just an example. Some medications are much more expensive than mine, and mine isn't cheap if you have to buy it at full price.The point is that beyond a certain point, you cannot control or predict what your medical needs will be, and if you forgo them for cost reasons, you can do that, but it could easily shorten or end your life. It's just not the same as forgoing a laptop or a flat-screen tv or a car or a vacation.
Re food: Yeah, food is cheaper than health care. Let's talk about food for a moment. Food is a tangible product that is sold in stores. It requires no expertise to sell, beyond an abillity to operate cash register. Anyone can sell it; you don't have to go to college or grad school or get a license to sell food.If you can afford food, there are sources of hellp, as you mentioned, but the reason those sources are so much easier to find than sources of help for medical expenses is that anyone can provide them. It's not just food stamps and food pantries. Your neighbor or landlady can help you out or cook for you if they know what's going on. Relatives and friends can cook for you or help you out with money. I just feel, and maybe you still don't agree, but I do feel strongly, that food is so different from health care in almost every way you can think of that it's really not the best analogy to use. I'm sorry, but a mammogram or a CAT scan are not only much more expensive than food, but there is never going to be a way to have a sale on mammograms and CAT scans that can make them a bargain like the sale at your local supermarket where you can get ten boxes of spaghetti for the price of five.
Re: We can't ignore the free market's ability to lower costs and improve services.
I continue to hear this sentiment expressed over and over when it's clearly not true for ALL human needs. It's true for a lot of things, maybe most things, but not for health care. Clearly, the free market does not, has not, and cannot lower health care costs. Over the past half century since Pres. Eisenhower established the federal employee health insurance system that our government officials still enjoy to this day, the cost of health care for everyone else has skyrocketed, and continues to do so. Furthermore, it's a fact that countries with nationalized health care systems (every industrialized country in the entire world except us) provide, at minimum, basic preventive health care to all their citizens at much lower cost than the free market does in the U.S. With a few exceptions, most of those countries' systems work extremely well. Even the exceptions, despite their problems (which are mostly due to underfunding) provide access to health care to more (all) of their citizens at a lower cost than we do with 50 million Americans uninsured.
Everyone is talking past each other.
Kathy and adelinesdad are both right, and both wrong. The demand for healthcare needs will never be as elastic as the demand for food because we need specific healthcare services and products that sometimes are expensive, and those demands can't be met by substituting cheaper services or products as is the case with food. And, Kathy's also right to point out that the provision of food can come from anyone who is willing to help you out (soup kitchens and food pantries and friends, family, and neighbors) while that's not true for medical procedures and surgeries that are sometimes necessary.
But what it also true is that the demand for healthcare needs is a good bit more elastic than our current system would indicate. When a third party is paying the bills, there's absolutely no incentive to keep our own medical expenses down. We have third party employers mostly buying the insurance policies (and although you'd think they'd want to keep costs down, they also can't necessarily choose the most economical policies for each of their employees because it's mostly a one size fits all approach, and there's also been a tendency for employers to offer gold plated plans that high quality employees want in order to attract better workers.) We also, of course, have third party payers for the medical procedures and products themselves, so that most of us don't even know how much our care costs. People do overuse medical services when someone else is paying the bills; and since the overall societal costs are too high, that is one source of 'fat' that must be trimmed. It would be far better for people to make more rational decisions on when to go to the doctor, when to get elective surgery vs. putting it off or using cheaper alternatives to handle certain problems, etc- than to have someone else decide for that person what they can and can't get. The RAND study in the 70's (yes, outdated, I know- someone really should repeat this kind of research to see if it still holds true) showed that most people did make rational decisions to limit their healthcare expenses, while still seeking medical advice when necessary- as long as they had a reasonable disposable income. For people who don't- the problem could be handled through govt funded vouchers or tax credits so that they wouldn't have to put off a doctor visit due to insufficient funds.
As for shopping for health insurance, I disagree with Kathy about knowing what our needs are. You don't have to know what healthcare services you're going to need in the coming years- you just need to know what you are able to afford. If you have you're own safety net of savings, you know that you can afford higher copays and higher deductibles. It's the same rational process we go through when we purchase homeowner's insurance or car insurance or life insurance. None of us knows what future needs those policies may need to provide for- but based on our current finances, we know how much protection we need to purchase from the insurer. We can decide to pay lower premiums if we have our own safety net of savings to cover more on the lower end of potential expenses.
