health care musings

Erik Kain

Erik writes about video games at Forbes and politics at Mother Jones. He's the contributor of The League though he hasn't written much here lately. He can be found occasionally composing 140 character cultural analysis on Twitter.

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78 Responses

  1. greginak says:

    This may come off as cranky, but I think discussions of various theories are irrelevant and pointless when there are real life examples of how to set up a health care system. If these problems happen in some of other countries that have national health care, then describe that. Theory is great and all that but reality rules and should be the arbiter of what theories work.

    “A truly free, deregulated health insurance market can work, but two things need to happen in conjunction with any deregulation of markets. The first is provisions for the lowest income brackets and for people with preexisting conditions; the second is a breaking up of the existing system, and namely the subsidization of big health insurance companies through untaxed employer benefits”

    This reads to me as, deregulation can work as long as there are regulations to prevent the business models of insurance companies from killing people. And health care companies are by there nature going to be big. It takes significant resources to provide insurance and the bureaucracy that goes with it.

    In reference to point 6, insurance companies don’t make money be providing care, they make money by limiting care. Their interest is not in preventive care. Why do you think they don’t want people with actual medical problems.

    Point 4- That’s why coverage has to be universal.Report

    • E.D. Kain in reply to greginak says:

      But I think there is a fundamental difference between regulation and safety net. A regulation seeks to modify or, er, regulate the actions and transactions within a market. A safety net supplies a buffer to mitigate risk and take care of those people who are inevitably left out of the prosperity of markets, or who fall on hard times, or who are ill or mentally ill etc.Report

  2. Travis says:

    As long as a provider’s profit margin depends on its ability to provide as little care as possible, the system will remain fundamentally broken.

    If the current insurance system is to be kept, I believe all participants should be required to convert to non-profit organizations. The people deciding what care will be provided should not have the conflict-of-interest involved in share prices, investors and stock options.Report

    • E.D. Kain in reply to Travis says:

      But Travis – wouldn’t a state-sponsored and rationed health care system also limit care? So doesn’t that argument work both ways?Report

      • greginak in reply to E.D. Kain says:

        Any health care system will limit some health care. It is an obvious and basic function of a care system. However profit margins, as a way of deciding how to ration care, of insurance companies has been found to lead to deadly practices and our current system.Report

      • Travis in reply to E.D. Kain says:

        A state-sponsored and rationed health care system would not be required to be responsive to stock prices and the quarterly earnings report, nor would it have to contend with the demands of shareholders clamoring for ever-increasing profit margins.

        It’s well-documented fact that insurance companies have offered bonuses to employees who find ways to deny claims based on the slightest technicalities. Why do they do this? Because the company’s first responsibility is to provide profits to its shareholders, not to provide health care to its policyholders.

        That is a broken, backwards and immoral way of rationing health care.Report

        • Mark Thompson in reply to Travis says:

          It is true that in the current system, health insurance companies make profits by denying care. This is because we have an employer-based health insurance system, though. Employers do not provide health insurance out of the goodness of their heart, though – they have little vested interest in whether the insurance company provides good service, only in whether they get a good rate from the insurance company for the type of plan they get. In other words, you have a strange situation in which the customer and the consumer are two different people with very divergent interests. Of course, the insurance company’s goal is to serve their customer just well enough that they keep that customer and remain able to get new customers – the end-use consumer is an afterthought at best.

          On the other hand, individual insurance removes this perverse incentive. An insurance company that develops a reputation for excessive denial of coverage is an insurance company that will soon find itself out of business.
          Other countries have individual health insurance markets that work fine; no other country has an employer-based health insurance market that works fine…in fact no other country has a significant employer-based health insurance market, period, to my knowledge.Report

  3. Jaybird says:

    Off the top of my head, I suspect that this could very well work… and it comes back to one of my fundamental questions when it comes to government regulation of a market segment:

    Will this create/contribute to a black market?

    Off the top of my head, I don’t see that it would be likely to.

    I think I could find reasons to not oppose this. Maybe even get behind it.

    Nice essay.Report

  4. Johnny Walker Purple says:

    ” only a healthy skepticism of the ability of the powerful to rule in the best interests of their subjects.”

    Yet you trust that the invisible hand will. Just substitute the word powerful for it’s synonym “rich” and you can understand why people are skeptical of libertarians.

