A few more thoughts on why I support the healthcare bill

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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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  1. Avatar Jaybird
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    says:

    Coverage is not healthcare.

    Healthcare is a widget.
    Coverage is a set of words phrased to look like a promise.

    What we have is a government waving a piece of paper saying “health care in our time”.
    I’m sure that people, in the short run, will cheer.Report

    • Avatar Erik Kain in reply to Jaybird
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      says:

      No, coverage is not healthcare. But if you’re implying that now that more people are covered they simply won’t be able to find healthcare, I think you’re taking a pretty huge leap. If there is a shortage of supply then certainly there may be a period of time in which it is harder to find a provider. I think the market will respond, however, especially since there will be more jobs in the healthcare industry and we’re still sitting pretty at 10% unemployment.Report

      • Avatar Jaybird in reply to Erik Kain
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        says:

        I’m not implying that now that more people are covered that they simply won’t be able to find health care.

        I will come out and say that there will likely be a number of people who didn’t get health care before that are getting it now… but there will be a number of people who were getting health care before and are now finding themselves with less… maybe it’ll manifest itself like a long queue. Maybe it’ll manifest itself like government recommendations to get check-ups or tune-ups less often. It will, however, manifest itself.

        If this also manifests itself somewhat as increased costs among the folks who feel that they have less health care than they used to (taxes, co-pays, what have you) then we will have a situation where people will be saying such things as “we’re paying more but getting less!”

        That doesn’t strike me as particularly sustainable.

        But, hey, maybe you’re right. Maybe everybody will be better off. Wouldn’t that be nice?

        It’s certainly something worth writing on a piece of paper and waving around.Report

        • Avatar Erik Kain in reply to Jaybird
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          says:

          So there seems to be two competing arguments here. On the one hand people are saying “If you subsidize something people will get more of it” implying that since more people are covered more money will be spent on healthcare. On the other hand, people are saying “There will be a shortage of supply” implying that since more people are covered demand will surpass supply. These seem to work against one another.Report

          • Avatar Jaybird in reply to Erik Kain
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            says:

            On the one hand people are saying “If you subsidize something people will get more of it”

            It strikes me as *EXCEPTIONALLY* important to define what “something” and “it” are in this sentence.

            What are we subsidizing? It’s *NOT* the provision of health care. It’s the wherewithal to stand in a queue for health care.

            So we will have more people standing in a queue for health care.

            Health care is not being subsidized. That is, this bill isn’t paying more people more money to hand out health care. It’s paying more people to “cover” health care.

            But, as has been pointed out, coverage is not health care.

            On the other hand, people are saying “There will be a shortage of supply” implying that since more people are covered demand will surpass supply.

            It’s not that demand will surpass supply. It’s that the rate of growth of demand will be larger than the rate of growth of supply which will manifest itself one (or, more probably, both) of two ways:
            Larger costs
            Longer queues

            This bill may result in providing health care to folks who never had (or felt they had, anyway) the wherewithal to stand in a queue for health care.

            This has an effect on other folks in line. If the rate of people joining the queue grows at a rate faster than the queue is moving… well, I’d hope that I’d have enough political connections to get cutsies near the front.Report

            • Avatar Alex Knapp in reply to Jaybird
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              says:

              The United States already ranks abysmally low among OECD countries when it comes to wait times compared to other countries with universal coverage. And that’s even compared to countries like France, which have fewer doctors per capita than we do. Part of the reason for wait times is that different insurance providers have different “networks” of doctors. For example, I have a friend who needed to see a neurologist, but there was only one “in-network” neurologist in the area he could go to. So he had to wait 8 weeks, even though there are dozens of neurologists in town. Nationally competitive exchanges will hopefully broaden the base of networks, or, even better, get rid of them entirely.Report

          • Avatar Mark Thompson in reply to Erik Kain
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            says:

            If, however, you place artificial restrictions on the sorts of returns that suppliers can make on their investment, or you have restrictions on the amount of suppliers you can have in the first place (e.g., licensing laws)then you wind up preventing the market from reaching an equilibrium where supply can catch up with increasing demand.

