Mugged By Reality: A Conservative for Universal Health Care

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Dennis Sanders

Dennis Sanders is the Associate Pastor at First Christian Church (Disciples of Christ) in Minneapolis, MN.  You can follow Dennis through his blogs, The Clockwork Pastor and Big Tent Revue and on Twitter.  Feel free to contact him at dennis.sanders(at)gmail(dot)com.

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424 Responses

  1. Avatar Mike Dwyer says:

    I’ve always been okay with social safety nets, even as a conservative, and I am increasingly feeling that way about health care. Will people abuse it? Certainly. But the net good far outweighs the bad. Yes, universal healthcare is hard to navigate and problematic in other countries. So let’s fix it and make the American version the envy of the world.

    Great post Dennis.Report

    • Avatar Oscar Gordon in reply to Mike Dwyer says:

      Agree, excellent post.Report

    • Avatar Bob Wallace in reply to Mike Dwyer says:

      I’m sorry it this has already been posted but I didn’t want to read through almost 500 comments.

      In Dennis’s first few paragraphs he talks about getting sick when insurance was too expensive for him at his low wage job. Not having insurance he went to a hospital emergency room where he received inadequate treatment. If he had health insurance he would probably have gone to his primary physician soon after getting sick and received better care. (I suspect the hospital physician was overloaded as happens in emergency rooms.)

      Since Dennis did not receive the care he needed he ended in the hospital for an extended – and expensive – care.

      This is what we should be calling “Reagancare”. Ronald Reagan signed the legislation that requires hospital emergency rooms to treat anyone who comes in their door. The emergency room is the default doctor for those without health insurance. And it’s a very expensive way to deal with non-serious health issues.

      Those expensive emergency room flu, twisted ankle, injuries are paid by the rest of us through higher hospital bills when we get sick and higher health insurance premiums.

      We need to understand that prior to the ACA we were paying the health costs for the millions of Americans who did not have insurance. And we were paying for them to receive basic service at luxury prices.

      One of the great values of the ACA is that it meant that everyone could get affordable health insurance and get their problems dealt with before they became more serious and more expensive to treat. And they could get an annual checkup and routine tests so that problems could be spotted sooner – fixed cheaper.

      Want to replace the ACA? Hate that Obamacare? OK, take a stab at it. But don’t shoot us all in the foot by putting us back into the condition where the millions who will no longer have health insurance return to the emergency room where it will cost hundreds of dollars to deal with something that could have been dealt with for tens of dollars.

      Let’s be wise. Please.Report

      • Avatar Dark Matter in reply to Bob Wallace says:

        But don’t shoot us all in the foot by putting us back into the condition where the millions who will no longer have health insurance return to the emergency room where it will cost hundreds of dollars to deal with something that could have been dealt with for tens of dollars.

        We have had attempt after attempt to make policy based on this idea.

        It makes intuitive sense, however apparently it’s cheaper to not treat large groups of people (even if that on rare occasion results in an EM room stay) than to treat them. Our bodies either heal on their own or we die. The “it’s cheaper to treat them” concept appears to not be true.Report

        • Avatar Bob Wallace in reply to Dark Matter says:

          Yes, Palin’s Death Panels should be a big money saver. Especially if we pre-assign people to groups based on their income/net worth.Report

          • Avatar Dark Matter in reply to Bob Wallace says:

            Yes, Palin’s Death Panels should be a big money saver.

            Half your *lifetime* use of medicine happens in the last year or two of life. Write someone a blank check during that time and it’s a problem.

            Death panels are necessary to make the system work. If you can’t stare those facts in the face and live with them, then math breaks the system.Report

            • Avatar Damon in reply to Dark Matter says:

              Like we don’t have “death panels” currently. It’s just called something else, like DOB, or review boards or policy limitations, etc.Report

              • Avatar Dark Matter in reply to Damon says:

                Like we don’t have “death panels” currently. It’s just called something else, like DOB, or review boards or policy limitations, etc.

                Do I sound like I’m arguing against panels? I’m bringing up the issue because the supporters of this sort of thing have to get real comfortable with supporting them.

                …and the politics of it may make this impossible. The issue is less the facts and more the political optics.

                1) Politicians who vote for (or to maintain) this are going to face ads *literally* showing them throwing little old grandmas off of cliffs, and the crying relatives talking about how their child could have been saved with more money.

                2) There’s a shockingly high number of people who think *everything* medical should be funded for *everyone* because the public “has the money”. These types of programs are often politically sold with that sort of promise, and the politicians who do are may be serious rather than cynical.

                It’s the whole “tier 1” vs “tier 2” thing but on steroids. Our political system is not well equipped for this. If we can’t convince the public it’s a good idea then those political ads showing throwing grandma off a cliff sink the entire program.Report

            • Avatar Brandon Berg in reply to Dark Matter says:

              Half your *lifetime* use of medicine happens in the last year or two of life.

              That appears to be a myth.Report

              • Avatar Dark Matter in reply to Brandon Berg says:

                Interesting… although I’m not sure this detracts from the whole “death panels” issue. We keep unhealthy people alive year after year.