    Also I find that it’s libertarian anarchists who are often idealistic. Believing that once you remove the state suddenly everything will work itself out perfectly.Report

  5. mike farmer says:

    I held back from joining in, because it’s the same old division regarding the evil rich and their dirty profits vs the representative government with no profit motive. It appears to me we are in a numbers game, because now we truly have a democratic process with a pratically unlimited interventionist government — so it will depend on whether the public can demand and get what they want.

    As long as our government is capable of taking over the healthcare system, there will most likely be enough people who demand universal healthcare, and it will be run by the government. They may start out offering a compromise between private and government, but government will take over eventually, just as it is virtually in control now. The people who blame the private market for the present screwed-up system simply can’t see the government’s role in these problems.

    The proponents for universal, government-controlled healthcare seem to believe it’s just a matter of shifting money and control to the government so that profits are no longer a consideration. But you are right, E.D., the government will be subject to the same financial pressures. There won’t be a board of directors demanding higher profits, but there will be a public which resists higher taxes. Government will be forced to choose between denying care to some or raising taxes. It’s a matter of trusting private companies or trusting government to come up with the best solutions.

    There are some who continue to say other countries are providing healthcate with no bad results, but we can’t compare the US with France or England or Canada — our government has military bases all over the world, we fund the World Bank and IMF, the UN — we give more than anyone to foreign aid — we have a much more diverse population with more and more immigrants coming in — we’re stretched thin and tapped out. Talking about reality — this is a reality.

    If we go the route of universal healthcare under government control it could literally collpase government and create a crisis in our economy that could take decades to turn around. Government is trying to control too many things and it will stifle private enterprise. There may come a day, soon, we beg the dirty profit-makers to start being dirty again.

    I’m afraid this naive reliance on government is going to put us in a very bad situation. I mean, just look at what cap and trade will do, if it’s passed — what is going on in this nation?Report

  6. td says:

    Why do we not have these same kinds of discussions about single payer police and fire departments?Report

    • Jaybird in reply to td says:

      Let’s say I wanted to become a fireman.

      What would I need to get my foot in the door? How much training would I need? How many people would I have to compete with to get there?

      Let’s say I wanted to become a policeman.

      What would I need to get my foot in the door? How much training would I need? How many people would I have to compete with to get there?

      Let’s say I wanted to become an internalist.

      What would I need to get my foot in the door? How much training would I need? How many people would I have to compete with to get there?Report

      • Bob in reply to Jaybird says:

        Jaybird, td ask about the single payer issue, not qualifications necessary for employment. Change the subject if you wish but you did not respond to the question.

        Countries with SP systems have high standards for employment do they not?Report

        • Jaybird in reply to Bob says:

          Well, let’s look at it this way. Medical care is expensive. Why?

          Price is a function of supply and demand, to some degree. If demand remains static and supply increases, that creates a downward pressure on price. If demand goes down and supply remains static, that creates a downwards pressure on price.

          I am not under the impression that we are experiencing anything approaching a “crisis” when it comes to a shortage of police or fireman at this point in time. (If anything, reading Radley Balko’s stories of the new police professionalism tells me that the police are looking for stuff to do rather than being overwhelmed.)

          Health Care, on the other hand, is experiencing a crisis… mostly that it’s far, far too expensive. We go back to our handy-dandy supply/demand formula. Demand is increasing (we agree on that, right?). Maybe supply is remaining static, maybe it’s increasing more slowly than demand is increasing, maybe it’s even decreasing.

          The point is, if you want to know “Why do we not have these same kinds of discussions about single payer police and fire departments?”, I’d look at the questions of supply and demand relative to price, and see if there is a supply/demand dynamic in health care that doesn’t also exist with police/firemen.

          As for what other countries can and cannot do… the question of “why can’t we be more like Denmark?” is a very interesting one. It probably deserves an essay in its own right.Report

  7. mike farmer says:

    well, although it’s been accepted among limited government advocates that police, military and courts are legitimate functions of government, there is no reason to not discuss private alternatives to any of them, and many libertarians have discussed these issues.

    But limited government is predicated on the idea that some collective needs such as police protection are better suited government management — however, extrapolating from that and saying heathcare should be under the control of government is not reasonable — they are two totally separate endeavors. Yet, we might find, if we experimented, that private protection agencies would suffice and actually do a better job, if contracted out locally with agencies competing for the contract. Who knows?Report

    • Travis in reply to mike farmer says:

      No, we already have an historical case study for what happens when you hire a bunch of private thugs, give them automatic weapons and let them run rampant.