Back to the original post, there's also a similar situation of people talking past each other. Klein says that we ration now, but Bailey points out the difference between different kinds of rationing. Because the word itself has varying definitions (some definitions include market based rationing as one form, while other definitions specifically use the word to mean 'non-price marketing' which is most often a govt based rationing.
The reason that's important to point out, of course, is that the people who criticize the current reform proposals on the basis that they'll lead to rationing, are using the form of the word that Bailey refers to. The govt decision making process is specifically what such people object to, and Klein knows it. He's using semantics to argue that their concerns are unfounded, when he probably knows very well that the very thing they're concerned about (giving authority to government over the decisions of allocating scarce healthcare resources) are correct. If Klein wants to make an honest argument about why those people shouldn't be concerned- that the govt will oversee this process in a manner that won't have worse outcomes for some people- then he should do so.
“How would that work, in practice, given that you don't necessarily know in advance exactly what health care you're going to need over the course of your entire life?”
As CStanley said, you don't need to. That's why you're buying insurance. You need to have some idea of what the risks are of getting very sick, and what your financial situation is.
“How would eliminating employer-based insurance lower costs?”
By providing more choice. Even the best employers only provide a handful of choices, and those are usually very similar choices. Some employers only provide one option. If every insurer knows that their customers have a plethora of other choices, they need to make sure their product is attractive to customers. How do they do that? There's one two ways: reduce cost and/or improve the product. And yes, their third incentive is to maximize profits. So how do they do all three?
The only way is find ways to provide the product at a lower cost to the insurance company. They can pass some of the savings on to the customer and keep some of the savings as profit. The more competition in the market, the more pressure there is to pass the savings on the customer.
So, how could the insurance company provide the product for cheaper? The only way to do that is to encourage more healthy behavior (and less over-use as CStanley mentioned). Polimom brought up one idea of getting back to true “insurance” (http://themoderatevoice.com/44031/health-care-a…), which would discourage over-use of routine services, and create a financial incentive for staying healthy without bankrupting those who don't. (I pointed out a slight modification I would make to the pure “insurance” model in a comment in that thread)
“Food is a tangible product that is sold in stores. It requires no expertise to sell, beyond an ability to operate cash register. Anyone can sell it; you don't have to go to college or grad school or get a license to sell food”
It does take expertise to produce food. But granted, once it is provided, anyone can sell/share it. I *can* help my neighbor with his health care expenses, just as I can help them if they can't afford food. No, I can't give them a check-up, but I can contribute to their expenses just as easily (besides the fact that it's like to cost more, which I've already addressed). What difference does it make if I go to a store to buy some food for my neighbor, of just give him the money to do it himself? If there's no difference, then why can't I give my neighbor money to help with health care just as easily?
“Clearly, the free market does not, has not, and cannot lower health care costs. Over the past half century since Pres. Eisenhower established the federal employee health insurance system that our government officials still enjoy to this day, the cost of health care for everyone else has skyrocketed, and continues to do so.”
And for most of that time we have had intrusions into the free market, like the incentive to buy health insurance through one's employer, and Medicare (which uses its power to implement cost controls which hurt providers, as the public option would). Our current system is not a free market system. I don't favor a purely free market system (like I said, I favor some regulation as well as some help for the poor. I've explained my reasons why healthcare, as well as education, cannot entirely be handled by the free market here: http://sovereignmind.wordpress.com/2008/10/11/f…), but I do think we need to return to some of the free market principles to help us reduce cost.
Interesting article penned by a liberal
How Sarah Palin Rope-a-Doped All-Too-Many Liberals
http://pajamasmedia.com/ronrosenbaum/2009/08/28…
<snip>
Outsmarted by Sarah Palin, oh I bet some left-wing egos are smarting.
bet bailey had to look thru 18 dictionaries before he found a definition w/the word “government” in it. why not websters? why not funk & wagnalls?
dictionary.com sez rationing is:
nowhere does the word “government” appear. the closest thing is “military.”