                This might make death panels more politically palatable because they’re mostly not out there waiting for everyone. Or it may make the whole idea of rationing both more needed and less palatable because the people affected could be kept alive.Report

      • Avatar Damon in reply to Bob Wallace says:

        The ACA, was IN THEORY, a decent idea. I’d have a whole lot less of an objection to it if:

        1) people could keep their doctors/plans they already had if they wanted to.
        2) the plans didn’t have one size fits all components….like my single unmarried female friend really needs dependant care coverage.
        3) that stupid idea to tax people for not having healthcare.Report

        • Avatar Don Zeko in reply to Damon says:

          So you like it except for the parts that are necessary for the whole to function? guaranteed issue and community rating are going to effect the insurance market and make some people’s plans go away, change their price, or fiddle with their coverage networks. If you don’t include an individual mandate, then you get the actuarial death spiral. How do you have anything like the ACA without 1) and 3)?Report

  2. Avatar DensityDuck says:

    I really think that if you asked some random person what their idea of “ideal health insurance” was, they’d describe Medicare.

    But if you say “Medicare for all” then you hear “ermagerd, SOCIALIZED MEDICINE” from some, and “psshhht, get real, nobody will ever go for that” from others.Report

    • Avatar Saul Degraw in reply to DensityDuck says:

      The other issue is that a lot of people like the idea of socialized medicine but don’t want to give up their own employer based insurance.Report

      • Avatar notme in reply to Saul Degraw says:

        You mean like what Obama promised the ACA would do?Report

      • Avatar DensityDuck in reply to Saul Degraw says:

        I think people would happily give up their employer based insurance.

        if they thought the replacement would be as good.Report

        • Avatar Morat20 in reply to DensityDuck says:

          Uncertainty is a killer.

          If what you have is enough — just barely enough, maybe back-breakingly expensive, would you take the leap to what someone says will be better? Something never really tried in the US?

          Most people won’t make the leap unless they’re so desperate they can’t imagine anything could be worse. The bird in hand, no matter how sickly…Report

        • I suspect that employers would be happy to get out of the business of trying to manage group plan health insurance as well.Report

          • Avatar Morat20 in reply to Michael Cain says:

            Didn’t Warren Buffet just make that point?Report

          • Avatar LeeEsq in reply to Michael Cain says:

            And I thought that the entire tourism industry would be a big advocate for mandatory paid vacations like they have in Europe because people would head to the beaches, theme parks, cities, mountains, and forests to spend their time and money but they aren’t. There are hundreds of thousands of businesses and individuals that would benefit from mandatory paid vacations but the entire tourist industry doesn’t seem to have any interest in lobbying for it.

            Most American employers as individuals with beliefs seem mainly opposed to any welfare state or government intervention in the economy with some notable exceptions. This is true even if the welfare state or economic intervention could help them by unloading certain responsibilities like providing health insurance or giving them opportunities to make money as in the tourist industry and mandatory paid vacations. Low taxes and a general strict anti-statism when it comes to government intervention in the economy seems more important to the employer class as a whole and they act on that belief.Report

            • Avatar InMD in reply to LeeEsq says:

              I think you’re painting with way too broad a brush here. Most people aren’t policy experts, they respond as best they can to incentives within the system. I’ve been on the business side of the healthcare industry long enough to know that views about the government’s role vary pretty widely. There are bad and cynical actors but you don’t find a lot of ultra libertarian ideologues. They’d never make it in an industry so intertwined with the government.Report

        • Avatar Dark Matter in reply to DensityDuck says:

          I think people would happily give up their employer based insurance.
          …if they thought the replacement would be as good.

          It probably *can’t* be as good.

          Employer based insurance is for people who are (or were) healthy (and *functional*) enough to be employed. It’s also often only located in zipcodes where various problems are minimized.

          UC implies either the current employer based types either accept less service or pay a lot more.Report

          • Avatar pillsy in reply to Dark Matter says:

            It probably *can’t* be as good.

            It has a better ability to negotiate prices, is much more likely to be accepted by a given provider (if it’s actually UC), and likely to be better-subsidized.

            A lot of existing employer-based plans are pretty crap.Report

            • Avatar Dark Matter in reply to pillsy says:

              It has a better ability to negotiate prices, is much more likely to be accepted by a given provider (if it’s actually UC), and likely to be better-subsidized.

              There are factors which suggest it’d be better, there are others which suggest it’d be worse and/or more expensive. On the balance, I suspect between regulatory (& political) capture, increased demand, and decreased (because of price controls) supply, I’d be worse off.

              I’d love to be proven wrong, but we’ve seen states try things like this and it’s blown up the budget. My assumption is the math simply doesn’t work (without serious restrictions which are never mentioned) or we’d have done it already.Report

              • Avatar pillsy in reply to Dark Matter says:

                There are factors which suggest it’d be better, there are others which suggest it’d be worse and/or more expensive.

