Liberty, Community and the “Blue Beast”

A very liberal colleague of mine opined recently on Facebook if God was more concerned about budget issues which in his view only affected the rich, or in making sure that health care was expanded.

I tend to think that most of my pastor friends, who tend to be liberal are thinking the same thing. They tend to believe that making sure that people have health care is not only the moral thing to do, but it is something God requires of all people and damn the cost. For them, this is an issue of justice, not economics.

While I share some of their concerns about the lack of access to health care, I do think that budgetary concerns are an important issue. They can’t be the only issue, but they are important. If we enter a Greece-style situation, then we will have to slash all these domestic programs we have enacted, but never truly funded. It’s far better to make sure these programs are sustainable in the long run instead of whistling past the graveyard.

What this comes down to is what economist Greg Mankiw notes as a trade off between equality and efficiency or between liberty and community. Neither side is necessarily bad, they are just two ways of look at American society and government. Liberals have always concerned themselves more with equality and community. This explains why they were so adamant on health care. Having millions of Americans with no access to health care and millions more in danger of losing it, is something that Democrats can’t tolerate. In their view, this leads to a breakdown in community. Conservatives tend to focus more on efficiency and liberty. Conservatives wonder about the cost of something, especially a government program. They worry about debt and dysfunction (or at least they pretend to worry). They see government as something that can intrude up liberty.

I grew up with parents that took the equality and community issue to heart and some of that remains with me to this day. But I also believe in efficient programs and gives its people a modicum of liberty.

As David Brooks notes today, the Democrats have it in their DNA to ensure community via a social welfare system, with near-universal health care as the crowning achievement. But when it comes to efficiency, someone else is going to have do the dirty work:

The task ahead is to save this country from stagnation and fiscal ruin. We know what it will take. We will have to raise a consumption tax. We will have to preserve benefits for the poor and cut them for the middle and upper classes. We will have to invest more in innovation and human capital.

The Democratic Party, as it revealed of itself over the past year, does not seem to be up to that coming challenge (neither is the Republican Party). This country is in the position of a free-spending family careening toward bankruptcy that at the last moment announced that it was giving a gigantic new gift to charity. You admire the act of generosity, but you wish they had sold a few of the Mercedes to pay for it.

Brooks is taking on something that writer Walter Russell Mead has talked about in the past: taking on the “Blue Social Model.” Mead describes it as such:

In the old system, both blue collar and white collar workers hold stable jobs, a professional career civil service administers a growing state, with living standards for all social classes steadily rising while the gaps between the classes remain fairly stable, and with an increasing ’social dividend’ being paid out in various forms: longer vacations, more and cheaper state-supported education, earlier retirement, shorter work weeks and so on. Graduate from high school and you were pretty much guaranteed lifetime employment in a job that gave you a comfortable lower middle class lifestyle; graduate from college and you would be better paid and equally secure.

Life would just go on getting better. From generation to generation we would live a life of incremental improvements — the details of life would keep getting better but the broad outlines of our society would stay the same. The advanced industrial democracies of had in fact reached the ‘end of history’: this is what ‘developed’ human society looked like and there would be no more radical changes because the picture had fully developed.

Call this the blue model, and the chief division in American politics today is between those who think the blue model is the only possible or at least the best feasible way to organize a modern society and want to shore it up and defend it, and those who think the blue model, whatever benefits it had in the past, is no longer sustainable.

In many ways, the health care bill that has just been signed into law is part of that blue social model. It’s a holdover from the glorious days of the blue social model in the 50s and 60s. However, like the introduction of Medicare Part D before it, the health care bill enters a new age where the model is breaking down.

Mead argues that we can’t expect the blue beast to keep going forever. Government as he notes, is breaking down:

The real crisis today is the accelerating collapse of blue government. It’s a colossal, multi-dimensional meltdown that affects our lives and our politics in many ways. Today there are three elements of the blue government meltdown in particular worth mentioning.

The first is the government’s role in providing the benefits associated with the blue system. When we talk about ‘runaway entitlement programs’ today we are talking about commitments by the government to provide retirement and other social benefits that originated as part of the blue system social contract. Workers could retire as early as 62 with a combination of Social Security, private pensions and, as of the 1960s, Medicare coverage. These costs are now exploding and it is clear that the government can’t pay them into the future.