[...] [...]
Of course there would be rationing. There are numerous other concerns, involving not only competence but intentions and other consequences in addition to rationing that concern people.
The nature of the effort to defend the current Democratic initiative is revealing, not merely defective, too.
No Kathy, she's my wife. But I resent your continuing efforts to use her and people like her as vehicles to demonize everyone who disagrees with you. I'm very angry at this particular attempt because I have spent the last year dealing personally with the exact same disease that you use as a mere rhetorical club to beat people up with that you don't like.
It is simply not true that “public option” is the only possible alternative to maintaining the status quo. Other options, like co-ops and subsidization of purchases of health insurance, are available. Why don't you actually discuss the substance of the arguments instead of just misrepresenting and demonizing everyone you disagree with?
Kathy, serious reforms of the existing system have repeatedly been listed repeatedly. To recall:
* End discrimination (not a pejorative when the insurers are doing what insurers obviously should be doing under “experience rating” and related risk assessment) against those with pre-existing conditions or a history of illness, surgery, etc., and the practice of recission.
* Change from experience rating to “community rating,” which is the concept people who want universal government health care are thinking of, anyway. This would necessitate enlarging the pool of insured people by coercive legislation, probably, but again, that's what universalists want, anyway.
This would be on a state-wide, regional-wide, or nation-wide basis. (People who aren't mobile don't recognize the appropriateness of the regional approach to this and other issues, while at the same time the regional approach addresses problems some smaller states might have with community rating.)
* Implement a uniform benefit package. Make the package a reasonable minimum so as to control costs. This might be the time to educate the ignorant on the difference between true insurance (the catastrophic events that we normally avoid and wish to avoid) and comprehensive health care (that typically includes preventive care and to which states add all kinds of costly unnecessary things now).
* Change (obviously) to a household (individual or family) system from the employer-based system that is the norm for so many (there are many of us who long have had individual policies instead).
* Assumption by government (probably federal, though state and local should be considered first under our US system, again) of many preventive and other basic health issues (with costs kept at a minimum by not overreaching as many want to do with preventive care) as a government public health function.
In addition, the current federal programs could be reformed (actually, not merely in unbelieveable promises of Obama) and should be reformed, even if this is more difficult than dabbling in new stuff.
* Correct the “doughnut hole” and other defects identified with the current Medicare Drug B program.
* Achieve long-term sustainability for Medicare, Medicaid, VA, Indian Health (and Social Security).
* Integrate and unify Medicare and VA, Indian Health, use common procedures and paperwork, etc.
Incrementalist measures other than the clumsy, vague public option stabbing-at-universality are:
* Incorporate Medicaid into Medicare. (This aids the states, and stimulus funds might be used to pay the one-time costs of conversion.) In other words, all of it would be federal Medicare.
* Incorporate VA and Indian Health, etc., into Medicare (if not done as earlier consistency task). In other words, all of it would be federal Medicare.
* Offer Medicare to children (incorporating S-CHIP into Medicare fully if not done beforehand). Address criticism of this blatant age-related expansion “flank attack” on the taxpaying adults by deflecting it with a more general term (which conservatives will attack, still): “dependent care.”
* A “public option” in a reformed, honest, open market as a political test for universality (once many others in addition to the elderly are beneficiaries of Medicare), and incentive to become universal.
(I.e., the “public option” intelligently applied, and correctly timed in the correct environment for it)
These are the kinds of things that any intelligent, rational person would promptly expect, not merely assume, should be the first things undertaken or at least considered, before continuing the kind of behavior the Dems (notably the House lib Dems) have engaged in, as well as in legislation sought. Not only should true insurance reform (of true insurance) have been the object of “reform” measures, but the reforms of the existing federal health care programs, logically, should have been undertaken and completed before beginning to consider expanding the scope of federal heatlh care, certainly before beginning to undertake it (and that should be purposeful, constructive action, not this year's).
There is, or at least there shouldn't be, anything difficult about understanding what is obvious. The problems lie in the details. Note that the rational goals, were they sought instead, also preclude at least some opportunity for excess and mischief (in scope and in detail) by government, which may be why the rational approach (as with honesty, coherence, etc.) have been avoided in the current effort.