                This I can’t disagree with.Report

              • Avatar Nevermoor in reply to Dark Matter says:

                As I understand it, the problem for states is that they can’t run Y1 deficits and a change this fundamental will require significant startup costs. The other problem I remember when Vermont failed was having to deal with citizens of other states (meaning the change would ADD administrative complexity because healthcare providers would still need to accommodate everyone else’s private insurance).

                Also, of course, the very real political problem is that you’ll have to significantly increase taxes to pay for the program, which is a tough sell even if you’re raising taxes a lot less than the insurance costs people would no longer have to pay.Report

              • Avatar Dark Matter in reply to Nevermoor says:

                …a change this fundamental will require significant startup costs…

                If memory serves, the problem has been costs explode until the budget breaks. That doesn’t jibe well with “start up costs”. It does jibe with the below.

                Also, of course, the very real political problem is that you’ll have to significantly increase taxes to pay for the program, which is a tough sell even if you’re raising taxes a lot less than the insurance costs people would no longer have to pay.

                A lot less?

                The amount of taxes you need to raise is NOT equal to what we’re currently paying in insurance. You’re adding a large number of currently untreated (or under treated) sick people into the system. If we were going to wave a wand and insure those people, it’d be hugely expensive. You’re also giving better insurance to people who currently are uninsured.

                That’s over and above the political problem of “no death panels” or whatever which is one of the functions that insurance companies play. Trying to give everyone a GM Autoworker plant’s insurance is way more expensive than the money you save by getting rid of insurance overhead.

                The budget breaks because of the underlying assumption that the new system will be cheaper (a lot less), and there’s a lack of politically painful “death panels” method of restricting access.Report

              • Avatar Nevermoor in reply to Dark Matter says:

                You underestimate the waste in private insurance. Medicare’s admin overhead is a few percent. private insurers are 15-20%.Report

              • Avatar Dark Matter in reply to Nevermoor says:

                You underestimate the waste in private insurance. Medicare’s admin overhead is a few percent. private insurers are 15-20%.

                Even assuming that’s true, the big costs of the system are driven by a small percentage of sick people. If you’re going to be increasing that by a lot, then 15% more doesn’t come close to balancing out.

                That’s over and above the problem that firing two administration types working for an insurance company won’t create one doctor.Report

      • Avatar Pinky in reply to Saul Degraw says:

        I’m convinced that most of the problems in the private health care market (unrelated to government) could be solved by the elimination of employer based insurance.Report

        • Avatar Morat20 in reply to Pinky says:

          What, including affordability? My brother had stage II Hodgkin’s. (Has, technically. A surgery to go). I believe the projected premium increase for having had a case of cancer was 150k a year?

          Peanuts for someone working in the lucrative field of helping special needs students.

          I’m sure he’ll take that out of his spare change jar.Report

        • Avatar Saul Degraw in reply to Pinky says:

          @pinky

          Employer-based health insurance is a tricky issue. It started during WWII when there were restrictions on raising wages but worker’s were getting restless and it stuck. Now we are stuck with this system and 150-160 million Americans (so nearly half the nation) get insurance because they or a loved on is employed. No politician is going to suggest just pulling the rug from this system and ending it immediately without something in place.

          The truth is that no one knows how to sell ending the system except everyone knows it is kind of nuts. I’ve seen liberals try to talk about how single-payer would encourage entruprenurship because people would not worry about losing healthcare but most people just want good jobs with benefits and pay so that is not a great argument.*

          I could see the self-titled Freedom Caucus being for ending the employmer tax break for health insurance but not having anything in place because they are chaos agents.Report

          • Avatar Morat20 in reply to Saul Degraw says:

            I could see the self-titled Freedom Caucus being for ending the employmer tax break for health insurance but not having anything in place because they are chaos agents.

            Every American loves the idea of a giant hike in their taxes. Seems like an electoral winner.Report

          • Avatar Pinky in reply to Saul Degraw says:

            I know the history, and I know the likelihood of it changing, neither of which should stop me from calling a spade a spade. (I just double-checked, and the expression doesn’t have a racist origin.)Report

        • Avatar Mike Schilling in reply to Pinky says:

          I welcome the opportunity to move from a system where an expert who represents a lot of purchasing power negotiates health insurance for me to one where I have no power whatsoever.Report

          • Avatar Davebo in reply to Mike Schilling says:

            I welcome the opportunity to move from a system where an expert who represents a lot of purchasing power negotiates health insurance for me.

            I have news for you. That expert isn’t negotiating on your behalf.Report

            • Avatar Morat20 in reply to Davebo says:

              Really? He’s jacking up the price the insurance company pays? They should hire a new expert then.Report

              • Avatar Nevermoor in reply to Morat20 says:

                How about this:

                I’d rather the “expert with a lot of purchasing power” be a government employee with no profit motive (and near-infinite purchasing power) who will thereby seek the best over all deals (for example, if a more costly short-term method prevents long-term issues, it could be on-balance cheaper) instead of trying to maximize his next bonus.