The second crisis is that the government is now the last true-blue employer in the country. Federal, state and local governments are often staffed by lifetime civil servants, whose jobs are protected by law and by some of the last truly powerful unions in the country. That means it is incredibly expensive for governments to do anything at all, and they are poorly equipped to respond nimbly to the fast-changing conditions of America today. The cost problem is aggravated because quasi-governmental sectors of the economy (like the health and university industries) are also by and large pretty blue: high wages, stable employment, cumbersome procedures — and powerful unions. Government is simply too unproductive, too unresponsive and too expensive to do what needs to be done at a reasonable cost. (Government also still has the anti-consumer mentality of the old blue monopolies: if you don’t like the crappy services government provides — move.) Public schools are increasingly expensive to run, and yet they do not provide improved services to match those exploding costs.

Finally, culturally and intellectually, bureaucrats and politicians often remain blue. That is, they think instinctively in the old ways, come up with blue solutions to non-blue problems, and often fail to grasp either the constraints or the opportunities of the new era.

That said, people rely on many of the programs of the blue social model like Social Secruity or Medicare. Since these were programs that were created by the Democrats, the breakdown of the blue social model or “blue beast” affects the Democrats greatly. Mead notes, the people know that the model is going away, but still see the importance of said programs.

So what do we do?

I think for Republicans, we have to find a way to support these “blue” programs with some innovative “red” thinking. Red thinking does not mean repealing the new health care law. The fact is, most Americans want some form of health care protection. As the reforms take place, most of us, including myself, will warm up to the new plan. But the fact is, we can’t afford the plan in the way we could back in 1958 or 1963.

This is where the conservative penchant for efficiency comes in. We have to find ways to get the best bang for the least bucks. As Brooks notes, it means having to add consumption taxes, and cutting benefits for the middle and upper classes. It probably includes other things no one has even thought yet.

It’s time for the GOP to grow up and deal with the situation at hand. We lost our chance to stop this bill, but we now have chance to make it better and more efficient.

Crossposted at Republicans United

Author: DENNIS SANDERS

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33 Comments

  1. “It’s time for the GOP to grow up and deal with the situation at hand. We lost our chance to stop this bill, but we now have chance to make it better and more efficient. “

    Goodness, where did you come from and why aren't you head of the RNC? This attitude would go very far in bring the GOP back into the good graces of the American public.

    Repeal or Fix….sadly I think you are in a serious minority.

  2. Actually, the “repeal it” theme the GOP warned they would be beating up Dems on, is already over.
    http://voices.washingtonpost.com/ezra-klein/201
    And the oft-repeated GOP meme that Dems were going against the will of their constituents has also evaporated, as polling now shows (surprise!) public support (50% to 42%) for having passed the bill.

    Otherwise I appreciate the good laugh from this shamelessly partisan post. Oh yeah, Republicans are for efficiency and consider costs. Wrong. They're for deregulation, privatization and cutting social services, which increases wealth gap, privatizes gains and socializes debt. They are responsible for nearly all of the national debt because of their fiscal irresponsibility, and even with health care, as in Medicare Rx program, they both failed to assess the costs, and to pay for them.
    http://zfacts.com/p/318.html
    blech

  3. Lets not dump all Reps into the same barrel. This new law needs tweaking and we can take good ideas from everywhere.

  4. What nonsense!

    Sorry, but really…

    The article started out great. Dennis quoted some devastatingly accurate critiques of the HCR as a representation of the last dying gasps of the New Deal ideals which created a Big Blue model for solving social problems, a model which worked when we were flush with cash and had a much more stable society, but now is completely unsustainable.

    And then you guys think the take home message from that is that the GOP should do the responsible thing and figure out how to do the impossible task of fixing the Big Blue programs?

    The whole point is that we need to figure out a new design for fixing these problems, because the old models aren't working for us anymore. Sure, it's true that the GOP can't just repeal the new law, and can't neglect to find new ways to fix our societal problems. But the articles quoted just explained how and why the Dems' HCR is fatally flawed, so why would the GOP attempt to work on fixes that aren't possible?

    On that note too, I think Dennis misreads Brooks about the taxes that would be necessary to pay for all of this. He wasn't exactly suggesting that favorably, I don't believe (if he was, then he's off of his rocker too.)

  5. “impossible task”
    “Dems' HCR is fatally flawed, so why would the GOP attempt to work on fixes that aren't possible?”

    The new law isn't going anywhere. At some point people are going to have to stop being so terribly negative and start being constructive. Yes, developing new models and ways of thinking is very important, but you should realize that HCR is here to stay and that our best bet is to modify reform into these new models, once they are developed, but still keeping the intent of trying to provide health care for all Americans.

