public plans, vouchers, and choice


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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115 Responses

  1. Avatar Sam M says:

    “no one is willing to say publicly that it’s OK to leave millions of people without healthcare. ”

    I think a lot of people are willing to say that publicly. For instance, the people who could afford it buty choose not to buy it seem to be OK with that.

    These people do, in fact, exist. I was one ofr a long time. The gamble paid off for me. I saved thousands and thousands of dollars, which I instead spent at the bar. People are dumb sometimes.

    So for every single mother of four who’s getting health insurance she needs, you are going to have at least one dumb shmuck milking the system.

    Speaking of healtcare realities that people don’t address, I would like to see Drim spend a little more time discussing the moral and financial implications of universal coverage, particularly the public health, nanny-state implications. Once I am no longer responsible for paying for my own liver treatment… should I be allowed, legally, to be a drunk?

    Should I be allowed to have 9 kids? Nine abortions? Nine cigarettes per day?

    Who decides?Report

    • Avatar Jaybird says:

      In that vein, when Obama said that huge numbers of the uninsured happen to be younger people who would be relatively easy to insure… the thought “we need these younger people to pay for older people’s care!” went through my mind.

      It struck me as… well, one interest group taking advantage of another.Report

      • Avatar Chad says:

        Maybe I’m wrong here, but isn’t that how insurance works? Insurance companies use the money from the l0w-risk customers to pay for the claims of the high-risk. If you don’t get a wide base of customers that includes low-risk people, you have to raise the price for everyone else to compensate.Report

        • Avatar Jaybird says:

          Sure. But forcing people in, say, Rifle to pay for flood insurance to help cover people in New Orleans strikes me as somewhat shady.

          New Orleans is very likely to need help after a flood.
          Rifle is in the Rocky Mountains. It ain’t never gonna flood.

          This strikes me as a great deal for New Orleans while Rifle gets the shaft.

          Forcing Rifle to purchase flood insurance strikes me as somewhat immoral.

          Even if, yes, that *IS* how insurance works.Report

          • Avatar Bob says:

            From Wiki:

            “Flood insurance is available for residents of approximately 19,000 communities nationwide.”

            I bet a billizon dollars Rifle is not one of them.Report

            • Avatar Jaybird says:

              And getting the young who want only Major Medical to instead get something absolutely comprehensive to help pay for the elderly strikes me as somewhat dishonest.Report

          • Avatar Michael Drew says:

            That’s why Obama isn’t trying to force an individual mandate down our throats the way Hillary Clinton would have. He’s instead trying to “Nudge” us freeloaders into the system by changing the incentives. But his basic insight, that too-large numbers of people are opting out of the system and that denies us cost-sharing advantages that we could otherwise have is right. He’s approaching that problem in about the most hands-off way he can. My concern is whether it’s really going to be enough. When this is all said and done, is a low-wage worker whose employer doesn’t insure her really going to be able to find a plan she can afford that is worth purchasing. because I agree that the way things stand right now, many of those opting out today are making an extremely rational, defensible decision from the individual standpoint (which is of course the one that counts).Report

            • Avatar Jaybird says:

              I don’t see “self-insured” as the same thing as “freeloading”… anymore than my lack of flood insurance in Colorado Springs is freeloading.Report

              • Avatar Michael Drew says:

                If you (or I) come down with a chronic life-threatening disease, will you agree now to accept only that tretment that hospital management determines you are a safe bet to be able to pay or amortize? If yes, then you are self-insured. If not, then the rest of payers have your (and my) back.Report

            • Avatar Jaybird says:

              Alright, fine. Vail then.Report

              • Avatar Travis says:

                Nope, Vail floods too.



                People who whine about New Orleans are generally living in glass houses. There aren’t many places (particularly in the arid Western United States) which aren’t subject to flooding at some point or another.

                You’re in Colorado Springs? You takes your chances. The Colorado Springs area suffered a major flood in 1965.


                Is New Orleans a city particularly prone to flooding issues because it’s built below sea level? Sure. It’s also true that dams on the Mississippi/Missouri systems upstream are taking much of the silt load out of the river, the same silt that built southern Louisiana. Recent human activity is largely responsible for the hydrologic changes which are causing the whole delta region to erode right into the Gulf.

                We can take steps to reduce building in floodplains… but ultimately, people like living near watercourses. We could take steps to reduce building in tornado areas, too… but that would require the evacuation of much of Oklahoma. Same with earthquakes and California.Report

            • Avatar Bob says:

              Jeez, that hurts. Need to spend more time on the Google. Installments? Jaybird.

              But a lame attempt to recoup, no one is forced to buy flood insurance.Report

              • Avatar Jaybird says:

                Will the young, those easy to insure (according to Obama) be forced to buy health insurance?Report

              • Avatar Michael Drew says:

                No, that woud’ve been Hillary’s approach. Obama caught hell from Krugman for steering clear of that in the campaign. Obama wants to encourage (us) to buy in via hopefully better prices and regulatory floors on quality. No guarantees, though.Report

    • Avatar Chris Cziborr says:

      >Once I am no longer responsible for paying for my >own liver treatment… should I be allowed, legally, to >be a drunk?

      >Should I be allowed to have 9 kids? Nine abortions? >Nine cigarettes per day?

      Health insurance companies already do this. It’s called, “pre-existing condition.”Report

  2. Avatar Bob Cheeks says:

    Why are you people getting all excited about “health care,” His Holiness is about to shove his plan down your throat. Sit there, be quiet, and take it like a man! You wanted him, you got him.Report

  3. Avatar Herb says:

    Hmm…deregulating insurers? I don’t know, I’m still of the mind that the insurance industry is one of the reasons why healthcare is so expensive in this country.