                I’d also rather the guy processing my claim not have a direct financial incentive to reject it.Report

              • Avatar Morat20 in reply to Nevermoor says:

                Hey, me too.

                I’m just saying your insurance company has a lot of money invested in keeping the costs down, because they’re on the hook for them too. They’ll get a better deal than you will.

                Unless you think it’s normal for the doc to slash 50% or more off his cash price for you. (Seeing the “negotiated prices” stuff just drives home how nuts this is. Billed Price: 2500. Negotiated price: 212 dollars. WTF?)Report

              • Avatar Nevermoor in reply to Morat20 says:

                That’s certainly true. Which is why the individual market pre-ACA (and post-AHCA if enacted) is such a disaster. But its less true for insurance companies than for the government (to go along with insurers having less leverage).Report

              • Avatar DensityDuck in reply to Nevermoor says:

                Having no profit motive doesn’t mean you stop caring about costs.

                ” if a more costly short-term method prevents long-term issues, it could be on-balance cheaper”

                If the more costly short-term method doesn’t fit under the organization’s mandated budget cap for this year then it doesn’t make a damn bit of difference what the long-term issues might be.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                Of course it doesn’t mean you stop caring about costs. It means you are more likely to be objective.

                Does medicare have a mandated budget cap that works in the manner you describe?Report

              • Avatar Davebo in reply to Morat20 says:

                He’s jacking up the price the insurance company pays?

                Not sure where you’re going here. I assumed Mike was talking about his companies HR/Benefits specialist.Report

              • Avatar Davebo in reply to Davebo says:

                an expert who represents a lot of purchasing power negotiates health insurance for me

                Certainly appears to be the case…Report

              • Avatar Morat20 in reply to Davebo says:

                Ah, I was thinking his insurance company. Then again, my company is big enough to self-insure, and thus uses Aetna/Cigna/Whatever as administrators. So I happen to know my HR works hard to cut what they actually pay doctors.

                On a related note: HDHP/HSA’s would be great if I was a single, 25-year old guy with a good attitude towards savings and investment. As a 40-year old with a family, they are the absolute worst form of insurance coverage I’ve ever used.

                Co-pays and those 80/20 plans have always pushed against going to the doctor for trivial things, but HDHP’s….

                It’d be one thing if I’d had a few years to build my HSAs up, but they forced us to switch the year I hit 13k out of pocket. Single sickest year, by far, my family has ever had.Report

              • Avatar Mike Schilling in reply to Davebo says:

                I am. Getting the best deal out of the insurance company is in both his interest and mine.Report

        • Avatar pillsy in reply to Pinky says:

          I… don’t.

          That’s not because it’s a bad idea (it’s not), but that’s just one problem of the many, many problems we have.Report

  3. Avatar Jaybird says:

    I read a very interesting comment somewhere the other day and wish I could attribute it to its author but I can’t find it and so I’ll just paraphrase it.

    It said something to the effect of:

    Both sides are going to have to compromise to make this work.
    Republicans/Conservatives are going to have to reconcile themselves to there being Socialized Medicine
    Democrats/Progressives are going to have to reconcile themselves to there being two tiers of medical careReport

    • Avatar CJColucci in reply to Jaybird says:

      I suspect that Democrats and Progressives would take that deal in a New York minute.Report

      • Avatar Jaybird in reply to CJColucci says:

        I’m suspicious that that deal will quickly turn into discussions about how we, as a country, have a responsibility to provide the same care to undocumented dreamers that would also be available to ex-Presidents and anyone who says “no, there are treatments that should be available to ex-Presidents that would not also be available to undocumented dreamers” are really arguing, at the end of the day, that undocumented dreamers should die.

        And that suspicion makes me suspicious that that deal described above would *NOT* be taken.Report

        • Avatar Nevermoor in reply to Jaybird says:

          Your evidence, presumably, being that the ACA did none of those imagined (I assume you think) horribles?

          @cjcolucci is dead right on this one, which is why your BSDI attempt fails.Report

          • Avatar Jaybird in reply to Nevermoor says:

            Your evidence, presumably, being that the ACA did none of those imagined (I assume you think) horribles

            My evidence, what little of it I have, consists of nothing more than discussions about health care reform that I have had with people online and with people in real life. Here’s an example of a conversation I had back in 2011:

            In discussing health care, I discussed one of my fixes which was a two-tiered approach. Everybody is covered for X and Y. If you want Z? That costs money. We will always have someone argue that we, as a society, are rich enough that we ought to be able to cover Z for the poor. The person I was arguing with asked “well, why *CAN’T* we provide coverage for Z?”

            So we’re going to have a situation, no matter what, where someone will ask what kind of society we live in where Donald Trump can afford Z but poor children from the wrong side of the tracks cannot. “Do you want the poor children to just lie down and die?” seems to be a question that can be asked unless, of course, Trump can’t get the treatment either.

            Do I have proof that that will happen?

            No. Not really. Though I suppose I could find other examples of conversations of Health Care coverage/reform that we’ve had on the site… would comments count as evidence?