      It’s called Blackwater.Report

  8. E.D. – Great post. And for what it’s worth, the question of deregulatory capture has been on my mind a lot lately, and is a big part of why, when I get the chance, I want to go full bore into that series on overcoming narrow special interests in the legislative and regulatory process.

    One nit to pick on preexisting conditions, and it’s probably not even a nit since I’m somewhat conflicted on it; still, it seems worth bringing into the picture.

    I think you definitely need to have a prohibition on preexisting condition limits at the outset. That said, since you propose a voucher system (which I think gets you to universal health care even without a mandate), once the change to the new system is complete, I think you may be able to drop the preexisting condition restriction. At that point, everyone has coverage, and they can’t lose their coverage just by switching jobs. The problem then becomes just that someone with a preexisting condition won’t be able to change to a different insurance company, but they still get to keep their old coverage. This is still a problem, obviously, but I suspect it’s not as large a problem as the additional costs to the system of mandating preexisting condition coverage. This not really an easily quantified tradeoff, though, and I’m not at all certain that I’m right. Plus, if you eased out the preexisting conditions prohibition, you would need to have some sort of safety net government program for people with preexisting conditions whose insurance companies go out of business.Report

  9. mike farmer says:

    In a private healthcare system unburdened by regulations, with no government favoritism to protect certain companies, within a society paying lower taxes, which has formed associations funded by private donations to deal with those who can’t afford coverage, you would have healthy competition and innovation which works to make healthcare coverage affordable — you would have a safety net to cover those who are in need — and you would have a dynamic market for healthcare, attempting many different strategies to lower costs, including reforming licensure laws, which would attract talent so that quality is assured.

    This is the ideal theory from a private perspective. Would it work perfectly? Nothing ever does. Could it work? Yes. Would we have to have a transition period to get out from under the consequences of government interference? Most likely — it all depends on which direction we choose — toward socialized medicine or toward private efforts. A mongrel solution between private and government, with the government still attempting to gain control, will not work, because government has the power of coercion and it will gradually gain more and more control.Report

  10. mike farmer says:

    BTW, I agree — great post, E.D.Report

  11. the other Patrick says:

    “…within a society paying lower taxes, which has formed associations funded by private donations to deal with those who can’t afford coverage, you would have healthy competition and innovation which works to make healthcare coverage affordable — you would have a safety net to cover those who are in need…”

    Why should anyone assume there would be associations funded by private donations? Why should anyone assume that there will be a safety net and that, should there be one, it would be sufficient? It’s a hell of a leap of faith to make. What if everybody just says “not my problem”?Report

  12. greginak says:

    Anything can work in the ideal situation. But we have a world where…you know…. various forms of national health care have already been proven to work that use either a mix of private and public or single payer style programs.

    What regulations do people think are such a burden and problem in the health care market???? I haven’t seen any examples just the generic complaints about regs.

    Where and how would all this wonderful competition develop in a deregulated system? To be an insurance company requires serious resources. Somebody can’t just open Sanford and Son Insurance Company out of their house. If we don’t have competition now why would all sorts of competition up? The market itself has moved to the situation where there is little choice in most areas and I don’t see how that is the governments fault.

    We all have our ideological predispositions. It seems at times some of us just throw out the fact government that is involved to explain why the free market doesn’t work. Well I’m not seeing it in this case. So , not in theory, but in practice, how do the government regulations, which have been implemented to correct the failings of the market, cause serious problems.Report

    • Mark Thompson in reply to greginak says:

      A few things:
      1. Looking to see “what works” in other countries must include the recognition that the reason particular approaches work in other countries is that they occur against the backdrop of those other countries’ overall systems.

      2. The biggest difference between US health care and health care in the rest of the world is that it’s employer-based because of our tax incentive system. Just like us, every other industrialized country (with the exception of Switzerland, which has a system similar to what ED suggests here) has some sort of combination of public and private, ie, some sort of two-tiered system. And let’s be very clear – we already have a mix of public and private health care, and almost no one is proposing that we go completely private with no government safety net whatsoever. However, that our system is employer-based is very much a result of government regs – especially the tax incentives. A solution that does not put an end to employer-based private insurance is a solution that will not succeed because it will be a solution that does not address the single most distinctive aspect of the US health care system.

      3. You’re underestimating the ease in which someone can start up an insurance business, particularly one with lower barriers to entry than currently exist. There are, in fact, quite a few small companies providing most forms of insurance.