    The focus shouldn’t be on covering costs, but on reducing them. All that insurance company overhead/profit seems like a good place to start.Report

    • Avatar E.D. Kain says:

      The problem is that we’ve sponsored monopolistic companies, Herb. The reason those insurers are driving up costs is there isn’t any competition. Seriously – around here, for instance, almost every single person in town is covered by Blue Cross/Blue Shield. It’s a monopoly – no choice = high cost.Report

      • Avatar BCChase says:

        But will deregulation allowing insurers to act across state lines lead to more insurance companies? I think it will lead to fewer, as those well-established ones buy up and buy out the smaller ones. Or maybe you could explain why this system would destabilize, rather than expand, the power of the monolithic insurance companies.Report

        • Avatar E.D. Kain says:

          In Claudius the God, Messalina, his wife, at one point encourages him to appoint certain companies as monopolies – her reasoning was that all this competition was creating waste. He foolishly heeds her advice, appoints specific merchants and traders as monopolies over certain goods, and watches as the prices shoot through the roof. Riots ensue; shortages; price-gouging. He is forced to break up the monopolies and repeal the laws that erected them in the first place.

          The point being that government is the creator of monopolies and the same is the case in the US with our insurance providers. Even if the “big players” went around buying up the little guys, having three or four big players offering their services and competing in any given location would still be an improvement over having only one per region/town/etc. More than likely, without government sponsorship, more companies would enter the mix. So long as we didn’t bail out some of the big ones (when have we ever bailed out a big insurance company after all?) then competition would serve to lower prices, etc. etc. etc.Report

          • Avatar Sully Fick says:

            (You posted right as I was writing the reply below) 🙂

            So, your answer really just boils down to:

            Let the Magic Market work its magic, and competition will increase, prices will get lower, and everything will be better!

            I seem to recall this argument being made in the 90s about repealing Glass-Steagall (including support from Larry Summers).

            I don’t recall, how did things work out when we de-regulated the financial industry? Did the big players buy up the little guys, but then competition increased and prices dropped and everything got better?Report

            • Avatar E.D. Kain says:

              Were banks prevented from operating across state lines? In the 90’s were banks limited to essentially one per town? Or could banks compete freely across the country?

              You’re comparing apples to oranges. This is not the same scenario, nor is it the same sort of deregulation. See, you’re making the fallacy of equating all regulatory reforms when in fact they have very little to do with one another.Report

              • Avatar Sully Fick says:

                “Were banks prevented from operating across state lines [in the 80s and 90s]?”

                Well, um, yes. The Reigle-Neal Interstate Banking and Branching Efficiency Act of (signed by Clinton) allowed banks to open branches nationwide (deposit your check anywhere there’s a branch). Up until that point the name of the bank was the same, but for all practical purposes your branch was separate bank.

                Health insurers are not limited essentially to one per town, so I will not address this hyperbole.

                “Could banks compete freely across the country”. Yes, the same way that insurers can compete freely across the country today.

                I don’t see apples and oranges with the arguments you’ve made, though there might be other arguments that show me the apples/oranges difference (but, you’re not making those arguments).

                I don’t see the difference, so I’ll ask some questions:

                – is Blue Cross/Blue Shield prevented from competing freely across the country (or any other insurer)?
                – are towns limited to one insurer per town?
                – are insurers prevented from operating across state lines?
                – if any of these questions have a yes answer, could you point me to the regulation(s) for that item?

                I think the answer to these questions are no, no, and no. Perhaps you disagree. I’d like to see your evidence for yes answers.Report

              • Avatar E.D. Kain says:

                Quick question – did repealing Glass-Steagal allow banks to compete across state lines or was that already allowed prior to said repeal? I was under the impression that this allowed banks to merge with investment banks, not that it allowed banks more national competition.

                And no, Blue Cross/Blue Shield does not compete across state lines. There are different manifestations of it in every state.Report

              • Avatar Sully Fick says:

                Quick Answer – Glass-Steagle allowed banks to merge with investment banks. Riegle-Neal allowed interstate banking. Riegle-Neal was already allowed when Glass-Steagle was repealed.

                IMO, B.C./B.S. operates today like banks operated prior to Riegle-Neal. This makes it similar, in my mind.Report

              • Avatar E.D. Kain says:

                So was the current collapse the fault of Riegle-Neal or Glass-Steagle? I mean, without personally weighing in on the merits of Glass-Steagle, it seems that banks were doing okay prior to that point so did Riegle-Neal (allowing banks to operate across state lines) really cause any harm?Report

              • Avatar Michael Drew says:

                I believe the situation is that to insure someone a company has to have a business address (thus be subject to taxation and regulation) in the state that that person lives in. So Blue Cross-Blue Shield can operate everywhere, but they have to essentially “live” in your state to insure you. They’re like the Borg — one entity, many locations. If E.D. got his way, they could just set up an office in one state and cover people all over the country. But they’d be subject only to the regulations of the state where their office was located, as well as federal regs.

                Does that sound right to you E.D.? I have to say, while I can’t obviously prove it would go the way things did with credit cards, I’m not sure you make much of an argument in the post about why it wouldn’t other than, well, maybe it just wouldn’t. The co-op model you describe seems to be a locally-based solution that hopefully profilerates, as people seem happy with it, but I really don’t at all see how that model is hindered by retaining state-by-state regulation of the interactions between the behemoths that operate all over the country and the various states’ citizenry. It seems to me that the likely effect of deregulation of the cross-state limitation would just be far less accountable national behemoths continuing to undercut small competitors with their advantages of scale, only that would be accelerated due to their new windfall from being able to avoid the sundry states’ regs. (I am 100% on board with beginning to tax benefits both federally and by states for that reason).

                It seems to me that this is where a public option begins to gain some traction — precisely on the question of competition. What is undesirable about introducing a new, very big fish to this picture to put the current big fish in their place?Report

              • Avatar E.D. Kain says:

                Well here’s a question – can we justify a federal public option as a measure to bolster competition while at the same time boxing insurance providers into the states? I mean, if we have a national public plan competing against really crippled state-based private plans – is that particularly fair?