            Arguably, this bill increases systemic demand for health care, but does nothing to allow supply to increase. If you accept the premise that we already have a supply-side shortage, then a bill that increases demand but provides no incentives for increased supply will result in the types of problems outlined above by Jaybird. If the problem of demand outstripping supply is resolved by increased prices, you will move somewhat towards an equilibrium again (although this is not necessarily a good equilibrium since prohibitively high systemic costs are the biggest problem in our system in the first place), but even then it’s reasonable to question whether an equilibrium can be achieved when we consider the prohibitively high – and artificially imposed – costs of entry to becoming a supplier of health care.Report

            • Avatar Erik Kain in reply to Mark Thompson
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              says:

              Perhaps, Mark. But what if that premise is wrong? What if supply isn’t the problem but rather access? What if the inefficiencies in our system create an artificial limit to access rather than actual shortage of supply? (See Alex’s comment above.) Reading Matt Welch’s piece on the French healtchare system made me think that this may be much closer to the truth than an actual shortage of supply.Report

              • Avatar Jaybird in reply to Erik Kain
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                says:

                If the problem is access and not supply then I am wrong and this bill will make things better for a lot of people without making things appreciably worse for more.

                That would be very nice, if it were the case.Report

              • Avatar Mark Thompson in reply to Erik Kain
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                says:

                I think it’s perfectly consistent to say that lack of access and insufficient supply are the same thing. Remember, for the most part no one is defending the present system. The problem with this bill, as far as I can tell – and it’s the problem I’ve had with the entire line of thinking the Dems have followed in just about all their non-Wyden-sponsored reform plans this year – is that it gets the diagnosis of the problem completely wrong, and in the process makes the underlying problems worse. It rewards existing suppliers by increasing demand for their services, which arguably already outstrips supply, while doing little to nothing to encourage the entry of new suppliers into the market.Report

              • Avatar Erik Kain in reply to Mark Thompson
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                says:

                But do you think it prevents future reforms to increase supply? How? And what reforms would you like to see in that regard?Report

              • Avatar Jaybird in reply to Erik Kain
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                says:

                It doesn’t prevent future reforms to increase supply but the philosophy behind the bill seems to indicate that it doesn’t apprehend that the problem is a lack of supply in the first place. It doesn’t prevent future bills that would actually help, no… but… so what? It’s a bill that makes things worse without making things better elsewhere.

                The fact that it doesn’t prevent some theoretical awesome bill in the future seems… well, tertiary at best.

                Patriot doesn’t prevent some awesome law that protects personal property from unconstitutional confiscation on the part of the government. So what?

                (As for future reforms, not that you asked me, I posted my future reforms in a comment to the sidebar a few days back: http://www.ordinary-gentlemen.com/2009/12/the-state-of-reform/#comment-34770 )Report

              • Avatar Erik Kain in reply to Jaybird
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                says:

                But now that the coverage question has been answered all future reforms will be about cost and supply. I think that is a huge step forward. I don’t think in this world, in this America, with this government you can address everything at once. I just don’t think that’s a realistic expectation. So you have to address different questions at different times, and this paves the way by removing the coverage issue from the conversation.Report

              • Avatar Jaybird in reply to Jaybird
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                says:

                Really?

                It seems more likely to me that all future reforms will revolve around how children are dying and the conservatives and libertarians are wrecking things by standing in the way of real reform that would work. We just need more funding.Report

              • Avatar North in reply to Jaybird
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                says:

                They may Jay, though that’s a slightly more old school Democratic Party position than the newer one. It would certainly clarify things. I’m hoping along with Erik that once they have it in place they’ll actually try to make it work better. A lot hinges on whether Obama actually makes good on his pledge to get the books in order once we get out of the economic storm.Report

              • Avatar Jaybird in reply to Jaybird
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                says:

                This very site had a discussion revolving around what kind of people would refuse to save the life of Deamonte Driver (e.g. Megan McArdle). It focused on how people were suffering and how people were dying and how people who opposed the reform of health care like the bill we were talking about in August were refusing to deal with the human cost of doing nothing.