  6. They could try to fix problems with technology and de-couple the dependency culture. For instance, sorry to all that have heard me say this a 1000 times, they could buy water makers for people in need for a one time cost of around $1k or we can continue to pay water bills every year distorting a market that if filled with people that can't pay on their own would not exist without gov intervention. And we will have gov intervention because if the GOP refuses to Dems will be voted in…it would be lovely for the more ideological among us if that were not true but that is reality. Similarly instead of food stamps, that also distort local markets often creating stores where they should not exist since the populace cant support them without gov assistance, we could bring back family style soup kitchens which would also be cheaper and stop distorting the local market.

    If the GOP would find other answers to our problems I would likely start voting for them again but instead they either want to tinker around the edges cutting funding but not the programs, which by the way is why gov often runs so badly under GOP rule it is not incompetence its lack of funding, or they want to burn it all down and let god sort it out since this will be a boon for local business both the prison and those replacing stolen items kind.

    Do not tell me why people deserve punishment, or their “lot” in life. Do not tell me its not your burden because #1 many of the things you support, military/prison industrial complex and the laws that enable them and the empire they control, I do not and I do not want to be weighed down with that burden either so either we make a deal or neither of us get our way and #2 regardless of what I am now I was raised a christian and from my view you are wrong…it is your burden.

    Give me answers, new ones, inventive ones, at least act like you care about your fellow Americans and not just their souls. Do not attack the poor because they are my fellow citizens an attack on them is an attack on me, find ways to help them instead of brow beating them and note how much they improve. Backing health and education funding to me is conservative because it invests in the sectors most likely to benefit as many as possible to keep the US competitive, but ANY ideas are acceptable…just stop telling me you are going to cut gov…because you ARE NOT GOING TO. The most you will ever do is cut one needed program and shift its funds to one you favor that likely is owned by one of your campaign fund contributors, conservatives have taught me well to not believe pols. I know the Dems will give me corporate answers to my problems the issue is that the GOP gives me corporate answers to corporate problems while they destroy the answers to my problems(the only ones that have been offered) and replace them with nothing…except new corporations ready to charge me 5 times as much for the same result with no guarantee that it will fix what ails me. Buyer beware is a great motto but it does not work in all fields without causing major social upheaval.

  7. the conservative penchant for efficiency

    Well… that might have been the old GOP, but not much evidence it applies anymore.

    it means having to add consumption taxes, and cutting benefits for the middle and upper classes

    Not sure how that would square with the anti-tax mantra the GOP is wedded to. As for cutting benefits for the upper classes, that seems to go against the GOP grain too.

    It probably includes other things no one has even thought yet.

    I sure do believe that. Is Washington really capable of thinking that far outside the box though?

  8. We can't do the things the bill does, in the way that it's been constructed, for less money, yet we don't have the money (and no sustainable source to get the money, even if all of the wealthy people were taxed at 100%.)

    How in the world do you fix that?

    I'm sorry to be so terribly negative, but they've made a terrible law.

  9. “it means having to add consumption taxes, and cutting benefits for the middle and upper classes.”

    Clearly you have no idea what “efficiency” means.

    These things might be important for balancing the budget, but they aren't efficiency measures.

  10. TheMagicalkyFather:

    Thank you for boiling down an issue that has been “misportrayed” as political, as fiscal, as ideological, etc. to what it really is: an issue about our humanity, about who we are.

    You are so on target!

  11. We develop new cost reduction models. We have to reduce costs. Maybe we need to move our scientific focus toward cost efficiency.

    We can take skin and turn it into beating heart cells….I think we can develop better ways to provide health care.

    I think Mikkel is working on something big in this area….although he isn't ready to tell us what it is quite yet :)

  12. I completely agree that that's the direction we need to go in but the question is whether or not any of those things could create enough increased efficiency, in a short enough time period, to pay the tab for the new law- and I think the answer is clearly no.

  13. I second Dorian's comment, nice job of cutting through the bs!

  14. 1. Dorian, note and file the following. Consider it in light of an eventual federalization of the Blue Cross Blue Shield system as a public non-profit “competitor” [holding straight face], even more than what it means as far as our eventual shift to Medicare first as our model, then eventually to the VA system.

    http://www.washingtonmonthly.com/features/2005/

    2. Now that they're past the GOP obstruction,

    Will the Blue Beast run rampant the rest of the year?

    That is the serious question on serious minds.

  15. “We develop new cost reduction models. We have to reduce costs. Maybe we need to move our scientific focus toward cost efficiency.”