                And I’m still not sure how opening the market to more competition results in less responsive companies…that seems to fly in the face of pretty much all other examples of competition in markets. I mean, why shouldn’t my co-operative be able to operate in Arizona and Nevada and Utah? And maybe New Jersey also. And some other co-op could, too. And a corporation could as well, and we could all compete in all those places…Report

              • Avatar Michael Drew says:

                Do they seem crippled to you at this moment? That doesn’t seem to be your previous argument. As it stands now, they could use some more competition. Is that not your current view?Report

              • Avatar Michael Drew says:

                If all the world were made of health co-ops, we’d live in a more beautiful world. But there Blue Crosses and Blue Shields to deal with. And your co-op can operate in those states if it opens a branch there, at least that is the understanding I am describing, which I’m not fully confident is right. But you’re right that it would be nice to give smaller competitors a leg up. We could simply have a floor under which state-by-state regulation is exempted.Report

            • Avatar Bob says:

              Even the late great A. Greenspan (I don’t mean he is dead, just not great) admitted that markets can’t be trusted to self-regulate. What did he say, his fundamental assumptions were brought into question? Something along those lines.

              Continued belief in so-called free markets is a wondrous thing.Report

        • Avatar Sully Fick says:

          I second this.

          And, would like to hear an explanation of why deregulation won’t lead to greater monopolies.

          In fact, please point to a single example of an industry getting deregulated that did NOT lead to greater monopolies (doesn’t even have to be health care).Report

          • Uhh…..regulations usually/often protect monopolies and oligopolies by dramatically increasing barriers to entry (see, e.g., the way in which AT&T’s monopoly was heavily reliant on massive telecom regulation; see also, the effects of the CPSIA on small competitors vs. its effects on large market participants).

            Deregulation won’t lead to greater monopolization specifically because, at least in the type of deregulation E.D. is advocating, it will significantly reduce barriers to entry into the marketplace.

            As for specific examples, I’d say the most obvious one would have to be the huge number of breweries that have popped up since the beer industry was deregulated. We went from having to choose between Miller, Budweiser, and Coors, to being able to choose those three companies, plus Yuengling (yeah, I know, it’s been around for ever, but it’s only been able to go national for the last decade), Sam Adams, Saranac, Magic Hat, etc., etc. almost ad infinitum.Report

            • Avatar Sully Fick says:

              Give it time, Mark Thompson.

              In the early years, deregulation often leads to greater competition. Yet, over time, deregulation almost always leads to monopolies. There have been hundreds of papers written about this (though they do have charts and numbers which tend to scare away many MagicMarket(tm) types).

              As an example, the cable television industry was deregulated in 1984. What happened? Prices skyrocketed, programming quality crashed and burned, and thus began the era of only being able to buy a cable “package” of channels (a la carte, when available, is much more expensive). From 1986 through 1990, the cost of basic service rose 56 percent. (source: Washington Post “Cost of Cable Service Up 56% In 4-Year Period, Study Says”

              Get some better data and wait a longer period of time. After all, Reagan and the Republicans (and then Clinton) de-regulated the financial industry (remember S&L crisis?) and repealed Glass-Steagall, and everything looked mighty fantastic for 20 years. Then came the reckoning…

              Come on! Give me something better than “the market will fix everything once you take away the regulations – see you can buy more beers now!”Report

              • Avatar E.D. Kain says:

                You are ignoring the fact that cable has increased in both the number of channels and the availability of programming as well as inflation. Back in the day you had maybe 20 channels tops. Now you have HD, you have hundreds of channels, and you’re paying maybe twice as much for it, maybe a bit more. Now take inflation into account.

                Or how about this:

                In 1970, of the 862 stations in the country, only 82 operated independently of the three networks. The number of independent stations doubled in the 1980s. By 1995 there were 1,532 stations, of which 450 were independent of the three major networks.

                Hell, the only reason the networks have monopolies was the government granting them the airwaves. The list goes on and on.Report

              • Avatar Sully Fick says:

                Well, now we’re really having an apples/oranges conversation.

                Back in the day there was ABC, CBS, NBC.

                Now, these are minor players, and we have GE, Westinghouse, Viacom, Disney, Time/Warner, and NewsCorp.

                This doesn’t seem like LESS monopoly to me, it seems like MORE. Hell, Rupert Murdoch controls more channels, papers, magazines right now than were available “back in the day”.

                The point is that de-regulation made the companies larger (and hence, more monopolistic) than they were in the past.

                I think we’re just going to have to agree to disagree.Report

              • Avatar greginak says:

                The gov didn’t “grant” them airwaves. The airwaves are public and each station got a license to use part of the public waves.Report

              • Actually, the beer industry was one of the first to get deregulated under Jimmy Carter, which makes it an example with one of the longest track records.

                And you asked for just one example. I gave you just one example.

                It does not surprise me in the least bit that there is a tendency towards consolidation after an initial flurry of greatly expanded competition from deregulation – if someone is able to offer a quality product for cheaper, then of course people are going to flock to it and away from competitors; no one denies that economies of scale exist.

                The question is whether the end result is as much monopoly as existed before deregulation and whether that monopoly is stable and permanent in such a way that it can behave as a monopoly (ie, extort a monopoly price). Yet the evidence shows that large corporations are far less stable now than they were 30-40 years ago. I don’t have the statistics in front of me right now, but CEO job stability nowadays is somewhere in the neighborhood of only three years, whereas in the 50s-70s it was greater than that by orders of magnitude. Similarly, the list of the largest US companies was essentially static between the 50s and 70s; now, something like 1/4-1/3 of the list changes every year (again, I don’t have the source for this available at this moment).

