improvements to the current health care reform proposals


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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18 Responses

  1. Avatar Zach says:

    Ditto on national regulation. This is the one idea that Obama should take from the GOP and run with. Regulation in many states is corrupt if not broken, anyway, and the Feds have to double check everything since half the money being spent is theirs. I suspect this is where you might run into actual constitutional issues, though.Report

    • Avatar Zach in reply to Zach says:

      Also, an obvious problem with this is that increasing the regulatory burden on the Feds would raise the cost of the bill substantially… at least a few billion. Of course it would save states that are now going broke way more than that, but it’s still a hurdle.Report

  2. Avatar North says:

    You realize E.D. that merits of this bill aside it’s a giant bucket of liquid death for the Republicans. If the Dems manage to pass substantive legislation like this, especially with fiscally responsible proviso’s that make financial libertarians take another look at the Democrats in a favorable light, the Republicans could be looking at an absolute blowout in the next election. Especially if the economy puts up more green shoots. Merits aside the short term political calculation says that the Republicans need to kill this thing more than ever.Report

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

      I’m not terribly concerned about short-term political outcomes. I care a great deal more about structural outcomes, and health reform is simply necessary at this point. Whatever short term benefits the Democrats may gain, they’ll lose again through hubris.Report

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

        Well yeah me too only sortof the reverse. I think my point is that merits aside the Republicans are going to throw everything including the kitchen sink and Granma’s cat at this thing to sink it regardless of its own merits.Report

  3. Avatar Andy Smith says:

    Amidst all the talk about how to reform health care, I find it astonishing that so little attention has been paid to the one factor that every one of us has some control over: our lifestyles. Eating well and exercising regularly don’t guarantee good health, but everyone knows that there are a few relatively simple steps that we can take that improve the odds. Shouldn’t this knowledge be built into any approach to health care in the 21st century?
    Much of the opposition to Democratic proposals for reform is based on visceral dislike of government running our lives—at least, that’s the message being made loud and clear in most of the protests. There seem to be two aspects to this resentment of big government: 1) critical decisions over what doctors we can see, and when, and where, and for what reasons will be taken out of the hands of individuals; and 2) tax money will go to provide care for those who otherwise can’t afford it.
    But if people really want to control their own lives, shouldn’t that begin with taking better care of their bodies? Isn’t it hypocritical to demand more individual control over medical decisions while pursuing dietary and exercise habits that increase the odds that one will get heart disease or cancer? Isn’t it equally hypocritical to resent public money helping the poor when poor lifestyle choices help drive up the costs of health care for everyone? By one estimate, for example, obesity adds several hundred billion dollars to the total. Aren’t people who knowingly persist in unhealthy habits the new welfare queens?
    How about a credit for health insurance payments according to the efforts one makes to take care of one’s health? If this sounds radical, consider that poor health habits amount to a pre-existing condition, for which there are already massive penalties. Someone who eats a lot of junk food, and/or doesn’t exercise regularly, and/or smokes or drinks heavily is increasing the odds of needing medical attention just as surely as someone with a family history of some form of cancer.
    Yes, I know that evaluating what is and is not a healthy lifestyle is not easy. Which foods count as healthy, and which don’t? How much exercise is sufficient, and what kinds? While there is quite a bit of scientific information bearing on these questions, there would nonetheless be very heated arguments over them. I also know that it would be exceedingly difficult to enforce such a provision–to validate that someone is, or is not, for example, sticking to the diet he claims to be following. Opponents would have a field day over scenarios in which health cops probed into every aspects of our daily routine.
    Yet there are some easily measured parameters, like body mass index, blood pressure, cholesterol level, white blood cell count, et al. that could be used. We know what healthy levels of these and other physiological processes are. Why not build into the insurance program incentives to improve these parameters?
    The ultimate goal, of course, would not be to credit or penalize people, but to use peer pressure to persuade people to make better choices about their health. And in the meantime, whenever someone raises the specter of government control, ask her, how well are you exercising the one form of control you have over your medical future right now?Report

  4. Avatar Ryan says:

    I had to reread #5 a couple times myself. What Ezra means re: bipartisan incentives is to make it obvious that compromise counts. Baucus created a bill that gave Republicans most of what they want at the cost of things his own guys want, and he got nothing out of it. What Ezra wants is to make it clear to Republicans that, if they aren’t willing to provide votes, the Democrats aren’t willing to compromise. And, conversely, that if they’re willing to provide votes, the Democrats are willing to compromise.

    So the incentive mechanism looks like this: either Grassley and Bennett and Snowe, et al, starting actually signing on to the bill or we’re going to jack up subsidies, stick in a public option, and otherwise cram a whole lot of crap down the GOP’s throat. If they aren’t going to vote for the thing, who gives a crap about appeasing them? Let’s just have a liberal bill. Again, conversely, if they’ll actually vote for the damn thing, we’re willing to have a much less liberal bill.Report

  5. Avatar PD Shaw says:

    Ezra Klein has never made any sense to me about the reasons for a public option, other than it exists as a compromise on the Left on a single-payor system. At least I understand the virtues of a single-payor system: the government has monopolistic power to set price and it has compete discretion to charge (or not charge) premiums based upon public equity. It also solves portability and removes the employers from the role of primary decisionmaker.