            As for this part, responding to the statement that “both sides will have to compromise” with “BOTH SIDES DO IT!” seems to not get the argument.

            Whatever we end up with will leave a lot of people (on both sides, even) unhappy.

            This is not intended to demonstrate that both sides are morally equivalent? I guess?

            It was intended more as coming out and explicitly saying that, yeah, we’re going to end up with Socialized Medicine someday and, yeah, women and minorities will be hardest hit.Report

            • Avatar Jaybird in reply to Jaybird says:

              Oooh, I remembered another exchange I had.

              I discussed the two-tier system here (in a comment that I’m still kinda proud of) and it led to this exchange with Francis:

              “And if you can’t afford to pay out the nose, well, then we’ve got this 1987 health care available right here”

              a/k/a

              “go die”

              Why be subtle about it?

              So when you ask “Your evidence, presumably, being that the ACA did none of those imagined (I assume you think) horribles?”

              I can only say “my evidence is conversations I’ve had when I’ve discussed two-tier systems”.Report

              • Avatar Francis in reply to Jaybird says:

                “The best available healthcare that 1987 can offer should be made available and affordable to all.”

                To be clear, the proposal contemplates that:

                hospitals will split in two, one with current equipment and one with 30-year old equipment;
                doctors will keep two sets of medical expertise in their heads, current and 30-years old;
                pharmacies, nurses,and the entire rest of the medical industry will split into two – one current and one 30 years old.

                Since the 30-year old health care is to be available and affordable for all, at least insurance companies are excluded from this exciting idea. Of course, the federal government will be just thrilled with the idea of running (or at least funding) an entire health care system on a running 30-year lag.

                Think of all those exciting new jobs that will be created! Think of all the monitors you’ll need to hire to ensure that doctors are using only 30-year old teaching and that hospitals are using only 30 year old equipment.

                Or, think of the avoidable deaths, pain and suffering. Think about how to find doctors and nurses willing to give up everything they’ve learned about medical ethics and treat only to a 30-year old set of medical knowledge.

                This country is going to make a multi-billion dollar investment in devising a system of delivering medical care to a 30 year old standard? No, that’s just magical thinking. Anyone who purports to be serious about such a proposal is sending a clear message to people too poor to afford existing insurance: You are not deserving of taxpayer support. If you cannot find charity care, then go die.

                I just jumped straight to the conclusion last time. I thought that the readers of this blog would be smart enough to fill in the intervening analysis on their own.Report

              • Avatar Jaybird in reply to Francis says:

                Hey, if you don’t like the idea, that’s great.

                Part of what I argued at the beginning was that some people would argue that they don’t like this idea.

                Somebody else asked me if I have any evidence for this.

                Could you please check in with Nevermoor? Thanks.

                Now to the meat:

                To be clear, the proposal contemplates that:

                hospitals will split in two, one with current equipment and one with 30-year old equipment;
                doctors will keep two sets of medical expertise in their heads, current and 30-years old;
                pharmacies, nurses,and the entire rest of the medical industry will split into two – one current and one 30 years old.

                It’s more that I suspect that we will have doctors who keep up on new techniques and doctors who will be allowed to no longer keep up on new techniques. Hospitals that feel the need to buy the latest and greatest new technology… and hospitals that have the same equipment they had right until the moment they stopped feeling the need to buy the latest and greatest new technology.

                If you’re not crazy about the 30-year lag, change the number to 20, or 10. I’m fine with working with that.

                One thing we do, right now, is extend patent protection to new and improved drugs (and we allow generics to be created after patent protection ends). My idea was that we’d have a continually evolving baseline that moves along every day.

                I’m not married to the number of years. Hell, I’m not even particularly married to the mechanism. I’m just noting that we kinda have something set up like that right now for pharmaceuticals and wondering if we could get stuff like “doctors” and “hospitals” to work the same way.

                Let the doctors eventually say “I don’t want to learn new techniques” and just coast on what they’ve spent years doing.

                If you want something that was developed recently? Get yourself one of the new doctors or one of the doctors who keeps up on such things.

                Let’s face it, the vast majority of problems that the vast majority of Americans suffer from are things that do not require bleeding or cutting edge tech.Report

              • Avatar Nevermoor in reply to Jaybird says:

                There’s a difference between objections to two tiers as a concept and objections to a shitty bottom tier.

                I take from @francis ‘s reply that he wouldn’t object to the bottom tier being Medicare. Where does that fall in your BSDI can’t-we-all-be-reasonable proposal?Report

              • Avatar Don Zeko in reply to Nevermoor says:

                Shitty and also conceptually screwy. Cheap health care today isn’t the same as normal health care in 1987.Report

              • Avatar Jaybird in reply to Don Zeko says:

                How much of cheap health care today is somewhere around the same as cheap health care in 1987? (I imagine that the advice is somewhat better today… “You need to lose weight! Stop eating so much food with high fat content and start eating more pasta!” has not held up well.)Report

              • Avatar Don Zeko in reply to Jaybird says:

                Would you accept “it’s complicated” as an answer? Either way, I don’t understand what you’re getting at with this point. The ACA includes some form of tiered coverage, in which some procedures are paid for by the government while other types of care are not but can be purchased with private money by the wealthier. The pre-ACA programs create similar de facto tiers, with Medicare, Medicaid, the VA, and private coverage all offering varying levels of stinginess. The systems in other countries that Liberals want to emulate all have some level of tiered coverage, even the most radical single payer systems like Canada. The trouble isn’t the left, it’s that the right rejects the concept of universal coverage outright.Report

              • Avatar Jaybird in reply to Don Zeko says:

                Would you accept “it’s complicated” as an answer?