I only hope the Dems learn and behave more sanely next month, or the earned criticism will continue.
“The RAND study in the 70's (yes, outdated, I know”
“Let us insist on real controls over what doctors and hospitals can charge” — Teddy Kennedy
Somehow I believe Kennedy nowadays would be fully up-to-date as well as open to concession.
The problem with the alternatives offered to the public option by the true believers in free market economics is that the co-ops have failed as often as they've worked and the subsidies are food for the existing structure provided by the government, meaning that it will cost more and do less. Most of the numbers tossed around as being adequate subsidies would in today's market give money to the insurance companies in return for very little care. And no, that isn't really reform.
Why, then, do health care reform opponents so love to talk about waiting lists, which as the French Health Minister has said, are for elective procedures? If you want enough surgical suites to meet any emergency, but not so many that there's one standing idle waiting for a facelift, it seems sensible that you wait for an opening unless it's medically necessary, or unless you want to pay for a private clinic, of which there are plenty to assure the wealthy “me, now” crowd can always get what they want on demand.
Perhaps there is an overuse of doctors when none is necessary, but I'm not sure that's really been documented. We could probably stand to allow more paraprofessionals to step into the gap for less expensive care, such is available in my town through the “People's Clinic,” a nonprofit clinic that utilizes nurse practitioners and physicians' assistants for nonemergency routine care. A doctor overseees.
I think there's a serious underuse too, with mostly poor people not seeking care or checkups because they can't afford it. That, too, increases the lifelong cost of care. But a for-profit insurance company is focused on quarterly reports, not lifelong care, especially when they reserve the right to ditch a customer who becomes too costly for them.
And Bailey probably knows that there's no practical difference between a government bureaucrat and a corporate bureaucrat making that decision. He chooses to ignore the current rationing (policy limits, denial of claims, delays in pre-authorizations, outright rescission) and uses a fear tactic to imply that this would be a departure from the current practice. After all, when an insurance company denies you precisely what you're paying them to deliver, that's just “market outcomes” you don't like.
I have looked into that possibility myself. Have you? Catastrophic insurance policies are not really that affordable, so the assumption that you can back routine care out of insurance coverage currently does not seem viable. I could be wrong, though, so tell me. What's the cost of a catastrophic plan (say $5,000 deductible) for a 30 yo woman and a 50 yo man?
So instead of my country valuing the health of its citizens, I should rely on the charity of my friends and neighbors? I don't see that as a sensible national policy. On the other hand, I do support your idea of decoupling employment and health insurance. The 18% of our population that gets a federal tax handout for having such a policy might not agree with that though, especially when they see the cost of individual policies, which I've had to buy for myself for decades.
I disagree with that. 97% of doctors take new Medicare patients, despite the 19% lower payment v.s. private insurance. Nearly ALL hospitals do, despite the 25% lower payment. No one is holding a gun to their heads. If what Medicare pays “hurts” them, they can walk away and treat only the privately insured.
Private insurers have NOT reduced costs. They've certainly had every opportunity to, but why should they?
GreenDreams. No, I have not looked into such a plan, since my employer doesn't offer one, and I'd be foolish to forfeit the amount that they are putting into my health care plan (instead of paying it to me) in favor of an individual plan. But if you have specifics on what the difference in cost is between a full-coverage plan and a catastrophic plan, I'd be interested in those numbers.
“So instead of my country valuing the health of its citizens, I should rely on the charity of my friends and neighbors? I don't see that as a sensible national policy.”
No, that's not what i'm advocating. Kathy brought up that as what she feels is a difference between food and health care, which I disagreed with. It was a tangent to our discussion. In my ideal world, we would all take care of each other without the need for government programs, and I do think there is a role for charity to play, but it has not proven itself to be up to the task. Maybe it would be if people didn't have so many taxes to pay, but that would be a pretty big role of the dice. So no, I'm not advocating that our public policy on this issue should be based on private charity (although if any charitable movement wants to prove me wrong on that, I'm all for that).