                Read it yourself:
                http://www.ordinary-gentlemen.com/2009/08/would-megan-mcardle-have-saved-deamonte-drivers-life-if-it-meant-expanding-government/

                Freddie is many things. He doesn’t strike me as particularly “old school”.

                When it comes to making it better once it’s in place, I can’t help but compare to such things as the TSA getting better since its creation, or the Department of Education getting better since its creation, or the DEA getting better since its creation, and so on.

                I don’t see this bill making things better. I don’t see it setting a foundation upon which things can finally be addressed in such a way that things will be made better.

                We’ll have just as many dead children as before and they will be waved in the faces of others as proof of the moral rectitude of those who care deeply enough to wave dead children around.Report

              • Avatar North in reply to Jaybird
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                says:

                Gotta disagree Jay. No disrespect to Freddie, he’s passionate about what he argues about but his “People are suffering, don’t just sit there, do something, anything, now!!” lines strike me as somewhat pre-Clinton old school left wing. I’m not saying that attitude is vanished entirely from the Dems but I do think that a consciousness of the economics (and a wholesale abandonment of the communism as a potential alternative to capitalism line of thought) has made the party more thoughtful about spending than it once was. Also the people at most of the party levers are much more centrist and DLCist than before.
                Now maybe this is just that they’ve noticed that when they act serious about economics they do rather well in the polls and have sold their soul for power but I think the party has grown up (a little). Or maybe it’s just that the Republicans are turning so jeuvenile in comparison. I dunno for sure. I may be projecting the Liberal party from Canada onto them.

                Your points on the TSA or the idiocy of Homeland security are fair. I still agree with Erik though ya can’t expect them to dedicate much thought to making something cost effective if it doesn’t even exist yet.Report

              • Avatar Jaybird in reply to Jaybird
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                says:

                Well, saying something to the effect of “manicheanism is a relatively recent phenomenon” is something that would, seriously, tickle me pink if I saw someone use it in an argument against me so I’m not going to go there.

                But didn’t there used to be a basic assumption that the opposition was loyal? Was I just raised funny? Ah, maybe you’re right.Report

              • Avatar 62across in reply to Mark Thompson
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                says:

                I question the contention that this bill increases systemic demand for healthcare. I don’t see the consumer saying “Now that I have insurance, I’m going to go get that hip replacement surgery I’ve always wanted.” Maybe there will be a rise in routine care and some elective procedures, but even there I don’t see how this bill would drive demand to a point that it would necessarily outstrip supply. People don’t love seeing the doctor that much.

                Healthcare simply is not like other markets. Demand for medical care is driven primarily by the health of the populace. If medical care is needed, the consumer goes out and gets it, mostly regardless of cost. The alternative is chronic pain or death. That’s why there has been so much medical bankruptcy; means to pay is disconnected from the immediate need to be well.

                This bill WILL lead to an increase demand for health insurance. There sure aren’t any supply issues there.Report

              • Avatar Jaybird in reply to 62across
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                says:

                This bill WILL lead to an increase demand for health insurance. There sure aren’t any supply issues there.

                One cannot help but wonder why if there is a surplus of health care, more and more people are saying that they can’t afford it.

                One cannot help but wonder how an increase in demand would rectify the situation.Report

              • Avatar greginak in reply to Jaybird
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                says:

                you know health care is not one item or thing. there is plenty botox providers but we are short of primary care docs. and of course there is a shortage of money amongst many people to pay for primary care, meds, etc.Report

              • Avatar Jaybird in reply to Jaybird
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                says:

                Sure. How much of these not one item or things are being created by this bill? Any?

                Is the rate of increase of the supply of this not one item or thing increasing at a rate greater than the rate of increase of demand for, for example, primary care, meds, etc?Report

              • Avatar 62across in reply to Jaybird
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                says:

                You are using health care and health insurance interchangeably and they are not the same thing.

                I don’t claim there is a surplus of healthcare. I think we actually agree there is a shortage of healthcare which is part of what has driven the costs so high. (I also agree that I see nothing in the current bills to improve supply.) What I am saying is that I don’t believe that increasing access to health insurance will lead to a significant increase in healthcare consumption (demand), because it doesn’t logically follow that there will be more illness or injury just because this bill passes. Sure, there could be some marginal increase from people who pursue medical attention that they’ve put off because they were not insured. But for the most part, I think people consume medical care because they have a medical condition that requires it. If that meant going to the Emergency Room or going into bankruptcy because they were uninsured or underinsured, they were going to get what they really had to have regardless.