      The bottom line, though, is that most of the systems that you would have us emulate rely to a not-insignificant extent on private insurance markets, which seem to work just fine. Expanding and improving our current public healthcare system ultimately needs to be done in conjunction with some sort of deregulation of the private system. But to say that the problem in the US is manifestly that the free market has failed ignores that the aspect of US health care that is most unique and most responsible for our system’s failures is directly attributable to a government intervention that exists almost nowhere else in the world.Report

  13. mike farmer says:

    Licensure regulations, not being able to buy insurance across state lines, a doctor not being able to charge a monthly fee, tax subsidies to employers when we’d be better off buying directly with a menu offering and having lower taxes individually, the list goes on and on. Healthcare is one the most heavily regulated industry in the US — without government interference, costs would likely be much lower. We’d still have the problem of those who can’t pay, but I trust voluntary benevolence. If our society knew it was up to us, and couldn’t rely on government to handle the problem, society would respond — there is no gaurantee — but we all know we would. That’s how statists scare everyone into submission — Oh, without the state, people will starve, die without healthcare, get no mail and drive on dirt roads. But if we choose to hide within the arms of Big Brother, because we don’t trust ourselves, then we’ll have to pay the price.Report

  14. greginak says:

    But how do those things account for the high cost of medical care. So we have licensing requirement? Do other countries not have licensing requirements for doctors or nurses? I think they do. Those requirements also help to increase professionalism and training.

    How does doctors not being able to charge a monthly fee lead to our high costs? Beats me. Buying health care directly??????? Huh…no really huh. What experiences have you had with buying insurance? Individuals have no bargaining power in the insurance market. Large companies or the government can get better rates. Why the hell would an insurance company ever insure an individual with health problems. They don’t make any money on people with health problems, that is why health insurance in purchased through large groups. Years ago my son had hundreds of thousands of dollars of operations and ICU care. I worked for a small mental health center and my sons care cost more then everybody else’s at the centers. If it wasn’t for the bargaining power of a group I would never have been able to get insurance. That is one of the biggest ways the insurance market is qualitatively different from other things.

    How does not being able to buy insurance over state lines lead to increase costs? There are only a relatively small number of giant insurance companies. Also see above.

    And just to be a pain in the ass. I can point to several examples of workable national health care systems with lower costs and good outcomes. Critics complain and criticize and throw at various theories.

    What was that quote, originally in regards to liberals I believe, about nattering nabobs of negativism.

    The opinion piece you linked= OMG OMG gov in bad ewww icky icky.Report

    • Mark Thompson in reply to greginak says:

      Greg: You keep reasserting this claim that individual health insurance would not drive down costs. As I’ve explained before, this claim makes little sense. There is remarkably little difference in insurance prices for large businesses versus small businesses because there are very few economies of scale in providing insurance. I believe I have previously pointed to statistics demonstrating this quite clearly. Instead, the relevant economies of scale are, if anything, the insurance company’s ability to negotiate prices with doctors and pharmaceutical companies.

      More importantly, however, as I’ve repeatedly pointed, employer-based health care ensures that the profit incentive for insurance companies lies in denying as many claims as possible rather than providing the insured person with good service. In an individual-based market, the company has to pay out its claims to stay in business because otherwise it will quickly find itself without customers. This is a significant part of the question of the system’s costs because denial of claims results in the patient paying for both the insurance premium and the procedure/medication. A system in which insurance companies had an incentive to pay out claims would be a system with much lower costs because you would not have so many people paying for both denied claims and insurance premiums.

      Again, we are just about the only country with employer-based private health insurance. We are not by any means the only country that relies as much as we do on the private sector for health insurance – indeed, both the Netherlands and Switzerland, to name two, rely far more on the private sector. To say that the cause of our system’s high costs is a result of our reliance on the private sector when other countries rely far more on the private sector at far lower costs but no other country incentivizes employer-based health care makes little sense to me.Report

  15. ChrisWWW says:

    “After all, when industries already have so much control and power, why would deregulating now, after the fact, really lead to more competition?”
    I don’t think deregulation would lead to more competition. Markets without interference tend to become more monopolized over time, not less. For example, deregulation in the telecom and media markets has lead to greater and greater consolidation and ultimately fewer choices for consumers.Report

    • Jaybird in reply to ChrisWWW says:

      From my perspective, when I was a kid, there were three VHF channels and two UHF channels.