'No one is holding a gun to their heads. If what Medicare pays “hurts” them, they can walk away and treat only the privately insured.”
What you don't consider is the number of potential providers who choose not to pursue a career in medicine, partially because they don't feel they can make enough to justify the amount of schooling and debt required. That's a difficult number to measure, but it is obvious that if pressure is put on providers to lower their prices, there will be fewer providers.
Thank you for summarizing my argument, in your first paragraph, much more concisely than I did when I wrote it.
Unfortunately, I don't agree with the argument you make in your last paragraph. In fact, your putting the onus on Ezra as the one who was not making an honest argument set me to bristling. Bailey *clearly* suggested that Ezra had the definition of rationing wrong. He absolutely did NOT write that there were two definitions, one referring to market-based rationing and the other to government-imposed rationing. So what is your rationale for making Ezra responsible to “know” what Bailey “meant” and explain why the government will “oversee this process in a manner that won't have worse outcomes for some people”?
In point of fact, Ezra has made that argument many times, quite cogently, as have others — but in this particular post he was responding to a specious argument made by opponents of government-funded health care *all the time*; namely, that a public option will lead to rationing — which *clearly* implies that rationing does not already go on in the U.S. healthcare system as it currently exists.
In my view, the onus is much more on Bailey — in this specific exchange between himself and Klein — to show why rationing is not rationing when the mechanism is price rather than government fiat. Patronizing references to what the “dictionary” says don't do that. Indeed, it's a very lazy argument because everyone knows that dictionary definitions become outdated or incomplete rather quickly, given the way the meaning of language evolves and changes.
If every insurer knows that their customers have a plethora of other choices, they need to make sure their product is attractive to customers.
This begs the question, however. You're assuming that there would BE a “plethora of choices.” Why do you assume that? On what evidence?
No Kathy, she's my wife. But I resent your continuing efforts to use her and people like her as vehicles to demonize everyone who disagree with you.
No, Jason, she's NOT your wife. She's my grandmother. And I am tired of seeing your belligerence, paranoia, and pathological need to take offense at anything that is said by anyone you disagree with. I say this as someone who tends to take things personally, so it's not like I don't understand that kind of reaction or have sympathy for it. But your quality of taking almost everything as a personal affront leaves me in the dust.
Really, Jason. When I read your comment — when I saw the first sentence! — my first thought was, “Oh my GOD. What is he talking about? This guy is demented.”
“You're assuming that there would BE a “plethora of choices.” Why do you assume that? On what evidence?”
My evidence is everyone who keeps talking about the obscene profits they are making. That seems like a great opportunity for others who might want to get into the business and offer alternatives. And my evidence is also the choices that I see around me, which are not accessible to me because my employer decides for me that I should choose between only a handful of options (which are almost exactly the same).
Which is a serious concern under any scheme. We're less gray than most of the industrialized world, but our day is coming when we'll need a lot *more* providers to treat our aging population. We talk a lot about costs, but money is just a proxy for what health care is really about: hours of someone's time–a doctor, a nurse, a drug researcher, or the bajillion staff that support them all.
We either need to attract more such people into these fields than we do today (and price caps are unlikely to do the trick), or we need to get more mileage out of the people we have. I'm for the latter.
My evidence is everyone who keeps talking about the obscene profits they are making. That seems like a great opportunity for others who might want to get into the business and offer alternatives. And my evidence is also the choices that I see around me, which are not accessible to me because my employer decides for me that I should choose between only a handful of options (which are almost exactly the same).
This strikes me as, at best, an overly hopeful way cutting costs and insuring the approximately 50 million Americans who currently are either uninsured or underinsured. At worst, it strikes me as downright illogical. You are not offering any actual evidence that these others would actually consider it a good opportunity or be able to take advantage of it if they did, *in a way that would provide consumers with lower costs and better coverage* at the same time. The cost of health care and the profits of the insurance industry have been going up steadily, and more and more rapidly, since the 1950s.What is different now that all of a sudden there would be all these individuals wanting to sell health insurance and having a way to do that at a much lower cost while providing higher levels of coverage?
There's no real evidence there, either objective or historic, that this is going to happen. It sounds like wishful thinking to me.
