health care, flip-flopping, and drunken boxing…er…blogging


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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31 Responses

  1. Avatar ChrisWWW says:

    I think you’d like the way health care is managed in Singapore, something I first read about in the Undercover Economist.Report

  2. Avatar willybobo says:

    Changing your mind in the face of sound arguments is great, ED. Not being afraid to do that in public on this blog shows your commitment to fostering public reasoned consideration.

    About the vouchers, though… I’m much more in favor of demand-side measures as well. But writing a big check to Washington so that they can then in turn take that money and parcel it out back to me a few others to then allocate to health care providers seems, well, silly inefficient. Why not just let me allocate my own dollars to health care providers, and give me a tax credit for that? I’ll use the tax credit incentive to grossly overpay what I’m likely to cost, and lower income folks can use my surplus to cover the care which they can’t afford.Report

    • Avatar E.D. Kain in reply to willybobo says:

      That sounds great for those people who can afford it, but many people still remain too poor. It’s those people, and the chronically ill that I worry about.Report

      • Avatar willybobo in reply to E.D. Kain says:

        But the point is, I’m subsidizing care for the poor directly. If I allocate $100,000 to a health care provider in exchange for a $100k tax credit, and then use $0 of care myself, I’ve created surplus that can be used to treat the poor. The trick is getting Washington to focus on creating incentives for high income people to over allocate for health care, but letting people actually manage the allocation themselves. I believe that will do a much better job of fostering competition among providers, since individuals are more likely than governments to know which providers are worthy and less likely to pick just the biggest company.Report

        • Avatar FreeDem in reply to willybobo says:

          I am constantly amazed at that common short leap, that if I get an extra $xx to a for profit company they can use that surplus to reach out and help the struggling masses.

          The recent experience with the TARP Funds is a good harbinger of what would happen. Wherever people who believe in creative selfishness are given the freedom to put a dollar in their pocket or hand it to those in need, the pocket will always win no matter how obscene.

          To talk about a market in health care is to compare cancer treatment to Ipods. One can have a better Ipod or none and still live. One can compare features and price and look at ones wallet and make a reasonable decision.

          Cancer treatment (or other health issue) is nothing like that. You need it or you don’t, and if you need it, half measures are worthless, and nobody would willingly go there except at dire need, no matter what the price was.

          So health care is a lot like the Fire Department, they inspect for safety, and do heroic service in dire need. What they do not have is an Insurance Bureaucrat to say “I think that fire will go out on its own” or ” You had flammables in the house so we aren’t sending anyone” or other dodge to keep from paying a fireman to do his job.Report

  3. Avatar mike farmer says:

    You’re in good company:

    Do I contradict myself? Very well, then I contradict myself, I am large, I contain multitudes.
    –Walt WhitmanReport

    • Avatar E.D. Kain in reply to mike farmer says:

      I like that. I’m going to have to use that sometime…Report

    • “A foolish consistency is the hobgoblin of little minds.”
      -Ralph Waldo EmersonReport

      • Avatar willybobo in reply to Mark Thompson says:

        The Emerson in its context is better.
        “A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines. With consistency a great soul has simply nothing to do. He may as well concern himself with his shadow on the wall. Speak what you think now in hard words, and tomorrow speak what tomorrow thinks in hard words again, though it contradict every thing you said to-day. ‘Ah, so you shall be sure to be misunderstood.’ Is it so bad, then, to be misunderstood? Pythagoras was misunderstood, and Socrates, and Jesus, and Luther, and Copernicus, and Galileo, and Newton, and every pure and wise spirit that ever took flesh. To be great is to be misunderstood.”Report

      • Added that to the footer.Report

  4. Nob Akimoto Nob Akimoto says:

    I think posts like this one are the main reason I think this site is one of the best around in terms of blogging and commentary in general… So one moment to take a shout out to you guys before we get into abstractions…

    I think one of the main problems affecting healthcare (and indeed many “market oriented” solutions to things in general) is the assymetry of power between the suppliers and the demanders. That is: by its very nature an insurance company, no matter how small will always have a power advantage over an individual insuree. Now I know the standard argument here is that “well no company who screws over insurees will ever get their business”. The problem with that answer I think is again the assymetric nature of power between the consumer and the supplier, and second the unpredictable nature of healthcare as a business in general. People are going to naturally gravitate towards plans that offer A. a lower premium, B. low deductibles for routine care, C. accessibility to doctors of their choice, without really considering what would happen in cases of catastrophic conditions or the development of a chronic condition. (Currently the two areas where people get screwed most often) So you’d end up in a situation where the vast majority of insurance providers would gravitate towards providing nice, affordable plans to low risk individuals who would find some enormous cost when they actually do get sick.

    Presently there’s some “parity” between consumers and suppliers of insurance in that employer provided benefits give an outlet for collectivized action. Granted this an imperfect model, especially since the decision making on plans is done by the employer, not the collective employees, but there is still significantly greater leverage when you have the weight of a thousand people, rather than one person trying to decide between plans. Even in this case though, once an employee suffers a catastrophic medical condition (or their spouse) the insurance provider has ample means of pressuring the employer to drop the “problem” patient. In the end, decollectivizing and individualizing health insurance and making it “freer” seems to me simply a way to create an even greater disparity between individuals and corporations.