                Your example of the cable industry doesn’t make all that much sense, either. Between 1986 and 1990, cable went from being a luxury in relatively low demand to a necessity in very high demand; IIRC, the number of available channels on a given service provider increased substantially as well (in response to demand, mind you).

                The issue of a la carte costing more is a red herring – the cable company has to pay the same amount to carry a network no matter how many subscribers choose that network but, once transmission rights are obtained, it costs no more to send 100 channels to a customer than it does to send that customer 5 channels. In fact, it costs less because it requires a certain amount of extra customer service and labor to customize a package for a customer than it does to just send them everything at once.

                Now, if you wanted to create a situation where the cable companies simply didn’t exist and the government took ownership of the cables and treated them as infrastructure along the lines of public roads such that individuals contract directly with the networks they wish to receive, then a la carte would be significantly cheaper (on the other hand, tax dollars would have to be used to maintain that infrastructure). I am, actually, somewhat ambivalent about the propriety of such a move.Report

              • Avatar E.D. Kain says:

                I am, actually, somewhat ambivalent about the propriety of such a move.

                Keep government out of my tv and my cable packages please.Report

              • Oh, I’m not suggesting that government be involved in the least in terms of the availability of tv and cable packages. I’m just saying that cable-laying, much like road-building, required government assistance in the first place – it’s arguably (emphasis on arguably) infrastructure that would be acceptable for the government to own, but only provided that it set very, very low hurdles for broadcasting via those cables.Report

              • Avatar Michael Drew says:

                Jesus Christ, are we talking about TV or health care here?Report

          • Avatar E.D. Kain says:

            Oh, and Sully, thanks for engaging in the conversation, your really rude and unnecessary comment in the other thread notwithstanding.Report

            • Avatar Sully Fick says:

              You’re welcome.

              Didn’t mean to be rude. Perhaps I allowed my ire at lazy arguments to get the better of me.

              You are correct that it was unnecessary. I apologize for the final sentence in that comment, but for nothing else.Report

        • New trade theory applies here, I think. You may wind up with fewer overall insurance producers, but you will also wind up with a greater number of options from which a given individual may choose. IOW, if there are current 100 insurers nationally, but an individual in any given state cannot choose from more than 5 of those, deregulation would result in a situation where perhaps there would only be 80 insurers nationally, but an individual in any given state could choose from all 80 of those insurers.Report

      • Avatar Herb says:

        I don’t want insurance companies skimming their percentage…period. I certainly don’t want them competing for the honor.

        I’d like to remove them from the process completely. Wishful thinking? Probably.

        (Although I do endorse more competition in industries actually related to health care. But the insurance industry –who doesn’t diagnose or treat a single disease– doesn’t count.)Report

  4. Avatar mike farmer says:

    Even if a field has only a few big players, they have to get customers through quality and cost, like E.D. wrote, because if the entry is not blocked, more competitors will enter to meet the demand for quality and low cost.

    I know it’s hard to think about a free market when most people have grown up with a heavily regulated market and lots of government intervention, but we have to start thinking about a free market, not a mixed economy market, in order to consider alternatives.Report

  5. Avatar mike farmer says:

    I posted mine before seeing Mark’s.Report

  6. Avatar E.D. Kain says:

    There has been surprisingly little discussion of the portion of this post calling for vouchers alongside the public plan. Any thoughts?Report

    • Avatar Sully Fick says:

      It seems that a voucher is really just a government subsidy to the individual to use the money as they wish (purchase other basic coverage, purchase catastrophic coverage, etc.). This does nothing to helping reduce costs or cover more people. So, I guess it is just an option to allow choice.

      That’s fine, but aren’t we talking about a public plan option vs. private insurance and reducing costs and getting everyone covered? If a private insurer is going to provide the same amount of coverage – FOR LESS MONEY – and still make a profit, I don’t see this happening, unless the amount of the voucher is much higher than is necessary (i.e. much higher than the costs would be in a public plan).

      It seems like one of those red/blue compromises: the country is vastly in favor of this blue idea (public plan) so we’ve got to offer a red idea too (vouchers).

      There was much discussion (in a somewhat similar vein) about school vouchers. I see this devolving into a similar discussion. For example, what if I practice a religion that forbids medical interference? Will I be allowed to give my voucher to my spiritual advisor? What about my shaman?

      I’m definitely not convinced that competition provides better health coverage. At least, I’ve never seen any evidence of it. The goal for insurance companies is PROFIT, not good medical coverage. There are countless stories about this one topic. For as long as the goal is not good medical coverage, we will not get good medical coverage. Vouchers or no vouchers.Report

      • The goal of any business is always profit, not good _____; to act otherwise, at least in the case of a publicly-held corporation, would be to violate a fiduciary duty to the investors (and, in this day and age, the Investors ‘R’ Us). But in order to achieve profitability, you have to give your customers what they want – not what they say they want, but what they actually want via their revealed preferences.

        The problem with the US insurance market is that the customers and the consumers are not the same parties. US insurance companies tend to do a pretty good job of serving their customers’ needs; it’s just that in order to do this, the consumer’s needs are irrelevant.

        A subsidy to individuals rather than to employers (which is effectively what we do now) would change this problem dramatically.

        My original post on health care vouchers the other day I think answers some of these other concerns quite well.Report

        • Avatar Sully Fick says:

          First off, I completely disagree that “The goal of any business is always profit, not good _____”. There are many examples of businesses whose goal is not profit.

          However, I think you point out (above) some of the major problems with insurance (and business in general) within a capitalist system. Profitability does not always equal something that is good for mankind/the planet/a subgroup/etc.