                Sure. This is a topic where it’s impossible to talk about this thing without also talking about that other thing and, oh yeah, we also need to take these five things into account.

                The difference between acute and chronic care, for example, is *HUGE*.

                I think that something like Medicare-For-All will do a great job with stuff like, for example, the problem given by Dennis in his original posting. Something like that would have helped him immensely in that situation.

                “But what about people with chronic problems?”
                “Well… it’s complicated.”Report

              • Avatar Kimmi in reply to Jaybird says:

                Jay,
                Absolutely zilch in immunotherapy. We learned tons of shit from AIDS.
                Heart Disease went through a downswing in quality when they started putting stents in everyone.
                Strokes ain’t got anything to speak of that’s evidence based, so we’ll call that a wash.
                Physical Therapy? You don’t want the difference between 87 and Now, you want the difference between “We show you once” and “we guide you through the screaming pain, every time”

                … just off the top of my head.Report

              • Avatar Jaybird in reply to Kimmi says:

                Change it to 20 years then.
                Change it to 10.
                Change it to 7. I don’t care.

                I just think that, if you don’t, the engine changes.

                And we do *NOT* want the engine to change.

                (If we’re lucky, China will pick up where others leave off.)Report

              • Avatar Morat20 in reply to Jaybird says:

                I wonder how the UK, Germany, Singapore, France, Switzerland, Canada and Japan deal with this pressing, insolvable problem.Report

              • Avatar Jaybird in reply to Morat20 says:

                By sending people to the US.

                I can find examples, if you’d like.Report

              • Avatar Morat20 in reply to Jaybird says:

                We’re talking a billion+ people. Somehow…I don’t think “sending them to the US” is anything but a rare oddity. I don’t think we get millions of medical tourists a year…pretty sure people would have noticed.

                Even the “Canadians come to American to get MRIs” are statistically non-existent.

                (2015: 52,000 Canadians sought non-emergency care in the US. Assume they’re all medical tourists, which is laughable. Average number of doctor’s visits per capita in Canada: 7.6, per 2013 numbers. Canadian population in 2015: 35 million. Thus, medical tourism: 0.02% of all Canadians in 2015. Clearly, they are outsourcing modern care to the US)

                Honestly, it seems you’ve thought up what you think is a nifty idea and have decided to stick to it. In fact, I don’t even think you think it’s a good idea. You’re just arguing for the hell of it, which is waste of everyone’s time no matter how entertaining you find it.

                In the meantime, the rest of the first world (and also the US) has solved this problem. And your idea is…not even ballpark, for obvious reasons.Report

              • Avatar Jaybird in reply to Morat20 says:

                I misunderstood the question then.

                They deal with it by not having anything more than what everyone can have available.Report

              • Avatar Nevermoor in reply to Jaybird says:

                O RLY?

                Extra health insurance
                Government health insurance plans give you access to basic medical services. You may also need private insurance to pay for things that government plans do not fully cover.

                Report

              • Avatar Morat20 in reply to Nevermoor says:

                Not Invented Here syndrome, in spades.

                Mental roadblocks not just to the notion that it’s been solved elsewhere, but sometimes to the very notion that the problem has even been considered before — much less solved.Report

              • Avatar Nevermoor in reply to Jaybird says:

                It’s not the number, it’s the nonsense concept.

                Trivial example: everyone should get this year’s flu shot.

                Less trivial example: Imagine we came up with a 10x better resolution CT scan that costs 1.1x current technology. What possible reason would there be to delay it X years? Likewise, if we came up with a 1.1x better one that costs 100x current technology, why would we roll it out just because X years passed?

                The idea makes no sense on any vector, and appears designed to solve a problem that exists only in your mind (and not, as @morat20 correctly points out, in any system along the lines of what liberals want).Report

              • Avatar Morat20 in reply to Nevermoor says:

                Why does he even want that system?

                If it’s for “cost control” or “cost savings” it’s the stupidest possibly approach. Why not…actually take all the possible treatments for a condition, and actually determine the costs?

                Treatment length, efficacy, lifetime results — it’s not like this data doesn’t exist. In fact, Medicaid and Medicare spend a great deal of time doing that sort of work.

                Why on earth would you say “Let’s use stuff from 10 years ago, across the board” instead of “Let’s look at the most cost-effective treatment for this condition” like every insurance company already does.