      I’m going to need it explained to me how I have fewer options. Or was there a point between then and now that I had more, but those have started being pared away?Report

    • Mark Thompson in reply to ChrisWWW says:

      This doesn’t make sense to me. AT&T’s unabashed monopoly was created and nurtured almost entirely because of regulation – there is not, to my knowledge, any debate about this. Had those regulations not existed, there would have been no AT&T monopoly to break up.Report

    • ChrisWWW in reply to ChrisWWW says:

      Since Michael Powell relaxed tv and radio ownership limits, there has been a contraction in the diversity of the ownership of those outlets. And ownership can have a strong effect on the voice of the outlet. Ask any company taken over by Mr. Murdoch.

      As with Jaybird counter-example, it’s all a matter of where you jump into the timeline. If we start in the 1890s, then there was competition in the telecom market that was eventually eliminated through market dominance and finally government regulation.

      If we fast forward to the mid 1980s, again we see a competitive telecom market enforced by government limits on the size of telecom companies. Now that the government is no longer interested in enforcing anti-trust legislation, we’re seeing a big contraction in the market again. The current AT&T is the combination of five formerly separate companies.Report

      • Jaybird in reply to ChrisWWW says:

        An environment that allows Murdoch to own and operate a press is preferable to one that does not allow Murdoch to own and operate a press, or so it would seem to me.

        Honestly, I have oh-so-very many more choices than I did in 1999, and in 1999, I couldn’t believe how many more choices I had than in 1989. In 1989, I don’t think I thought about it much… but I had 30ish channels in 1989 and, in 1979, we had rabbit ears… and did not need more than rabbit ears until my dad heard about the existence of ESPN.

        I honestly do not understand how, even with consolidation!, I have fewer choices available to me today than I used to have.Report

        • ChrisWWW in reply to Jaybird says:

          I never said Murdoch shouldn’t be allowed to have a press, only that deregulation is allowing him to own more and more of the major media outlets. With that ownership comes control.

          Let’s put it another way…
          While there are undeniably more media outlets today, consolidation, allowed by deregulation, means that those outlets are controlled by fewer and fewer people.

          Check out this chart:

          • Jaybird in reply to ChrisWWW says:

            So do I have fewer choices before me or not?

            If I feel that I do have more choices than I used to, what is that blindness due to?Report

            • ChrisWWW in reply to Jaybird says:

              You’re mistaking ‘more’ with truly competitive choices.

              For instance, Microsoft releases various versions of Windows targeted at different types of users. Someone might say, wow look at all the choices I’ve got, I can pick Windows Vista, or Vista 64, or Windows Media Center, or Windows Vista Home. But they are all being supplied by one company, so it’s not really a true competitive marketplace.Report

  16. greginak says:

    Dereg in media has led to a small group of companies buying up all their competition. A handful of corporations own most of media outlets in the country. We have more channels because of technology not because there are many different companies in the market place.Report

  17. Michael Drew says:

    This discussion (when it was still about health care) is interesting as a theoretical thought experiment. But it is completely and totally divorced from the political reality of health reform that is underway as we speak, and it seems more than a little divorced from actual facts anywhere. It just seems to proceed by the force of its own assumptions and logic.

    I’d like to see a discussion of how it might be that all these good ideas have a chance at intersecting with the actual world in which the reigns of policymaking necessary to bring any of this about are passed back and forth between two and only two political parties, one of which has as a sole conscious objective protecting the position of the very interests that prevent such reforms from being enacted or even considered, and the other of which, while it may at least claim to have the goal of addressing health policy reform, is so completely influenced by the same interests that any actual intent to institute significant reform that might affect these interests’ position is consistently stymied and neutralized.

    So while there are some good ideas being explored here, reading this I’m more than anything just struck by its futility.Report

  18. Kyle says:

    I think you should be allowed to guest legislate. This a bolder proposition than anything coming out of Congress these days.Report

  19. mike farmer says:


    Nothing would ever change if we accepted futility as a reality. Just because there are many barriers to change doesn’t mean change can’t happen. We’d still be under the rule of a King if barriers couldn’t be overcome. Oh, we are under the rule of a King — sorry — nevermind.Report

  20. Michael Drew says:

    One other thing. I don’t know when or where Mark wrote that particular defense of his views so I don’t know the context, but one thing about it doesn’t fly. No matter how bloated, inefficient or unjust the U.S. government gets, we’re not its subjects. The government is made up of citizens just like us and can be held accountable; it is up to us whether we do it or not.Report

    • Michael Drew in reply to Michael Drew says:

      That said, I think much of what Mark has to say about health care, though I’d need to look at it more closely to have a full reaction, has merit as a potentially coherent overall approach. The idea of vouchers here, where private industry is the status quo provider of the bulk of health coverage for Americans, is much more attractive than in the education arena.Report

  21. James says:

    3) Whatever public plan – whether vouchers, single-payer, etc. – emerges, it should not be free.