          I think your post was linked above by E.D. I’ll take a deeper look later when I have a chance.Report

          • Avatar willybobo says:

            Apple SVP of Design on Apple’s goals earlier this month in BusinessWeek:
            “Apple’s goal isn’t to make money. Our goal is to design and develop and bring to market good products,” he explained. “We trust as a consequence of that, people will like them, and as another consequence we’ll make some money. But we’re really clear about what our goals are.”
            Apple’s shares have returned over 800% in the last five years, incidentally.Report

          • Please provide examples of publicly held corporations whose business it is to do something other than make a profit. As I noted above, if such businesses exist, then they stand a pretty good chance of getting sued by shareholders for breach of fiduciary duty.

            Also, I did not say that anything that is profitable is inherently good for mankind, just that in order to be profitable a company has to give their customers what they want – no customers, no profit. Sometimes what the customers want isn’t particularly good for mankind. Then again, history has shown us that central planners are usually even worse judges of what is good for mankind.

            The thing is that when the customers want something that is bad for mankind, if there’s only a handful of those customers, they’re not likely to do a heck of a lot of damage; if there’s an awful lot of those customers, then you have to make the argument that they don’t know what’s best for themselves (since they’re part of mankind) AND should be prevented from engaging in that activity.

            Finally, there is the issue of no one person having a monopoly on the knowledge of what is good and bad for mankind – there are myriad possible definitions of “good” and “bad.”Report

            • Avatar Sully Fick says:

              Good philosophical discussion, Mark Thompson!

              However, I think “The Tragedy of the Commons” applies here, in regards to the choices that people make that make their own lives better (to the detriment of the rest of society).

              In regards to profit, this is the problem – regardless of examples of companies that do not focus on profit (I think the recent Apple example is a good one, Google is another). If the priority is profit, then everything else is secondary – including good healthcare.

              I’m tired of the pro-market argument that the market will magically produce good healthcare. We’ve had a long time of the market trying to produce good healthcare (with profits being primary) and still do not have good healthcare.

              The reason? Because it is not the primary focus.

              If I focus on learning French, I will not accidentally become fluent in Swahili, though I may become more generally fluent in “language”. If we do not focus on good healthcare as the primary goal, we will never achieve it. Everything else is a non-starter.

              IMO, of course. 🙂Report

    • Avatar Michael Drew says:

      I’m fine with a voucher program in addition to a public plan. Great with it, in fact. The only thing that doesn’t come together is this:

      Money for vouchers would then be diverted out of the public plan’s budget.

      Here’s the thing. We’re not in a public-schools-like situation. People aren’t going to be opting out of a public program they have been in by default. They’ll either be opting into the public plan (at a cost), or not. So there’s not going to be any pool of public-plan-opt-out funding available. There’s just going to be however many people opt into the plan, with whatever the resulting cost works out to. Then in addition maybe there’ll be some vouchers. If you’re still for the vouchers (and the public plan) under that scenario, then I think we may have something to talk about.

      That is: unless you are proposing a cap on total enrollment in the public plan. That, though, would be an entirely different animal. Can you clarify, E.D.?Report

  7. Avatar BCChase says:

    There’s one other, entirely different critique I would make of the “deregulate the insurance industry” point: if you let the insurers go national, I think you would also have to institute more national regulations as to the process and level of coverage. The point was made in an earlier thread that once the companies go national, they will quickly seek out the most lax state law to operate out, a la the credit card industry. Now, the two businesses are very different, but I think there will be some similar factors: transparency, cost controls, different state models of health care a la Massachusetts. E.D. states he wants to preserve some minimal level of care. Unless you are convinced all 50 states have insurance law that supports that level right now, national regulations of practice would need to accompany deregulation of one-state law.

    Or am I missing something? Entirely possible, but this seems like the logical thing to do if I were an insurance company out to maximize profit.Report

    • Avatar E.D. Kain says:

      Good points BCChase. Then again, I’m not sure that the new national rules would be more damaging than the restrictions we have now. Certainly they wouldn’t be as destructive to competition.Report

  8. Avatar willybobo says:

    ED, I think your plan is built from some useful insights about the challenges of covering everyone while trying to avoid government-corporate monopolies on care and the problems sure to ensue from that. It’s a good step in the direction of a more conservative policy solution.

    The idea of subsidizing the demand side is a very good one. But as I’ve said before, there’s something glaringly inefficient about writing a check to the IRS only to have 70% of it come back to you in the form of a voucher (or whatever % is left after the administrative costs are taken out for processing this whole thing).

    Why not instead create demand-side tax subsidies instead of employer tax subsidies? That way, I could buy my own insurance or into a co-cop and write off the cost from my taxes. Less bureaucracy and more incentive for providers to market directly to me instead of trying to capture the government machine through special deals or access or whatever.

    On top of that, you’d have to create some new tax, maybe an across the board 5% tax, to create vouchers for the people who don’t pay any taxes or don’t pay enough to get the benefits of the tax incentive. Or maybe you just extend the Medicare tax, and give all of those people Medicare.

    The other problem to be solved would be creating guaranteed access for all the “uninsurable”. You haven’t mentioned that providers would be compelled to accept anyone’s voucher, so it’s likely they’ll still cost-ration all of those people out of insurance. Is your idea that those people would automatically get the public plan as well?Report

    • Avatar E.D. Kain says:

      Actually here’s what I had in mind – the vouchers would be as an alternative for people who qualified for the public plan. So not everyone would qualify. You’d still be able to purchase your own insurance directly unless you couldn’t – and then you could take a voucher or opt into the plan.

      I think that companies would have to accept the vouchers for the “uninsurable” somehow. I haven’t worked that out honestly. Government reinsurance? Or just the appeal of getting a lot of extra business so an acceptance of a government mandate?Report

      • Avatar willybobo says:

        Also, what do you think about Gawande’s point that cost control is not really (just) a question of who writes the check, but also (maybe more so) about who spends the money, namely doctors? Thoughts on conservative ways to incentivize providers to be more patient value-oriented than they are now?