    This hasn't gone unnoticed, Shannon. You can find examples of US medical literature going back at least as far as the 1980s that are concerned with costs and cost-effectiveness. (This is aside from greater kinds of issues like “appropriateness” and “futility” that have to do with more “strategic” views of allocation of scarce medical resources, though it's related to costs and their control.)

    I can tell you that my own experience with my pre-existing condition includes what many don't know, that insurers look to Medicare as a precedent-setter (and informal federal government seal of approval of forms of treatment or therapy, that the private insurers can refuse to pay for until Medicare approves it, if for no other reason than a handy legal and logical excuse for rationalization of denial of care to reduce expenses), and Medicare is sometimes (as in my condition's case) almost obscessed now with costs, already.

    Currently there is a well-known change to treatment for my condition that everyone with a brain knows is better, didn't neven need the study results to show it. Studies aren't just being done to prove the treatment is better. Ordinarily you might think that's all it takes, and the change should be made (after all, we can reduce costs to a minimum by ending all treatment, and all expenditures. Reduction to absurdity). But what has Medicare obscessed currently is the need to show that the change, which instantly doubles the cost of all disposable items and probably doubles the cost of labor [GULP] instantly, to, needs to show in the improved health results a related reduction in other costs of patients — which means reduced incidence and costs of hospitalizations, associated costs of related morbidity, and so on. In other words, the better treatment is not going to be approved by Medicare unless it is shown to be cost-effective, that the increased (doubled!) costs are matched or exceeded by reduced other costs associated with these patients. (And the insurers are not going to cover the improved, more costly treatment until Medicare does.)

    In other words, cost-effectiveness already has a long history in medicine and is more important than ever now.

  16. “whether or not any of those things could create enough increased efficiency, in a short enough time period, to pay the tab “

    That's the emphasis on cost-effectiveness we're currently seeing, and a criterion already for approval of some up-to-date therapies.

    Meanwhile, at the same time, this has been laughably neglected, stupidly so. For example, Medicare will pay for kidney transplants, but only pay for post-transplant immunosuppressants (to keep the organ alive!) for just 36 months (three years). The #1 reason for graft failure is rejection from failure to adhere to the regime of immunosuppressants, and the #1 reason for that is Medicare's termination of coverage after 36 months. Dialysis costs so much more as well as being poorer quality of life and effectively causing more complications, morbidity, and hospitalizations(!). Note that the policy is the opposite, the reverse, of being cost-effective! It deliberately costs more (and has other defects). Yet that's Medicare policy, still, today.

    And of course, intelligent resolution of issues like this is nowhere close to what was on the agenda for this “reform” legislation, and nobody with a brain expected ObamaCo to be concerned about such issues.

    * * *

    “Do not attack the poor because they are my fellow citizens an attack on them is an attack on me, find ways to help them instead of brow beating them and note how much they improve.”

    That's not just true with domestic policy (hopefully mass layoffs and capricious and venal behavior by many executives have made a number of people reconsider at least the idea they could be joining the ranks of the unemployed, and the poor, too) but with foreign policy. Leaving aside the issue of freedom of trade and globalism, this involves notions of not only altruism and other-ism but related ideas like the extension of communitarianism (to name one contemporary item) to the “world community.” This is related to what was on an earlier thread about various political philosophical topics.

    (Back to medical care, on this thead, I suppose…)

  17. “nobody with a brain expected ObamaCo to be concerned about such issues”

    Smiles and votes are what matters to the current people behind health “reform.”

  18. People outside of the health care insurance industry can make a lot of money designing new cost savings processes. The free market is good for some things :-P

  19. “In other words, cost-effectiveness already has a long history in medicine and is more important than ever now.”

    That is very true, but I think the current shortage of scientific funding and focus on clinical applications have forced biomedical scientists on all levels to rethink how they do science or at least the processes they create in order to develop new techniques. “Research funding doesn't grow on trees….maybe the money needed to pay for my super cool widget may not grow on trees either.” Thinking in terms of cost effectiveness at the beginning of new science may in the long term drastically decrease the cost of new procedures.

    I wonder how much your quality of life improvement is factored into all of those fun numbers?

  20. “I wonder how much your quality of life improvement is factored into all of those fun numbers? “

    My quality of life is diminshed by the current numbers and waiting by Medicare.  I'm disappointed (and worse) but not surprised.