On the other hand, there is abundant evidence — from our own experience and that of all the many other countries that have nationalized health care systems — that a government-funded health care system *can* work, and almost certainly *will* work *much* better than what we've got now.
Oh, for crying out loud. Either they're making obscene profits or they aren't. You can't claim both that they're making out like kings and that prices wouldn't drop with more competitors willing to make out like only dukes or barons.
The truth, of course, is that your conspiracy theories are wrong. Insurers are not making obscene profits that have been getting ever lewder since the 50's. Their margins are 4 or 5 percent, and they have to deal with a ton of crap to get that. They're getting squeezed hard between doctors and hospitals whose costs mysteriously keep rising, government insisting they turn into charities to help the less fortunate, and paying customers already reeling from sticker shock. Competitors are not flooding into the insurance market because it's a lousy one.
The providers are the ones that matter, they're the source of the relentless cost increases. They can improve, but it will be a long process. And the longer we keep shielding them from competition, the longer the process will be. Shall we start now, or would you rather wait another decade or two?
You can't claim both that they're making out like kings and that prices wouldn't drop with more competitors willing to make out like only dukes or barons
I didn't claim that prices wouldn't drop with more competitors willing to make out like only dukes or barons. You put that qualifier in, that wasn't me, Dr_J.
Your compassion for the suffering of the insurance industry is touching. Perhaps they would feel less squeezed if they were not spending millions of dollars a year on high-priced lobbyists and campaign donations to make sure that Congress never passes a publicly funded health care option that would then deprive them of the incredibly meager profits they do manage to scrape by on.
Compassion? As you may have read, I'm a deranged right winger without two compassionate cells to rub together. I certainly have no love for insurance companies. They're a low-value-add middleman between us and the people who really matter, and I tirelessly advocate reforms that will knock them off their perch as grand gatekeepers of everyone's health care.
I just think we're better off designing reform based on facts, and the fact is insurers aren't sitting on a pot of gold. Reform that's based on looting it from them is a mistake that will cost lives.
Kathy,
You've rightly pointed out that I've made some assertions that I can't necessarily prove, although I believe they are logical conclusions to draw based on market forces.
So let's return to the public option that you believe will significantly lower cost, and use as evidence other countries that have government funded systems. Do you agree that the primary cost-controlling mechanism in the public option is the government leverage that would be used to force providers to accept lower payments? Do you agree that if we use government leverage to pressure health care providers into accepting lower payments, we will have less health care providers? How can that not lead to less access to health care?
In those other countries, there is rationing. Just ask an MS patient in the NHS: http://www.dailymail.co.uk/health/article-96702… (this hits somewhat close to home as I have a member of my family who I believe is on this drug–fortunately in the US). Could this happen in the US with an insurance company? Of course, but at least then the company suffers the consequences of poor customer satisfaction: less future customers. Even if you are right that these countries provide “basic preventive health care to all their citizens at much lower cost than the free market does in the U.S.”, but what happens when someone needs more than that basic level of care?
As for your continued assertions about excessive profits, I'll point you to this article (http://www.kaiseredu.org/topics_im.asp?imID=1&p…) which actually has a lot of good unbiased information in it about the cost of health care. Take a look at the pie graph that shows where health care dollars are spent. I assume the excessive profits of insurance companies are within the “Program Adminstration” section of the graph. So let's assume we can magically drop that to 0% without any negative consequences (since, as I'm often told, insurance companies don't offer any meaningful “product”). We'd still have a long way to go, and we can no longer go after insurance company profits. So the only way from there is to either pay doctors and hospitals less (thus increasing the supply problem), or we make the system more efficient as Dr. J suggests. The public option takes the former path, while market-based reform would favor the latter.
It all comes down to whether or not the Democrats want to hold power or pass their healthcare reform bills more. If they want it they can have their public option until 2010 by using reconciliation. Of course that increases the chance they will lose the 2010 election and the 2012 one. Thing about reconciliation, is that anything passed with it automatically ends with the next election. So they can have it for a year, maybe 3 if they can hold on in 2010, but likely not much longer.