    Have you ever been poor?Report

    • Jaybird in reply to James says:

      How poor will he need to have been in order to have written what he did and maintain any kind of firm footing?

      Will he have had to spend time as a missionary kid in a civil-war torn country?

      Do his speech patterns (let alone his pigmentation!) betray that he has so much cultural capital that he obviously has never been poor enough to write what he did?Report

      • James in reply to Jaybird says:

        I’m not going to claim that I was “just wondering”. I just think that, failing a truly remarkable degree of empathy, that that sort of thing matters in the formation of such opinions. As someone who was poor when he needed some surgery here in England, where courtesy of the marvelous socialist government of 1945-1950 headed by Clement Attlee we have nationalised healthcare, I possess a scepticism towards those that proclaim the crucial element of the profiteer in healthcare provision that I’d imagine others lack. Entirely understandable. Perhaps some kind of misplaced loyalty to the system which provided my salvation clouds my eyes.

        But although I wouldn’t couch it in such terms as do the Leninists, that of Class Consciousness, I’d say that this scepticism is based not merely around self-interest but also around an awareness that there are many, many others in near identical situations to the one I found myself in, & had some wretched piece of affluent vermin deigned to line their pockets with silver extracted from the suffering in not only my instance, but theirs also, we would all have suffered. While the wealthy would have kept themselves safe. Kept themselves at the top of the list, at the front of the queue. The most important humans, they. That’s the state of play as it stands & as long as profit remains in play that’s how it’s likely to remain. I’m wary of that.

        I imagine that that scepticism is even more fierce amongst those that were in a similar position to myself, but were uninsured Americans. I suppose it’s a mixture of the tone, ethos & trappings of this website that lead me to believe that E.D. Kain has been in neither of those situations, but I could well be mistaken.Report

        • E.D. Kain in reply to James says:

          Two things:

          First, when I say it should not be free I am not saying it should not be very cheap for the very poor. Indeed, I’d say catastrophic coverage should be free for the poor, and co-pays on preventative care should be very minimal. In other words, it doesn’t take much, but somehow the divide between having to pay even just a little bit and having something for free makes self-rationing and caution more of a reality.

          Second, I have indeed been poor. Poor enough anyways. Between jobs at one point, having been laid off, and during a time when my wife and I were about to have our first baby we were not only poor but without health care. We had to go on state-provided health care, and this has been an important factor in my belief that we should have universal coverage. There are many problems with how payments work, how basic services are provided, etc. with the current state-run health care. I think there could probably be a better way. But there could be a worse way also – which would be no health care for the poor or out of work at all. And if that had been the case we would likely have been bankrupt by the medical bills after our daughter was born with some frightening complications.

          The problem as I see it is not that any of these suggestions are wrong – could nationalized health care work? Probably. Would it work in the United States the same as it works in Britain? Probably not. Would we have the political will to fund it properly? Probably not. But I also believe that in any deregulated market for health insurance, provisions need to be made so that nobody ends up going into bankruptcy or not being able to get the care they need. Could government provided catastrophic insurance coupled with vouchers work? I think so. Is it the only suggestion I’m open to? Not at all. I think the German model is also pretty good but I doubt we have the political cohesion necessary to implement something quite as graceful as that properly.

          So it’s not an easy question.Report

    • Michael Drew in reply to James says:

      It clearly should not be free. We already have Medicaid for that circumstance, though perhaps Medicaid could be folded into a public option (though the public option appears to be dying on the vine, leaving not much reform to speak of, as E.D. suggests).

      Premiums and deductibles might very effectively be tied to ability to pay, with the lowest rates being very low. But the message should not be sent that health care is a one-hundred-percent entitlement, divorcing citizens from the costs involved. The point here is that this service is to important to societal functioning to leave it to a free market that has proven not to be immune to system-threatening failures. In that circumstance the gov’t must be prepared to step in to repair a broken market on which we rely to maintain a critical social function.Report

      • James in reply to Michael Drew says:

        But why not repair it via an institution which provides healthcare for free? That ensures that nobody slips through the net, due to the universality being offered. Nothing you have said shows that it “clearly” should not be free, apart from some vague & bizarrely patronising urge to prevent the poor from getting uppity & expecting not to be allowed to rot unaided. Try again.Report

        • Mark Thompson in reply to James says:

          Making something free is perhaps the surest way of guaranteeing that demand will severely outstrip supply. This means excessively long waits and escalating costs to the system.Report

          • James in reply to Mark Thompson says:

            Yes, because I regularly think to myself: “You know what my life needs? Some heart pills.” Come now Mark, be rational about this. The only people who are going to use the healthcare system are sick people.Report

            • Michael Drew in reply to James says:

              Patently false. You and I are probably much closer to each other on the fundamentals here than either of us are to Mark, but you’re just mistaken that health insurance should be free for all. In fact that is just simply a fantasy: insurance is by definition paying a known amount now to avoid paying an unknown amount later. Guaranteeing free full coverage to everyone regardless of costs is completely anathema to aninsurance system of any kind. Besides which, for those about whom you are rightfully concerned, coverage already is free or nearly so, through Medicaid and state health insurance programs for families with low income. I don’t know all the specifics, and it probably varies state-to-state, but very low-income individuals may not be eligible merely because they do not have families — and certainly I and perhaps even Mark (from very different viewpoints) would be open to expanding that safety net to include individuals.

              But those who can pay should pay what they can. The place where the market is failing is among that group of people who could afford coverage in a functioning market, but in the broken environment either can’t afford any coverage or cannot afford sufficient coverage. Of course, increasingly the distinction between sufficient coverage that will be there when you need it and the hideous scams that masquerade as coverage plans but offer minimal actual coverage require specialized training to identify, which is what I see as the principal attraction of an opt-in government plan or plans.Report

              • James in reply to Michael Drew says:

                “you’re just mistaken that health insurance should be free for all.”

                When the hell did I say “insurance”? The system I actually advocate is a national health service. You know, like the UK has had for over sixty years.

                No need for insurance then, or at least it’s entirely optional rather than something upon which anyone needs to depend.Report

              • Michael Drew in reply to James says:

                This was my initial objection to some of the discussion here. If this is just going to be just a bulletin where we describe our fantasy scenarios of what health care in this country looks like without reference to where the politics actually stand, count me out. I think that’s pointless when an actual bill is winding its way through Congress now. Maybe two or four years ago when it started to look like there would be a Democratic tide and health care might actually be a priority at all, such a spectrum of possibilities would have been worth exploring (and if you were doing so, more power to you). But now I think it is imperative that we have these discussions with reference to the more or less momentous (which is to say, whatever their outcome, not likely to be revisited for a good long while) actions that are currently being considered. It’s just a failure to engage the issue at this point to be falling back on proposals that are outside the range being discussed by policymakers (unless you have a secret plan to elect enough officials in the coming cycles to make your preferred approach politically viable, which I would love to hear that you do, at which time I’d love to engage in a debate about whether a national health service or a single-payer model is better for this country).Report

              • James in reply to Michael Drew says:

                You’re being preposterous if you imagine we’re going to have any impact at all, beyond upon each other.Report

              • Michael Drew in reply to James says:

                If a few people read what I am writing and become convinced that a public option is a critical step at this time and consequently call their Senators or Representatives, it could have a small but not nonexistent impact. On the other hand if they read what you are writing and conclude that the best option is one that is not on the table, and that failing that whatever emerges from the current debate is equally pointless as whatever else might have and therefore don’t call, well then yeah, there is zero impact.Report

              • James in reply to James says:

                Perhaps we need to be complaining that perfectly valid options are not upon the table. Perhaps America needs a left.Report

              • Michael Drew in reply to Michael Drew says:

                I didn’t address your false statement directly. The point at which only sick people get medical attention is a point well after the entire situation has gone off a cliff and our budgets are being eaten alive by medical costs. We want healthy people to be able to see the doctor — that saves cost of treating preventable disease over the long run. We also want to be able to treat very expensively ill people who cannot afford to pay for their treatment out of pocket. So somehow we need to convince healthy people to pay into the system what in the short term will likely be a greater amount than they will cost it in order to have the resources to treat very ill people who require expensive care. Why would a healthy person pay in more than they are likely to get out? Because of the small chance that they could become one of those high-cost patients overnight. But failing that, the secondary value of being covered is that it gives them an incentive to get care to preserve their health, which benefits them of course, but also saves the system money in the long run.