    * * *

    “the current shortage of scientific funding and focus on clinical applications have forced biomedical scientists on all levels to rethink how they do science or at least the processes they create”

    Research has been neglected.  I'm not so much concerned with the inability to perform effective miracles and meet the unrealistic and silly expectations of stem cell fans, for example (who are lightweights who often are just being liberal activists bashing the Religious Right and other conservatives or Republicans primarily or exclusively, anyway, not acting on behalf of science any more than the “global warming” or climate change cult-religionists, who just hate the Right mostly, not seeking eco-socialism like the core practitioners).

    As I wrote elsewhere, for a non-related topic, the problem is the intellectual and other forms of drought that have developed.  (That's also a legacy of the later 1960s, to some extent.)

    Could we trust modern government and leaders elsewhere to lead us to the moon from scratch, today?  No.

  21. That sucks…and worse. It is sad to hear.

    I wouldn't be too hard are stem cell fans. There is a lot of really great working going on right now. Things are finally being pushed to clinic. The funding is being focuses on clinical applications. The science is getting there.

  22. What? Profit? Serving a function, to drive innovation and cost efficiency?

    Can't be…'cause profit's just what the greedy bastards skim off the top!

  23. I appreciate your frustration, but there ARE real problems when the GOAL of medical providers and intermediaries is not to deliver cost-effective health care, but to create “shareholder wealth.” I'm all for shareholder wealth, but in health care, our goal should be care, not profit.

    Two examples from the pharma side:

    Consumer Rx drug advertising. We're overdrugged, and these ads play on the fears and hopes (for erections, happy pills, etc.) to dive profits, rather than meet real needs. We don't need millions of consumers asking their doctors if they need the blue pill, the purple pill and the red pill. We need a system that assesses real patient needs and seeks a responsible solution.

    “New drugs.” So many of them are minor modifications of existing drugs that are going off patent. The old drugs are perfectly adequate and much cheaper, which is EXACTLY why a costlier new drug is developed and marketed. Not new needs, just new profits. Plus old drugs that haven't been pulled from the market are safer (over 50% of new drugs are withdrawn or restricted due to “post-approval” findings of safety problems that surface when new drugs are in wide circulation). New sleep aids, for example, cost 5-10 times what older generics do, are not needed by most patients, and have a 50:50 chance of being found to be so unsafe their approval must be revoked or altered. The older drugs have stood the test of time and the new “innovations” are often in profit making, not in benefit delivery.

    In fact, our entire drug R&D and approval process is custom made to favor only new, patentable, monosubstance chemical drugs, because that's where the profits are.

    Health care is a special case, because we are morally opposed -as we should be- to letting people die for lack of access to health care, hence we will pay for it one way or the other. We simply can't afford for the entire process to be geared toward drawing maximum profit from every step. This will become increasingly obvious. America simply can't continue to be the place where every procedure, drug and payment system is the most expensive in the world.

  24. You may be shocked, but I actually agree with most of that.

  25. In health care, our goal should be care, not profit.

    Except that proves to be ruinously expensive.

    Just yesterday I was on the phone about a mysterious $170 charge on a doctor bill I received. It didn't relate to anything that I remembered happening while I was in the office. What, precisely, was the charge for? The doctor's bookkeeper couldn't even understand the question, much less answer it. She assured me it was part of their “standard billing procedure.” I asked her to follow up with the doctor and get back to me. When she called back, the charge mysteriously disappeared.

    This doctor's office (and, I would wager, most others) is indeed putting care first. Ahead, unfortunately, of any sort of cost accountability. Why bother? Insurance companies will pick up the bills, and they won't know whether $170 of magic happened during my visit or not. Wackos like me on high-deductible policies are the only ones who might ask awkward questions, and there aren't enough of us to matter.

  26. Your example doesn't refute my point at all. When health care is just another profit center, the rule of caveat emptor applies. It's your responsibility to keep from being cheated, and their responsibility to get as much as they can.

    Though you're not a doctor, nor even play on online, you know about triage. We can't have it all. The cost is killing us. So we have to cut the least important things, those that don't directly contribute to care. We need to trim fat, not muscle and bone. All the things I have listed many times are at the bottom of the health care priority list, and hence my top list to cut.

    New insurance product development
    insurance, pharma and medical LOBBYING expense
    insurance marketing, sales, underwriting
    bloated claims denial departments
    excessive executive salaries, bonuses and perks
    corporate planes and cars
    resort conferences and retreats
    paying more than Canada for drugs
    protecting against negotiation by Medicare (and any other buyer for the public)
    consumer Rx drug advertising
    tax breaks for offshoring profits and jobs

  27. All well and good, GreenDreams, but how could any of that prevent the cost boondoggle I mentioned? No drugs, corporate planes, or lobbying were involved.