Both Kathy and GD raised a point about my previous comment regarding Ezra Klein making a dishonest argument. I admit I don't know his thoughts, but he seems to be quite intelligent and I believe that such a person would know that some people use the word 'rationing' to be a shorthand term for 'government rationing' (in fact some economic texts would use it that way or as a term which encompasses all other means of distributing scarce resources besides the market/price mechanism.) And since anyone who realizes that there are two different ways of using the term can choose to either see the people arguing about government rationing and respond to that concern with valid arguments, or could instead choose to try to diminish the intelligence of the opponents' arguments by assuming the form of the word which would make their argument nonsensical, I do think that Klein and others are probably doing the latter, deliberately. That's my opinion- your mileage may vary.
Also, note that I didn't feel the need to criticize Bailey for also making dishonest assumptions because that's what Klein already argued, and Kathy agreed. I was responding to those claims basically with the flip side, and pointing out that Klein's not necessarily arguing in good faith here either.
Kathy also mentioned that Klein has made the case in other articles of why govt based rationing would not be any worse than what we currently experience under price based rationing, but I have not seen that case made convincingly. I don't read his articles every day and if anyone cares to point out examples of good arguments he's made to that effect, I would be happy to read them.
Those doctors and hospitals accepting medicare's lower payments make up the loss by charging more to patients with private insurance. When the government plan drives the private insurers out of business, the doctors will have no one left to charge to make up the loss and many will go out of business.
Yes, Kathy. Clearly, anyone who is offended when you called them belligerent, paranoid, pathological, and demented is being blatantly unreasonable. You alone are blameless in all things.
As anyone who has been reading your posts on health care can attest, the truth is that you are persistent in name-calling people you disagree with, misrepresenting what they did or did not say, and impugning their motives by accusing them of being bought by the insurance industry. I don't object to the fact that you disagree with me. I object to the fact that you are seemingly unwilling to disagree with anyone about anything without always becoming abusive and dishonest about it. That's all.
I really don't think that criticizing this pattern of yours should be intolerable. It would be an easy choice for you to modify your approach and it wouldn't require that you alter your substantive views one whit. While it may be hard to tell from what currently dominates the political discourse, it IS possible to oppose single-payer and/or “public option” health care for reasons other than stupidity, racism, and/or corruption.
And to preempt, I should point out that the fact that I may also be guilty of being overly sensitive or abusive or just an all-around horrible person doesn't excuse it from you. Most of your fellow writers at TMV seem capable of expressing a wide range of views on health care without embracing an abusive approach. Even if you continue to have contempt for anything I might say, why not try learning a little from them?
My wife's experience with breast cancer (which did happen, but thank you for calling me a liar) has given me more complex views on the American health care system than can be encapsulated by the talking points from either of the purist extremes. But clearly that sort of viewpoint is thoroughly unwelcome in your simplistic black-and-white Manichean world. On a large site like TMV, you have a big platform. It is tragic that you insist on abusing it.
Actually, that's not the case. If it were, the fault would be with insurance companies, unable to negotiate the best prices. Look at Wal-Mart's $4 prescriptions. Medicare could do that if the GOP had not legislated AGAINST their ability to negotiate lower prices. You can argue that WalMart is causing drug companies to overcharge everyone else, but so what? Do you like the free market or not? Medicare is just a big buyer, and their vendors, or potential vendors, including doctors, hospitals and drug companies, are free to refuse their price and sell their wares elsewhere.
As for Medicare cost-shifting on hospitals, one study found a 0.4% to 1.7% increase in private payments in response to a 10% reduction in Medicare and Medicaid fees.
Clearly, anyone who is offended when you called them belligerent, paranoid, pathological, and demented is being blatantly unreasonable.
I called you those things AFTER your unprovoked, irrational attack on me, Jason. This comment, above, makes even less sense (if that's possible) than that initial comment. You are telling me you have a right to be offended by my response to your being offensive to me? Out of nowhere and for no rational reason?
My wife's experience with breast cancer (which did happen, but thank you for calling me a liar, especially about something like that!) has given me more complex views on the American health care system than can be encapsulated by the talking points from either of the purist extremes.