                The problem is that given the prices in the market now, those values to healthy potential insurance buyers are looking increasingly remote as compared to the daunting cost of obtaining even minimal coverage of uncertain long or short term value. That’s why I oppose a mandate — I don’t want to be legally bound to purchase a product I regard as a very dubious value — but support a public option — because of the advantages the government would have in providing a quality product at an affordable price, and the element of public pressure that would be applied to it to do so.Report

            • Mark Thompson in reply to James says:

              Well, people do regularly say, “Hey, I could use me some Vicodin right now.” Of course, this problem goes away if you make all drugs available over the counter…

              But that’s not really my point here – we’re talking about visits to the doctor, not access to medication. And people most definitely are going to be much more likely to try to see a doctor for an almost-certainly inconsequential issue if they don’t have to pay for it whatsoever….there are plenty of hypochondriacs in the world as it is, making everything totally free only makes more. It also encourages an excess of preventative care.

              Beyond that, I agree with Michael.Report

              • James in reply to Mark Thompson says:

                And people most definitely are going to be much more likely to try to see a doctor for an almost-certainly inconsequential issue if they don’t have to pay for it whatsoever.

                You are mistaking a bug for a feature. People are made wary of doctors visits when they cost money & thus early symptoms are missed. You deter people with perfectly treatable conditions from getting timely preventatives & leave things until they’ve worsened. So much for the efficiencies of the private sector!Report

              • Michael Drew in reply to Mark Thompson says:

                I don’t think we want to discourage yearly check-ups and the like, and people who get them aren’t hypochondriacs, right? Check-ups (ie seeing the doctor when you’re not sick keep healthy people healthy, which saves costs in the long run. It also gives healthy people greater incentive not to choose to be uninsured, which is a decision that ultimately harms everyone, but in the short term looks increasingly like a good risk to take given the costs of coverage. I think we want to encourage preventive care provided that people are covered, and work to achieve close to universal coverage by offering good coverage at an affordable price.Report

              • James in reply to Michael Drew says:

                What harms people is a pack of profiteers accumulating capital from sickness. It is in their interest not to do a good job of providing healthcare & as screening improves this will become more & more of a problem: the insurance companies will do their best to avoid covering, let alone paying out for, those who are most likely to suffer from chronic conditions, i.e. those most in need.

                I say that it is unacceptable that any be allowed to let slip through the cracks in a system run by the profit hungry, & insurance should be an option in the truest sense of the word rather than something people depend upon. Nationalise the hospitals, provide care which is free at point of access. Let it be paid for through taxes.Report

  22. Michael Drew says:

    Perhaps we need to be complaining that perfectly valid options are not upon the table. Perhaps America needs a left.

    That is a valid point, but it is a much broader discussion. Right now I want to get the best out of this moment that we can with the politics as they are. That means focusing on the boring details, as constrained by our small politics as they unfortunately are.Report

    • James in reply to Michael Drew says:

      It simply isn’t the stuff of wild fantasy to suggest that healthcare be nationalised, though. Unbelievable as it may seem that is what has happened to the state that lies to the USA’s immediate north.Report

      • Michael Drew in reply to James says:

        I’m very happy to have that conversation almost any time except when the outlines of what we probably will be dealing with for the next decade or two are being drawn up, and such options don’t have the support to get them on the table this time around. I’m all for the discussion, and trying to expand the range of what is on the table. But it just didn’t happen this time around.Report

        • James in reply to Michael Drew says:

          Ok, well, don’t reply to my comments, then…Report

          • Michael Drew in reply to James says:

            You have every right to your position, and I don’t mean to try to delegitimize it as a potentially viable approach. I merely think that right now it makes sense to pay close attention to the discussion underway that is likely to lead to some combination of a fairly narrow, predictable set of possible changes.Report

            • James in reply to Michael Drew says:

              That’s the kind of thinking that ensures the present neo-liberal hegemon stays so tight.Report

              • Michael Drew in reply to James says:

                You’re probably right it is the type of thinking that got us here. And I don’t want to restrict debate going forward. But it’s just simply a fact that parameters are set for this go-round, and I happen to be very interested in the outcome.Report

  23. Michael Drew says:

    …BUT! This place should be what its proprietors and the majority of its visitors want it to be, and if that’s a clearinghouse for a broad range of ideas on a braod range of topics (as it seems to be), then that’s what it should be. I don’t mean to state my preference for specificity and pragmatism given the currency of this issue right now as a criticism. I can get plenty on commentary and analysis of the current jealth care debate in a variety of places. I just think this is a potentially very valuable forum because of the openness of the minds that populate it, and I wanted to steer the discussion in a way that I thought would make it the most valuable. If its natural tendency is other than what I’d like see, I’m happy to stand aside and leave it to its natural inclination.Report