  28. DJ, I don't know the specifics of the charge you're talking about. Maybe error, maybe consumer fraud. If error, we need to do what we can to reduce errors. If fraud, prosecute or sue. But neither fraud nor error are the exclusive domain of either corporations or government. As for the idea that we all pay for health care directly, maybe that would help a little, but that's no panacea either. Even if it all came out of pocket, not everyone will catch an error or attempted fraud, just as they fail to scrutinize the tab at dinner, the parts list at the auto mechanic, or the hours worked and numbers of workers on a home improvement project. Same with providers. I doubt it is uncommon to miss an error when looking over dozens of extremely complex hospital bills every day.

    I know you believe in the magic of the market. In the case of health care, I don't, for all the reasons I list.

  29. My work involves processing a lot of data, GreenDreams, and there's a reliable rule that if you're calculating numbers no one looks at, they're pretty much guaranteed to be wrong. So it doesn't really matter whether you call my case this week error or fraud, the point is there is no mechanism in a single-payer or few-payer system to catch these problems. Can we agree on that?

    Then the question becomes how big a deal such boondoggles are. It's a tough one, because by definition no one is tallying them up. I suspect they're ubiquitous–a vastly larger problem than all the corporate jets combined. Every single health care transaction I have costs more than it seems like it should, from the $75 bottle of pills to the $150 for a 10-minute conversation with a doctor.

    I know you don't think consumers can negotiate these costs down, but I will again point out that they do in every other industry, and I managed successfully this week. All it took was a phone call.

  30. DLS's link demonstrates a lot of the problems with our current patent laws, and that's why in the example you gave, GD, market forces don't work. The patents prevent competition, so we're not talking about failure of the free market, we're talking about failure to allow a free market.

    I'm not in favor of abolishing patents altogether but it's an area where clearly reform could be applied.

  31. See how wrong I can be? I figured you would use this case to justify the high cost of the claims denial department, whose job it is to catch and deny such error or fraud. If the magic of capitalism can't even get a company to reduce fraudulent or erroneous “medical losses” that exceed the cost of their corporate jets, then there truly is no cost containment to be found in the for-profit model. Indeed, I thought that WAS the “mechanism” that was supposed to catch these problems. This was touted in the “Medicare fraud” flap, in which government bureaucrats were alleged to be incompetent compared to the profit-driven free market insurers. The argument was that bureaucrats don't care, it's not their money, but profit motive drives private insurance to rigorously root out waste and fraud.

    I'll tell you where we do agree. Everything costs too much. I also agree that competition could reduce costs, but probably not the competition you mean. I think we should be able to buy American and European made drugs anywhere, so the global best price becomes the price WE pay, not the penultimate price. Same with other costs. (A CAT scan in Japan costs $98).

    But in many cases, the consumer, er patient, cannot negotiate, even in advance. You think I can go to a hospital and say “if I ever need the ER, I'm paying the Walgreens price for bandages, not what you charge?” Or “say, doc, I want a 20% discount on office visits or I'm going elsewhere.” If it did work (it won't) the prices of every medical need would be like an airline ticket. You sit in a seat you paid $75 for, right next to someone who paid $800. And not assessed by need or ability to pay, but by negotiating skill. This just doesn't strike me as a realistic suggestion.

  32. The argument was that bureaucrats don't care, it's not their money, but profit motive drives private insurance to rigorously root out waste and fraud.

    That has never been my argument. Insurers both private and public, both here and in Europe, have failed to drive cost efficiencies into providers. They will never succeed. Which is why I.keep calling for a smaller role for them.

    I think we should be able to buy American and European made drugs anywhere, so the global best price becomes the price WE pay, not the penultimate price.

    I certainly agree about that. So let's ease up on the import regulations, FDA rules, and government subsidies that create the inequity.

    You think I can go to a hospital and say “if I ever need the ER, I'm paying the Walgreens price for bandages, not what you charge?”

    Not today. But imagine it was your own money you were spending, you had a choice of hospitals, and you could find online lots of data about their relative strengths, their outcome histories, their prices, patient experiences there, how reasonable people found their billing practices, and so on. You'd know ahead of time where you were going to be charged $100 for an ace bandage, and you'd be able to shop around.

    Of course, we have nothing like that sort of transparency today, but there's no reason we couldn't. By itself it doesn't solve the problem, though. We would also need consumers to actually care about the costs.

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