        Mike Farmer suggested that getting people to pay directly for an MRI will bring down the cost, something I’ve long thought true as well. But it seems to me a chicken-and-egg problem until we get costs way down from today to be even in the realm of what most people can start to pay out of pocket for.Report

        • Avatar Sully Fick says:

          Also, what do you think about Gawande’s point that cost control is not really (just) a question of who writes the check, but also (maybe more so) about who spends the money, namely doctors?

          I know you didn’t ask me, but…

          As long as healthcare is about profits and not good healthcare, we will not achieve good healthcare. We will continue to achieve good profits (and not good profits), but achieving good healthcare will be an accident.Report

          • Avatar mike farmer says:

            This focus on profits is ridiculous. If we get government-run healthcare, the added costs of bureacracy will dwarf profits made my private companies. The efficiencies of a private healthcare system are all you need to consider, not the simple fact that there are profits — plus, the profits are even skewed by government intervention — the new plan is making a deal with the specialists to protect their high pay. I am not calling what we have now a private healthcare system, because it’s not, it’s just the version of government intervention, so far — and now we are calling for more government intervention? Incredible. I fear for the sanity of the this country.Report

            • Avatar willybobo says:

              I’m not against the profit motive per se. Profits simply mean that people involved get paid. That keeps good people involved. But what I do think is a problem is that there are 17 different people in between the patient and the doctor that each have a profit motive. That’s what makes an MRI cost $2000.

              I’m not really sure why, beyond ideological aversion to government doing anything domestically, that conservatives automatically believe that the government couldn’t create efficiencies by moving to a single payer.

              Why do you think that, Mike? And believe me, I know it’s quite a leap to believe that the government could do anything well, and I’m not saying it would happen automatically. But, with just three parties involved — patient, health care provider, and government payment system — couldn’t in theory at least that be more efficient than patient, provider, patient’s company’s health care administrator, patient’s spouse’s health care administrator, hospital representative to patient’s specific health care plan, insurance and administrator…

              If it could in theory be more efficient, why not start asking, what it take to make the theory real in practice? What pitfalls and problems would we need to anticipate and design around?Report

              • Avatar mike farmer says:

                I will turn it around — if the government can pay for healthcare at a rate that prevents healthcare workers from leaving the system, and they can pay at a rate that allows physicians to utilize new technological advancements, thereby encouraging the development of new technologies, and they can prevent the overuse of care without seriously limiting use when needed, and they can also take care of other government responsibilities without raising taxes to the point that it stagnates the economy and keeps unemployment high, and they can keep their single-payer program efficiency high so that costs don’t cause cuts in other important areas like national defense in crime prevention, and they can prevent the program from being a political football whichs favors some interests over others, and they don’t use the medical information for political purposes, then it might work, but do you want the government to have that much power?Report

              • Avatar willybobo says:

                The government having too much power is a worry, but the government gets most of its power from defense spending. They allocate an ungodly sum every year in accumulating even discretion to launch operations around the world without ever having to ask the public to consent.

                If this doesn’t bother you, it’s hard to take seriously that health care spending bothers you. Why do you believe the government can be efficient in allocating and administering hundreds of billions of dollars every year to defense, but can’t maintain the same level of efficiency in health care spending?

                In terms of how that money is used, do you think the government is somehow less bureaucratic and error-prone when they’re operating overseas in places like Iraq and Afghanistan than when they are operating domestically?

                Now, I’m not advocating for replicating our approach to defense with our health care system. That would be a disaster. I’m saying rather that unless you’re worried about capture, corruption, waste, and over planning in defense, you aren’t really a limited government guy. At that point, we’re just arguing priorities. And I certainly think there’s a strong argument to be made that my family’s overall safety benefits more from spending on health care than from any marginal spending on defense above inflation-adjusted 1955 levels.Report

            • Avatar Sully Fick says:

              Proof please:

              If we get government-run healthcare, the added costs of bureacracy will dwarf profits made my private companies.


              The efficiencies of a private healthcare system are all you need to consider…

              This seems to be saying that a private _____ system is the most efficient system possible and nothing else need be considered. Proof please.

              If this is the case (that private systems have greater efficiencies), then why do we have public schools? Roads? Services? etc. Wouldn’t a private system be more efficient (hence, “better”)?

              Enron comes to mind here. A de-regulated private system for the sale of power to customers. More efficient? Well, more efficient at *what*? At profit? Yes! Very efficient at profit. Efficient at delivering power at a good price to customers? No! They were the antithesis of providing any “good” to customers. Profit was the only thing that anyone considered.Report

              • Avatar mike farmer says:

                The proof of bureacracy is in the history of government programs, the much higher cost of medicaid and mdicare than first predicted — bureacratic bloat runs throughout all government programs — there is good reason to expect it to continue with the new healthcare plan, just as it is in the present system which is virtually run by government regulations.

                What I was saying about a totally private solution is that efficiencies in in rivate healthcare need to be considered in determining which approach is best — if you micro-model both approaches, you’d get a good idea which approach would be more efficient — but just looking at removing profit is misleading.Report

              • Avatar mike farmer says:

                Sully, have you looked at government’s involement with Enron? Using Enron as a free market example is like using Michael Moore as an example of objective documentaries.Report

              • Avatar Michael Drew says:

                When one tries to make a point one is by definition not trying to be objective.Report

              • Avatar mike farmer says:

                Unless the point is objective.Report

              • Avatar Michael Drew says:

                Like 2 + 2 = 4? Why does one feel the need to take others’ time with such ‘objective’ points?Report

              • Avatar mike farmer says:

                Don’t be dense. For example, you could create a documentary film to make a point about problems with Canadian healthcare, to take a subject related to the post, and make the point using objective facts and information, including the good points and bad points — the main objective point being, perhaps, the bad points outweigh the good points.Report

              • Avatar mike farmer says:

                Conversely, you could make a subjective point by saying your gut tells you single-payer is better because it seems more fair and efficient.Report

              • Avatar Michael Drew says:

                Arguing that good points outweigh bad points will depend on an least somewhat subjective ordering of values and priorities.Report

              • Avatar mike farmer says:

                Not necessarily, not if you are using the accepted values which make up good healthcare and which can be measured. You could exclude all values which are deemed subjective.Report

              • Avatar Michael Drew says:

                This whole thing is about figuring out which values are going to be paramount. If there were universally accepted values — and consensus about their relative importance — then the solutions would be fairly apparent, even if undesirable. Politics happen because people have deep, prior differences in how to solve problems, resulting in a fight whose outcome some people are less happy with than others. All of that is because of subjective but real differences in how people approached the problem to begin with, rooted in their values. This all seems basic and obvious to me, but perhaps to you the values to be prized most highly are so obvious as to seem objective.