                The cost of health insurance, on the other hand, is not driven directly by supply and demand. Like all other insurance, health insurance costs are driven by the costs of what the plans need to cover factored with actuarial data on the risk to pay out to plan holders. The argument here is that a larger, younger risk pool should drive the cost of insurance down, but that is dependent on the insurers applying increased revenues from more premium payers to lowering the cost of their plans.Report

              • Avatar Jaybird in reply to Jaybird
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                says:

                I assure you, I am not. Allow me to quote myself in comment #1 “Healthcare is a widget. Coverage is a set of words phrased to look like a promise.”

                I know that they’re not the same thing.

                My problem with the bill is that it gives us more health insurance instead of giving us more health care.

                I don’t know how I can be clearer on that.Report

  2. Avatar RE Garrett, MD
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    says:

    Two comments: “Cheap, efficient health centers set up in shopping malls” are fine for people with minor acute illnesses, but they don’t work very well for people with chronic medical problems, such as diabetes or hypertension–unless their structure and personnel are set up to provide continuous and comprehensive care to patients with multiple chronic problems. And this makes them essentially ordinary physician’s offices. It’s quite practical to have both functions in the same building, but there needs to be at least a conceptual understanding that patients with different problems are to be handled in different ways, rather than shooting everyone through an assembly-line quick-care clinic.

    The idea of having a “Teach for America” type program set up for doctors sounds attractive (and, of course, it’s been done for years until most of the funding dried up under Bush Minor)– but what you get is a lot of would-be dermatologists or cardiothoracic surgeons trying to provide primary care in an underserved area, without the interest, commitment, or skill set that would enable them to do so. The physician in the TV program “Northern Exposure” was such a person, and at least at the beginning of the show he was always grumbling about being stuck in the back of beyond instead of being in New York as a specialist.Report

  3. Avatar RE Garrett, MD
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    says:

    A couple of other comments on the supply-and-demand issue. First: making significant changes in the supply and specialty mix of physicians is sort of like steering a supertanker– it takes a long time and requires a lot of planning ahead. A physician needs four years of undergraduate college, four years of medical school, and at least three years of postgraduate training before she is able to practice. Physician’s assistants and nurse practitioners don’t take as long to train, but they have limitations on their practice abilities that physicians don’t have.

    The second point, which is something I’ve hardly seen mentioned on the Internet, is that the majority of the European nations whose healthcare systems are better than ours have a distribution of physicians between primary care (family physicians, general practitioners, general pediatricians and general internists) and subspecialty care (everybody else) of about 50:50. In the US, I believe the mix is more like 80% specialists and 20% primary care docs. There are a lot of reasons for this bad balance, economic, political, academic, historical– but as one looks at healthcare in the US after this reform bill is passed, the lack of primary care providers is one of the most important obstacles in the way of achieving effective cost control and improved service to patients. The fix isn’t obvious or simple, but it’s an issue that will have to be addressed in the near future.Report

  4. Avatar historystudent
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    says:

    “First – and I think this is extremely important – it answers the question about coverage. Nearly all Americans who can’t afford to be covered will be covered by this bill.”

    Coverage means little if those who are covered can’t get access to physicians in a timely manner. It’s like having a piece of paper that says I’m entitled to live at the White House but the Secret Service won’t even let me in the door (different from recent experience, I realize).

    “Second, this bill creates a real market for health insurance. ”

    But is that really what health insurance reform ought to do? Is better health care a matter of being able to obtain a policy that the government has specified (as the House bill wishes to do), and being penalized if one either deviates and wants to purchase something more expensive and/or different from the approved policy or simply doesn’t want insurance?

    Also, there is the question of whether we should use insurance even as much as we do. In this graph (http://blog.riseofreason.com/inherent-problem-with-socialized-health-care/628/), we see again that there is a correlation between the increase in health costs and the decrease in patient responsibility for their bills.