    If the public option increases competition, it is not likely to reduce healthcare costs. It may increase them because healthcare insurance monopsonies have leverage to demand price reductions from healthcare providers. (Competition may promote some better insurance practices, i.e. competition in those services that the insurance company actually provide, but where the insurance company is acting as agent to negotiate cost reductions from third parties, it would appear to work the opposite)Report

    • Avatar Nob Akimoto in reply to PD Shaw says:

      If the public option increases competition, it is not likely to reduce healthcare costs. It may increase them because healthcare insurance monopsonies have leverage to demand price reductions from healthcare providers.

      This is actually not true. Insurance companies are presently used by healthcare providers to make up the shortfall in revenue (they believe) they have relative to the fees they charge Medicare.Report

      • Avatar PD Shaw in reply to Nob Akimoto says:

        My insurance provider has negotiated with local healthcare providers to pay 80% of approved charges; IIRC the House government option would have something similar. As I see it, the principle is similar. The government or dominant insurance companies in a given market can demand cost reductions due to leverage.

        Now you are probably right that these savings are passed on, but I assume they are passed on proportionately to those with less leverage.Report

  6. Avatar Michael Drew says:

    Very good round-up, E.D — useful. Thanks.Report

  7. Avatar JosephFM says:

    I agree, and thus have nothing constructive to say.Report

  8. Avatar Michael Drew says:

    Notably, this post dovetails really closely with Krugman’s column today. (Y’all know where to find it.)Report

  9. Avatar Ryan Davidson says:

    In re your comments on point four, urging for national regulation of health care: It ain’t gonna happen, and in all likelihood, you don’t know what you’re asking. There are two things going on here. First, what you suggest is almost certainly unconstitutional, and second, even if it were legal, you really, really don’t want that.

    On the constitutional issue, there’s this pesky thing called the “Commerce Clause” which gives Congress the ability to regulate interstate commerce, but has largely been constructed to prohibit regulation of purely intrastate commerce. Medicare and Medicaid may seem like national health plans, but in reality, what they really do is fund 50 individual programs administered by state governments. Insurance is and has always been exclusively regulated by the states, and I highly doubt that the Supreme Court would permit the federal government to assume responsibility for such regulation, no matter how badly it might want to.

    This is a different argument than the one which has been advanced against single-payer. I’m not addressing that at all. All I’m saying is that insurance regulation is a classic example of an economic issue which has always been regulated by the states without any federal interference, and as such, the Supreme Court is likely to strike down any attempted federal regulation of health insurance.

    In addition, even if such were possible, you really don’t want the federal government to regulate insurance, as attractive as the idea may sound on the surface. I’m an attorney in the insurance industry. I regularly research the requirements for P&C insurance in 50 states, as my company currently writes in 42 of them and is working on being admitted to the other 8. I’ll be the first one to say that this is kind of a pain in the ass and that it would make my job a lot easier if there were a single regulatory environment in which we had to operate.

    But this would be terrible for our insureds. State insurance regulations tend to reflect the overall environment, cultural, political, and economic, of their respective states. Health care is more expensive in some states than others, as property values, tax rates, energy prices, transportation costs, the desirability of various locations and the like all factor in to determining costs. There is no single rating plan that can adequately represent the interests of both, for example, New York and Missouri: either New York will have a woefully inadequate level of care, or Missouri will go bankrupt trying to match New York rating structures (actually, this very nearly happened as Missouri attempted to comply with Medicaid regulations), or, what is more likely, neither state will wind up with health insurance that meets its needs. The only way to avoid this is to create 50 different rating systems… which is basically what we have now.

    So national regulation of health care might sound like a good idea, but you really don’t know what you’re asking, and if you did, you wouldn’t want it.Report

    • Avatar Underwriterguy in reply to Ryan Davidson says:

      How about separating regulation from state mandated benefits? It’s the mandates that drive up the cost of health insurance. Fewer mandates, lower costs. Let consumers choose. Thoughts?Report

      • In theory maybe but in reality those mandates do serve a purpose in the thicket that is health benefits. I’d like to see more competition to compensate, but when there is little choice and no mandates to ensure necessary coverage, the consumer gets screwed.Report

    • Avatar Michael Drew in reply to Ryan Davidson says:

      This single comment does a better job answering some basic questions about why insurance regulation is done at the state level, whether it is in fact ‘illegal’ for insurance companies to operate “across state lines,” and what the pros and cons of the status quo and of changes to the arrangement might be than a number of posts and subsequent comments discussions here and elsewhere have done. Very helpful commentary.Report