    I think if anything is to happen absent a public plan or some sort of mass government supported “buy-in” option, we need to fundamentally tear down how “health insurance” is provided in the US and move towards a non-profit collectivized model of insurers, than ones that are more incentivized towards making a profit at whatever expense by keeping costs low. At least when profit motive is no longer the prime concern, the assymetry of power no longer looks so ominous.Report

  5. Avatar James says:

    “Oh sure, lots of other countries do it well. One hears this in the comments a lot. And I love some systems out there – especially the German system. Boy, if we could do that in the States I’d be all for it. It’s just not how our system works though. We have a less elegant form of government here, and that’s not changing anytime soon.”

    Could you elaborate a little on this, please?Report

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

      From everything I’ve read on the subject, it is simply far easier for the Germans to come to consensus and enact this sort of legislation than it is for Americans. They have a different view altogether on how government operates. This article, though not directly related to your comment might interest you as a Brit….Report

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

        Ah Civitas. As right-wing think tanks go they’re not terrible. This, however, is saying precious little…

        As for consensus: I think that if Obama made some more immersive efforts we’d see greater results. I’m coming to the conclusion that a centrist Democratic Party could hamstring him, with the recent environment fiasco being a case in point…Report

  6. Avatar mike farmer says:

    You have two groups — one group can afford an insurance plan to cover the services offered for by healthcare providers, or they can pay out of pocket — if government removes all the regulations and does away with medicare and medicaid. Healthcare providers are trained professionals who offer services and expect to get paid. If government would leave the healthcare field alone, the market would work out prices so that everyone who needs care can get it. Before all this business of making healthcare a right like a property right, and making it special, and different from other services for sale, people knew they had to pay for what they received.

    Then there are those who can’t afford a policy at any price, and definitely can’t pay out of pocket. This is a totally different problem, and although I don’t think government should be involved in the solution of either problem (I think charity efforts will be sufficient), if they HAVE to be involved, then they should concentrate on the problem of those who can’t afford any policy at any price. They don’t need to change and control the healthcare field to help those who can’t afford policies — hell, it would be less expensive to pay for their care directly. A trillion dollars will go a long way.

    The problem is that too many people who can afford a policy in a free market now smell what seems like free healthcare, but it’s a dead fish. We are on the verge of making a huge mistake in healthcare. Mark my words.Report

  7. Avatar Travis says:

    Nobody is arguing that health care will be free.

    What is being argued is the idea that the current system of health insurance middlemen is fundamentally broken, in part because the profit of shareholders is all too often placed before the health of customers and in part because we spend so much and cover so few.Report

    • Avatar James in reply to Travis says:

      Precisely. There’s no need for some shareholder to accumulate wealth with healthcare, in fact they serve as something of a distraction. More interested in profit than people, as is in their nature.Report

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

        On a gut level that sounds reasonable. But the fact is, profit can drive a lot of things, including lower costs for consumers. Non-profits don’t necessarily produce a better good or service. Viewing “profit” as bad, somehow, is to over-simplify.

        That said, I really like the idea of non-profit cooperatives as possible alternatives to for-profit corporations. I’m not sure anything is a panacea.Report

        • Meanwhile, we should keep in mind that when we’re talking about shareholders, we’re quite frequently talking about various pension plans, mutual funds, etc. that are, in fact, the retirement funds of a whole lot of people. When we speak of shareholders nowadays, we are no longer talking about a handful of wealthy fat cats.Report

          • Avatar Travis in reply to Mark Thompson says:

            There are plenty of other places to earn profits.

            Profit has been proven to be bad in the health insurance industry, E.D. It is the classic example of a perverse incentive, because the customer who most needs the product being sold is also the customer who is least likely to generate a profit for that company.Report

            • Avatar Travis in reply to Travis says:

              This being converse to, say, the medical technology section of health care, which does have the correct incentive: if a private firm creates a successful product which improves people’s health, it can be sold at a reasonable profit. The patient gets healthier, the company gets wealthier.Report

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

                Unless through regulatory measures and private/public collusion, one medical technology outfit is given monopoly by the state to provide medical supplies creating massive barrier to entry against their competitors. Just sayin….Report

              • Nob Akimoto Nob Akimoto in reply to E.D. Kain says:

                Instead you would rather just see private/private collusion?

                I’m not seeing the logic here. Unless your proposal includes completely dismantling the existing healthcare industry (service providers, insurers etc.) then the likely outcome instead is going to be a quasi-cartel system where because of the assymetry in knowledge, information, money and power, consumers are just going to wind up with fewer choices, worse outcomes and higher costs.Report

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

          “On a gut level that sounds reasonable. But the fact is, profit can drive a lot of things, including lower costs for consumers. Non-profits don’t necessarily produce a better good or service. Viewing “profit” as bad, somehow, is to over-simplify.”