    “One of the best concerns I’ve heard expressed over this bill is that it will limit the supply of medical providers – nurses, doctors, and so forth. ”

    This is of utmost importance. http://www.investors.com/NewsAndAnalysis/Article.aspx?id=506199

    “The exchanges will eventually expand into national markets and people will slowly drift from employer coverage to insurance via exchanges. ”

    And this again is an expression of support for state-sponsored health care crowding out private, competitive suppliers. Yet, competition (when it is on an even, fair and open playing field) is what provides the demand side with supply that best fits its needs. We don’t need a one-size-fits all, bureaucratic system that is more interested in perpetuating itself organizationally than in serving the customer.

    These posts of yours, Erik, suggest to me that you are trying to convince yourself regarding Obamacare. I hope you will unconvince yourself instead.Report

  5. Avatar 62across
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    says:

    Jaybird –

    Allow me to quote yourself in a little later on in comment #1: “What are we subsidizing? It’s *NOT* the provision of health care. It’s the wherewithal to stand in a queue for health care. So we will have more people standing in a queue for health care… This bill may result in providing health care to folks who never had (or felt they had, anyway) the wherewithal to stand in a queue for health care.”

    My point is that by the very nature of disease, illness and injury, people who would consume healthcare will, for the most part, stand in a queue for it regardless of whether they have the wherewithal to do so or not.

    The HCR bills will mean that some of those folks already in the queue without the means to pay for the care they require might be able to avoid devastating financial impacts due to their becoming sick or having an accident. That is a good thing.

    I agree with you that we could use more healthcare and I welcome any efforts public or private to improve that situation. But that doesn’t preclude the need for better health insurance coverage for the millions of Americans who need it and providing more people with health insurance will not exacerbate the shortage of healthcare to the extent that it is not a net good for the country.Report

    • Avatar Jaybird in reply to 62across
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      says:

      My point is that by the very nature of disease, illness and injury, people who would consume healthcare will, for the most part, stand in a queue for it regardless of whether they have the wherewithal to do so or not.

      Interesting point. So the healthcare divvied out will be pretty much to the same groups as got it before only now people will be declare bankruptcy less often than before because their health care costs will be paid for by everybody?

      It’s an interesting argument. Let me think about it.Report

      • Avatar greginak in reply to Jaybird
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        says:

        Huh. Jay are trying to be obtuse here. Is it a surprise that people without insurance get less healthcare or lower quality care? If it is then I’ll find some of the research done proving this although frankly it seems pretty obvious. The lack of ability to afford something results in people using said thing less. People w/o insurance don’t do things like get mammograms or preventive care, because they can’t afford them. to be clear, a lot of people will get more care, and have less fear of losing it, then before reform.Report

        • Avatar Jaybird in reply to greginak
          Ignored
          says:

          Oh, fair enough then. That makes sense to me.

          I’ll go back to what I said before then. If this bill creates “access” rather than “health care”, the best-case scenario is a redistribution of health care. For, like, a massive cost. Yay government.Report

  6. Avatar steve
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    says:

    You need to think about the provider side if you want to increase supply. We are starting a medical school at my hospital. Tuition will run about $60,000 a year I am told. With that kind of potential debt coming out of school, students want to be pretty sure they will have a job.

    I also think that Erik misses one of the strengths of this bill. It has a number of pilot programs looking at was to cut costs. Our health care system is so large, complex and perverse, that I can see how any well meant plan could actually increase costs or just plain fail, even the proposed free market solutions. I would much rather see what actually works before imposing it upon the whole system.

    SteveReport

    • Avatar Jaybird in reply to steve
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      says:

      More stuff I’ve thought about:

      School debt forgiveness for General Practitioners.
      Tax-free status for General Practitioners (if it’s good enough for our boys overseas, it’s good enough for those good people saving lives back here at home).

      When it comes to some of the tools that are needed to provide health care, I’d look at the FDA and see if they are harming more people than they are helping with their rules for clinical trials. (At the very least, rules should be relaxed for terminal patients willing to sign a waiver.)

      There are many things that could be done to help the amount of health care available in the pool.Report

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