                In any case, the analogy was about documentaries. It seems to me that documentaries of a political nature almost always have some ideological point or other to make — we take that for granted. They rarely pretend to be ‘objective’ like the NBC Nightly News. So calling out Moore’s films has always seemed to me little more than a political tic of people who differ profoundly with the particular angle he takes than as a coherent way to draw real distinctions between his stuff and other political documentaries. That might not be an objective assessment, however.Report

              • Avatar mike farmer says:

                Oh, so I have a political tic — I see. So, I guess we can honestly say that Moore’s work is the epitome of objective documentaries. My tic prevented me from seeing this — thanks.Report

              • Avatar Michael Drew says:

                No, my friend. Moore’s work, like most documentaries that intersect with politics, is not and is not intended to be objective. I hardly see how any work of art or commentary on life with a particular viewpoint can be seen as objective. I don’t think NBC Nightly News or the New York Times are objective, for all their protestations to the contrary. I just think that Moore hit a nerve with certain people back in 2004, and since then he gets singled out for something that is common to almost all political commentary — subjectivity, ie prizing one’s own political convictions or preferences over other ways of seeing the world. That singling out is what I am saying is a political tic. I’m certainly not saying Michael Moore is objective. I’m saying the political is a realm where objectivity is merely a pose.Report

              • Avatar mike farmer says:

                Micahel, do you understand the point of my analogy? To show that using Enron as an example of free enterprise is as ridiculous as using Michael Moore’s work as an example of objective documentary — you actually have made the point of my analogy. Thanks.Report

              • Avatar Michael Drew says:

                No, you’re right. I was going to say that ultimately your analogy holds up in a way…Moore, like most documentaries and political commentary, is not objective. I forgot to add that in. I’m just pointing out that a possible implication of your example is that we might expect non-Moore material to be ‘objective.’ I’m just pointing out that’s not the case. Hence the fixation on Moore being nonobjective (which I’m not saying you’re exhibiting, merely that large numbers of people once did) is just singling out a particular example of a commonplace phenomenon, in my view because his particular viewpoint was unwelcome. In other words, back in Farenheit days, a meme got started that Michael Moore was opinionated in some way that was beyond the pale when everything else in our political discourse in those days was by comparison in bounds. It never made any sense whatsoever. I have no idea how much you ever subscribed to that notion yourslef — you may just be leaning on that public view of Moore to make your analogy and nothing more. I’m just revisiting the underpinning logic of the criticism of Moore you’re invoking, just because I find it an interesting point to examine.Report

              • Avatar Michael Drew says:

                I guess my point was that, for all the criticism Moore received from, well, wherever, I don’t think even his defenders proclaimed him to be a paragon of objectivity and neutrality. They merely said that his perspective offered a way of looking at the war for example that was worth considering. At least that’s all I ever said or heard said to my recollection. Which to my mind makes it a somewhat weak analogy. You could have said that it was like saying George W. Bush was the greatest president in U.S. history. Assuming I agreed with you about Enron, I’d have to agree that the analogy works. But if no one is saying the thing you’re using for the analogy, then there’s not much leverage in the analogy. “Saying Enron is a good example of the free market is like saying the moon is a good example of a nice Roquefort” would be another similar thing to say.

                So then I chimed in to say, it’s really not remarkable, nor does it mean there is no value to the opinion expressed in the film, that Michael Moore produces films that many would agree are not objective. In addition to few people claiming the contrary, it’s also really not that much of a knock against him, nor does it distinguish him in any way from others in the same field.

                So yes, the analogy works formally. But there’s not much force behind it. To my mind, my initial response carried that meaning clearly. When we are making points, it is generally not assumed we are being objective, but rather that we are expressing a subjective opinion. I think Michael Moore would gladly cop to having an opinion.Report

              • Avatar mike farmer says:

                Well, if you could prove that the great majority of documentary films are subjective, then you might have a point, otherwise, your argumentation is specious, and just a little odd in its persistence. I really think, though, that we’ve exhausted the dissection of this analogy and I promise to never use Moore again in an analogy. As a matter of fact, I’m exhausted period and think I will spend my energy on my blog, rather than argue in circles here. There’s a strange resistance to objectivity from the left and right that I find very uninteresting. Later.Report

  9. Avatar SEF says:

    Does anyone here ever travel? Anyone have any ideas how European countries all have much cheaper (like, half the cost per person) health care with better results than ours? Some are socialized, some are insurance based, and every single one of them does a better job than the American “system.”Report

    • Avatar mike farmer says:

      SEF, can you show me proof of this claim, along with the medical inventions and innovations which improve healthcare?Report

      • Avatar dsimon says:

        It’s well known that many of our peer nations get comparable health results as we do while we spend nearly twice as much. Check out this graphic that compares the US to Britain, Canada, Australia, and New Zeland on five year survival rates for several illnesses.