          I think you’re misrepresenting our arguments: it is not that making a profit is bad. It is that if you are focused on that (as any company is obliged to be, remember) then this is detracting focus from helping people. You have split priorities.

          Which is what the healthcare system is for, after all.Report

  8. Avatar Michael Drew says:

    I too applaud E.D.’s willingness to change his view (though in this case I actually regret the particular change). The only criticism I would maintain is that when the view changes this much in this short a time, it’s really pretty necessary to acknowledge the changes that are taking place up front (in real time in this case — it’s actually pretty fascinating to watch). The language in yesterday’s post was pretty unequivocal, almost in the territory of what one might use to express immutable truth. Maybe I follow this blog way too closely, but my recollection was of a very different view in the recent past. And that’s totally fine, but when the change isn’t acknowledged up front, it can be somewhat bewildering. That’s just one reader’s experience.

    On the substance here, I’ve said this before, but the fact is this thing is well past leaving the station. Electing Democrats basically meant a push for health care reform: it was was a major topic of both the primary and general election campaigns, and it’s probably about 60% or more of the party’s basic reason for existing at this point. And given the way Obama is proceeding — very much giving Congress the lead — most of the likely reforms given this cadre of legislators have been available for scrutiny for some time. So while there is everything right and nothing wrong with exploring any and all ideas for how to reform health care here, in fact unless we engage with what is on the table in the current debate, we are engaging in just a potentially interesting policy symposium, but not really focused debate about the reform we are likely to see.

    That’s why I am a bit disappointed that the public option has lost a supporter in E.D., because that development does directly engage the debate now occurring in Congress. Indeed, many who want to see health care reform pass this year in the best form possible regard the public option as the only significant change that remains on the table beyond cost-control measures that nearly everyone agrees upon (even if they don’t regard them as sufficient). I realize this isn’t an argument on the merits of the public option — that can be found and better voiced elsewhere. But the problem is, as much as I acknowledge E.D.’s interest in exploring other avenues for reform, it’s just sadly the case that it’s too late to get a major alternative approach, such as vouchers (which to me seem not to address the basic problem of exploding costs) on the table. So the upshot of E.D.’s change in view is that the major plank of the reform effort now in play has just lost a supporter. my reaction is: bummer.Report

    • Avatar E.D. Kain in reply to Michael Drew says:

      All valid points. And you know – I think I over-stepped in yesterday’s piece. A public plan is NOT doomed to failure. But it does worry me a lot the more I look at numbers, think about long-term costs, and monopolization etc.

      That being said, if it means more people get coverage (and in its current form I’m not sure that’s what will happen…) then I’m happy at the end of the day. It’s a big entitlement and we’ll need to find ways to pay for it, and nothing’s free in the end, but if it means more people are covered, healthy, free of that heap of worry that sickness and being uninsured means, then that’s some sort of victory.Report

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

        Also, I don’t think any of my “preferred” or as Wilkinson called it “fantasia” ideas will ever happen. I mean, never in the current plan was there a public option coupled with real deregulation of the health care market plus taxes on benefits (well Baucus did try for that…) So I don’t think I was a real “supporter” of the public plan to begin with, unless it came with some real market reforms as well.

        My voucher plan would be as universal in many ways as the public plan would be, so in that sense I also haven’t moved so far afield from my original ‘tiered’ approach – only in how I see the implementation – gosh – I want to say “being best implemented” but that’s just stupid. I’ve lost my train of thought.


        • Avatar Michael Drew in reply to E.D. Kain says:

          I should have said, lost a *potential* supporter. I’m also okay with taxing benefits — what I don’t get is why that is either/or with a surtax on rich people. Why not have both? (snickers…)

          Here’s a question I have on the deregulation proposal, specifically allowing companies to operate across states. Aren’t you worried about the industry going down the road of the credit cards? The reason we have to deal with so much b.s. from credit card companies (unannounced rate changes, fee changes, policy changes, usury, etc., etc.) is basically that South Dakota deregulated and they all moved there. If we allowed health insurance companies to operate across states and deregulated federally in other ways, insurers would immediately have an incentive to move to those states with the best regulatory environments, and the states would have incentives to provide that to get the economic benefit of having lots of business move there. And we’d all be sending our payments there and be at the mercy of that state’s legislature. In my view, the health insurance industry is one in which we have clear and societal interest in having certain broadly agreed-upon outcomes (affordability, universality, quality coverage) be the norm, and which are not guaranteed to come about by the free market. It seems to me that is a situation in which the need for considerable regulation of various kinds is clearly apparent, and we should be talking about the best ways to do it, not denying the need and advocating major curtailments to regulation.

          How would you respond? (I’d be interested in Mark Thompson’s reaction as well.)Report

  9. i dont pretend to understand the complexity of cause, effect, supply and demand here – to whatever debatable extent these concepts apply to health care market to begin with. But to my mind the main issue of whether we can cover everyone is if we can pay for it. To that end I think thats the key issue – i’m on record as being pro-VAT. Taxing benefits seems like political poison in comparison.Report