                Does your prescription plan cover 10 year old drugs at 90%, 5 year old ones at 60%, and new ones at 0%? No. Why would they? They’re not run by idiots.Report

              • Avatar Jaybird in reply to Morat20 says:

                Why does he even want that system?

                Less subject to regulatory capture when there’s a year attached to it.

                It’s an attempt to attach some of the driver behind drug research to medical research.

                Why on earth would you say “Let’s use stuff from 10 years ago, across the board” instead of “Let’s look at the most cost-effective treatment for this condition” like every insurance company already does.

                Because I am trying to create an ever-rising floor where everyone on Tier 1 can eventually receive the medical care that was bleeding edge 10 years ago.Report

              • Avatar Morat20 in reply to Jaybird says:

                I don’t even know what to say to that.

                I will say, given we live in a country where every private insurer in the United States has solved that problem, where the governmental programs (Medicare, Medicaid, VA) have solved that problem, and in a world where every other first world country on earth has solved that problem…..

                Your deep investment in perhaps the most ridiculous possible solution to an already solved problem is….commendable.

                I’ll take the one that works in the real world already, thanks though. It’s not as simple, I admit — you can’t pass it down in a single paragraph from an ivory tower for the world to marvel at– but it works pretty well for what, a billion people at least? Not perfect, of course. Nothing is, in real life.Report

              • Avatar Stillwater in reply to Jaybird says:

                And we do *NOT* want the engine to change.

                Are you sure we don’t we want to change that? If you do NOT want to change the engine driving innovation, then you cannot change the incentives driving that engine, which means you cannot change the formula by which expected profit is determined, which means you cannot change the model (the status quo) upon which that expected profit is determined.

                Seems to me that viewing the preservation of that engine as a necessary condition on healthcare policy is an argument for either the status quo or alternatively increasing expected profit (and hence total HC cost, all else equal) by making that engine even more robust.Report

              • Avatar Jaybird in reply to Stillwater says:

                When it comes to the incentives driving the engine, I have a little more faith in avarice over long periods of time than in good will over long periods of time.

                When it comes to increasing expected profit, it seems like it’s a lot easier to do that through regulatory capture and making it so that only your epipen can be sold in this country rather than in allowing all eight major brands to sell epipens here.Report

              • Avatar Stillwater in reply to Jaybird says:

                That doesn’t address the issue, tho. If you don’t want to change the engine driving innovation you have to maintain the same financial incentives which drive that engine, which in turn means NOT changing (in particular reducing) the expected price points, which (in turn again) means keeping the current price points and more importantly the methodology by which those price points are determined as they are. Status quo.

                Limiting the power of patent protection would lower price for existing drugs but would also disincentivize innovation slowing down the engine you don’t want to change.Report

              • Avatar Jaybird in reply to Stillwater says:

                If you don’t want to change the engine driving innovation you have to maintain the same financial incentives which drive that engine, which in turn means NOT changing (in particular reducing) the expected price points, which (in turn again) means keeping the current price points and more importantly the methodology by which those price points are determined as they are. Status quo.

                Very true. Given that we’re making a major shake-up to coverage, I’m trying to figure out a way to keep GE in the business of coming up with another handful of percentage points of innovative improvements to their technologies every few years.

                This protection is the best way that I can think of that.

                Limiting the power of patent protection would lower price for existing drugs but would also disincentivize innovation slowing down the engine you don’t want to change.

                My thought process is something like this: If we limited the power of patent protection *RIGHT NOW*, we could allow generics to be made of all of the drugs that are so very expensive. Then everybody could be covered.

                And then, in 10 years, everybody could still be pleased to be buying the same generics as they were buying 10 years prior without having to worry if there were a drug that would do it 8% better without one of the seven side effects.Report

              • Avatar Stillwater in reply to Jaybird says:

                I’ll ask a question to get at the issue a little more clearly:

                Why do you think the innovation engine MUST be maintained as is given the constraints imposed on comprehensive (two tier, universal) healthcare provision? Ie., why is maintaining current financial incentives for innovation excluded from the cost cutting measures such a system necessarily imposes?Report

              • Avatar Jaybird in reply to Stillwater says:

                Merely because that’s what works for Pharma when it comes to patented vs. generics.Report

              • Avatar Stillwater in reply to Jaybird says:

                Again, that doesn’t answer the question or address the issue.Report

              • Avatar Jaybird in reply to Stillwater says:

                I must not have understood it… let me reread it…

                Oh. Let me try again. I know that going for universal coverage is going to be a bear for profit margins for the companies that make drugs and equipment.

                We’re changing a lot of things and it seems to me that there’s a chance that we’re going to be killing at least one goose laying golden eggs for us. That said, we could really use the meat in the short term (and, maybe, we’ve reached a point in R&D where all of the low hanging fruit is plucked and we won’t mind that we’re using ten year old tech ten years from now).

                But if we want to keep some of those geese growing strong (if not growing larger), we have to provide an incentive to not fly away.

                The setting a year thing struck me as the best incentive given that we’d be giving quite a shock to the system.

                The whole “it’s a canard that the US does more than its fair share of the heavy lifting” argument has been given me a handful of times and I don’t know… but it strikes me as one hell of a risk.