        I can’t speak to innovation, but if it’s innovation we want, there’s no reason why Americans should be the ones picking up the entire tab while everyone else gets a free ride.Report

        • Avatar mike farmer says:

          This doesn’t prove they have a better system than ours — there are many variables to determine before that conclusion is reached. And, regardless of what is “fair”, who is going to innovate and improve medical technology and procedures for the future? If we set up a system that like there’s that discourages the high costs of R&D, then who is going to do it?Report

          • Avatar willybobo says:

            I’d say better health outcomes at less cost is innovation in health care. And that’s not what’s coming from our system.

            Long term, we do have to worry about R&D, but right now the bigger problem is access rather than insufficiently good products and technology.Report

            • Avatar mike farmer says:

              This has become a useless argument. We’ll all see what developes. I will make a prediction, though, that as you see the US weaken in global affairs, as our economy is weakened from the burden of increased government spending and we have to pull back from UN support, foreign aid, military bases, the World Bank, etc — the countries which have given their citizens goodies due to the fact they haven’t been responsible for their own protection, or contributing to the problem of third world nations, or financing the World Bank, or R&D, etc., will be in an awful bind when they don’t have dirty capitalism to rely on to pay for all their social schemes. Socialistic schemes work only when, globally, there is enough capitalism generating enough wealth from countries willing to share the wealth with the world, and, in essence, supporting these schemes. The US will not be able to play that role, if we continue down the path we’re on. Europe will be vulnerable to external threats which surround them, and they are going to be financially strapped when they have to fund a response to this these threats. Survival will be more immediately important than R&D or healthcare access.Report

    • And the one difference that the American system has with every single one of the European systems (which as you correctly note run the gamut from fully socialized to heavily privatized) is that the American system is employer-based.Report

  10. Avatar KG says:

    You say: and healthcare and credit cards are hardly the same line of business

    As a lawyer that deals with lenders quite a bit, I’d think you’d be surprised how much insurers and lenders are alike. Both offer a “service” that is chock full of red tape, fine print, and one sided loop holes. They are effectively adhesive contracts (meaning they get to decide what the terms are, when the terms may change – without consideration – and the consumer has no real choice in the matter other than accept or reject), no negotiating any terms.Report

  11. Avatar Aaron says:

    I am a professional who has the highest level of standard in insurance possible; however, I also have a very rare lymphoma, and my experience with business insurance has been irritating at least and dangerous at most. Yes, insurance has done a lot for me, but it is my vigilence that keeps me alive–the companies would screw me over so badly if I did not fight. In fact, a fellow employee died because his cancer came back, but the hospital could not get him back in for testing. By the time he did get in, it was too late–he had 5 months.

    I was forced to leave my insurance this year after rates were raised $4000 for everyone in a single year. Since we have no raises the last few years, I had to go for the cheaper insurance (everyone did also). The coverage is the same. However, transfering information and getting my treatment restarted is a nightmare. I have been without treatment for 4 weeks. I have been told I cannot even have an appointment for 7 more weeks. I am currently throwing a fit because it is like a diabetic being denied insulin for 11 weeeks. One doctor even ridiculed me for leaving the previous insurance. If I were to fully explain the problems I have had with insurance run by business, you would be horrified.

    I should be one of the supporters of “choice” and no government option. Yet, when I was on the public option in college (because I was poor), I had much better care, and I was able to actually get from point A to point B without much problem. We need to quit thinking that somehow business works better. Government can work fine (such as with law enforcement). Business should work better, but I feel that there is no humanity in dealing with the business option. Universal healthcare is not a perfect idea, but I suspect I would have a much easier time dealing with my situation if the system was more continuous and connected (let me also just mention that my experience with French healthcare during my three years in France was perfect–the French love it, and the healthcare was much better than our healthcare)Report

  12. Avatar mike farmer says:

    Aaron, I suspect there will be many stories like yours forthcoming.Report

  13. Avatar Chris Cziborr says:

    I have lived and worked on both sides of the border and I found the Canadian and U.S. health care systems were roughly a wash for me… while I was working. Once I got laid off in the U.S. the U.S. health care system took a pretty steep nosedive for me. I had to pay $250 a month for COBRA, which is pretty steep for someone who is unemployed. 🙁

    My experience is that the U.S. health care system isn’t as bad as a lot of Canadians think, while the Canadian system isn’t as bad a lot of Americans seem to think. 🙂 However, I think both systems are pretty much below-average by industrial world standards.Report

  14. Avatar Chris Cziborr says:

    >Once I am no longer responsible for paying for my own liver >treatment… should I be allowed, legally, to be a drunk?

    >Should I be allowed to have 9 kids? Nine abortions? Nine cigarettes >per day?

    >Who decides?

    Insurance companies in the U.S.? It’s called, “pre-existing condition.”Report

  15. Avatar Chris Cziborr says:

    >Business should work better, but I feel that there is no humanity in >dealing with the business option.

    Coverage denial == more profit. Pretty basic stuff, and yet libertarians and conservatives seem to be pretty much in denial on this point.Report

  16. Avatar Rob says:

    I already have socialized medicine. As a member of the Cherokee tribe I get free medical treatment at tribe ran clinics. Is the care as good as at a normal city hospital? no. Do you wait more? yes. Do they rely on an external system a lot since they are under equipped for serious cases? yes. Is the selection of drugs limited to older, or cheaper versions? yes. Is the cost per person more then tribe members would be willing to pay given the quality of care? yes.

    I have free to me health care, but it isn’t free. The system only works at the level it does because the tribe has good external sources paying for it, treaties with the US government that causes them to compensate the tribe and a massive cash cow taking loot from the white man in the form of casinos.

    Any given system can only spend X on something before it becomes detrimental to the over all quality of life inside the system. This is true even with health care. I feel the US has already pushed too far into diminishing returns with health spending, so no matter the solution offered it needs to try and accomplish more with less money. Any idea or concept that ends up costing the nation more will ultimately lower our standard of living. We simply can’t seriously impact the income of 99 people to save the hundredth is what I am getting atReport