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.

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.

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.

The literature provides estimates of the extent of cost shifting in cases where it is theoretically possible. The March 2009 MedPAC Report to Congress: Medicare Payment Policy (Chapter 2A) includes a summary of such evidence. It concludes that the dominant dynamic in the market is that hospitals with strong market power have abundant financial resources. In turn they have a high cost structure (perhaps due to provision of relatively higher quality care) that causes lower or negative Medicare margins. In contrast, hospitals that are forced to run efficiently are adequately funded by Medicare payments. That is, Medicare payments are sufficient to cover costs but some hospitals run inefficiently and make it appear otherwise. Therefore, MedPAC has concluded that increased Medicare payments to hospitals would not reduce rates charged to private insurers. The primary effect would be to induce lower cost operations.

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.

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.

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.

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.

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.

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.

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?

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.

It is obvious that if pressure is put on providers to lower their prices, there will be fewer providers.

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).

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.”

This begs the question, however. You're assuming that there would BE a “plethora of choices.” Why do you assume that? On what evidence?

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.

“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.

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)

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?

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.

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.

Medicare (which uses its power to implement cost controls which hurt providers, as the public option would).

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?

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.

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.

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.

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.