I did not call you a liar, Jason. You attacked me for writing the following: “Because that breast cancer victim could be me, or my daughter, or a close friend, or another congregant in my synagogue, or my next-door neighbor.” You responded to that sentence, exactly as though it were somehow a direct personal attack on you and/or your wife, “No Kathy, she's my wife. But I resent your continuing efforts to use her and people like her as vehicles to demonize everyone who disagree with you.” And in response to THAT, I wrote, “No, Jason, she's my grandmother.”
Which, as even you should be able to see, clearly and explicitly echoes YOUR language in your initial attack on me. So if you perceive what I wrote as accusing you of lying, Jason, then plainly you accused me of lying about the reality of breast cancer as a threat to all women, including my grandmother, who died from it.
In point of fact, Jason, your wife is not the only woman in the world who has, or has had, breast cancer. In fact, my grandmother DID have breast cancer. In point of fact, as I wrote above, my grandmother DIED of breast cancer, Jason. A fact I did not mention until you told me, in effect, that your lock on the truth about health care reform is unassailable because YOUR WIFE has or had breast cancer. I understand your wife has breast cancer, Jason, and as a matter of fact I expresssed sympathy for that fact in another thread about this topic some months ago. I am not inclined to do that anymore.
Every American has reason culled from their own experience to have that “more complex” understanding of what is wrong with our health care system as you do, Jason. In addition to my grandmother having had breast cancer, my father committed suicide when I was 28, as the result of severe clinical depression, which in 1978 was not being treated or was not understood as well as it is now. My first child died of Tay Sachs disease shortly before her 4th birthday. If it had not been for the existence of a hospice unit within a larger hospital for children with chronic diseases, which operated on Medicaid guidelines regardless of ability to pay, we would not have been able to get the care for her or the support for ourselves that we needed.
I myself have been without health insurance for years. What that has cost me in terms of my health could very well be incalculable. But oh yes, I understand, Jason, only you, because your wife had breast cancer, can possibly have that “more complex” understanding of what is needed to reform the health care system in this country.
Why you should take personal offense at my writing that it could be someone I know or am close to that has breast cancer is beyond my powers of understanding, but understand this: It is your words that were and are abusive and irrational, and not mine. And as much as I hate having to engage in intemperate conversations in Comments, I will NOT allow you — or anyone — to abuse me. Disagreement, even strong disagreement, is not the same as abuse. You, Jason, are either incapable or unwilling to disagree without being abusive. I will not sit back and take it in silence.
Kathy,
For at least the tenth time, not every criticism of you or disagreement with you constitutes an “attack” on you. Perhaps if you begin to differentiate between criticism, disagreements, and “attacks”, you will be less prone to respond to almost every single disagreement or criticism with unwarranted aggression and hatred. You might even (gasp!) find that there are some people who disagree with you who are, at the very same time, decent human beings in spite of that fact.
As for the breast cancer and health care discussion, I never once claimed to have perfect knowledge or absolute certainty on the subject. That claim is totally an invention on your part, part of a continuing pattern of your completely misrepresenting what other people do and do not say. If you were to go back and review both yours and my posts on the topic, I think you would find that I consistently am calling for a two-sided discussion and am specifically acknowledging the legitimate arguments on both sides while you, on the other hand, are posting consistently one-sided assertions that do little more than claim the non-existence of counterarguments while impugning the motives of anyone who might dare to try to make a counterargument. You are the demagogue on this topic, not I.
I acknowledge the legitimacy of your perspective on the issue as someone who has struggled with seeing a loved one suffer from a fatal disease and as someone who has struggled with lack of health coverage. I do not concede that gives you absolute or transcendant moral authority, however, so as long as you insist on being kowtowed to as a prerequisite for civilized discussion, I will have to continue to disappoint you.
If you want to have a debate that focused on the legitimate arguments on both sides of the health care debate while dispensing with the demonization, misrepresentations, and name-calling, that would be outstanding. But then again, that would require that you move past the easy talking points to actually discuss details and trade-offs, and I understand that is something you find unpleasant and/or difficult. So once again I will suggest that even if you continue to have nothing but contempt for me personally, you look at some of your fellow bloggers for examples of how to disagree in a civil way.