                But something that doesn’t get invented isn’t even close to measurable.

                Hell, if we play our cards right, we might finally get more than one brand of epipen salable in the US.Report

              • Avatar Stillwater in reply to Jaybird says:

                Epipen is a bit of a red-herring in this argument since changing IP laws so they apply to delivery systems means changing IP laws for non-medical devices too.

                But for my part, I’m not at all wedded to preserving the profit margins that currently fuel the innovation engine (I don’t see how to do it consistently with constraining total expenditures, myself) so I’m curious about the reasoning of someone who views maintaining it as necessary. I’m not sure you’ve answered the question yet, to be honest, unless you misspoke above and are actually OK with not maintaining the current engine just so long as incentives still motivate at least some innovation.Report

              • Avatar Jaybird in reply to Stillwater says:

                Insofar as the epipen allowed to be sold in this country legally recently jacked up its prices, I don’t see it necessarily as an IP issue but an FDA issue. I think that moving to a more-European health care system requires also moving to a more-European attitude towards risk. Allow 8 kinds of epipens!

                I may have misspoke because it seems obvious to me that changing to a Medicare-For-All system is going to be changing, significantly, remuneration for innovation. The engine, already, is going to be changing. Maybe Tier 2 insurance will keep things well-oiled… but whatever we end up with won’t be the status quo for the people who invent the next-gen imaging systems that will then be sold to hospitals that will be treating people handing them Medicare-For-All cards.Report

              • Avatar Stillwater in reply to Jaybird says:

                Thanks for clearing that up. I agree.Report

              • Avatar Jaybird in reply to Nevermoor says:

                There’s a difference between objections to two tiers as a concept and objections to a shitty bottom tier.

                Certainly. For now.

                My main assumption is that health care will quickly become a positional good.

                Where does that fall in your BSDI can’t-we-all-be-reasonable proposal?

                It pretty much assumes that the second that people start measuring health care as a positional good the bottom tier will, by definition, become the shitty bottom tier.

                If you have an argument that only one side will be able to create a two tier system that will have the majority of the people who enjoy Gold Level Support (as opposed to Platinum Level Support) will see the baseline tier of health care as sufficient, I’d enjoy reading it.

                Bonus points if it’s set up in such a way that people who support there being things covered by Platinum (but not Gold) will not thereby evidence themselves as hating the poor. (Is it by just saying that the only stuff covered by Platinum but not Gold be stuff like breast implants, rhinoplasty, and private birthing rooms with Wifi?)Report

              • Avatar Don Zeko in reply to Jaybird says:

                Isn’t this just an observation that we will continue to have political debate in this country? Of course if we have a universal program we’ll continue to bicker and argue about how generous it should be, who should pay for it, how it should be run, etc. No matter what the status quo is, it’s not going to keep us from arguing about it. I’d much rather have those arguments than the ones we’re having now about whether or not people should be sentenced to preventable death or financial ruin because of a bad pull of the genetic slot machine.Report

              • Avatar Jaybird in reply to Don Zeko says:

                I’m not arguing that I think that you’re arguing that this plan will finally install Utopia.

                God, that always pissed me off whenever I argued something like “we need to end the war on drugs” and people argued against me as if I were arguing that ending the war on drugs would install Utopia. Jesus.

                I’d much rather have those arguments than the ones we’re having now about whether or not people should be sentenced to preventable death or financial ruin because of a bad pull of the genetic slot machine.

                Fair enough.

                I think you’ll be surprised by the ones that pop up, though. “The government is withholding treatment that will allow my loved one to live!” is going to be one.

                “I thought we finally have Medicare-For-All! Why do people still have gofundme pages for treatments that I would have assumed would have been covered by Medicare-For-All?!?”

                Wanting to trade our current problems for different problems is a perfectly reasonable position (and doubly so if the different problems are not as bad).Report

              • Avatar Stillwater in reply to Jaybird says:

                I think you’ll be surprised by the ones that pop up, though. “The government is withholding treatment that will allow my loved one to live!” is going to be one.

                We’re already hearing this argument. I don’t know why hearing it again, after universal HC is up and running, constitutes any kind of interesting or noteworthy worry or is an issue worth noting except trivially.Report

              • Avatar Jaybird in reply to Stillwater says:

                I think we’ll feel differently when it’s the government denying the treatment rather than the capitalists.

                I don’t know why hearing it again, after universal HC is up and running, constitutes any kind of interesting or noteworthy worry or is an issue worth noting except trivially.

                My original statement was that it’s something that the left will have to reconcile itself to.

                As trivially noteworthy things to point out, you’d be amazed at the amount of tumult followed.Report

              • Avatar Nevermoor in reply to Jaybird says:

                Again, I don’t hear a lot of old people complaining about Medicare, even though RIGHT NOW rich people can afford higher tier services.

                You’re inventing–and insisting upon–a problem that is not serious and insolvable (in other words, we can NEVER prevent rich people from buying better stuff if they want to). I don’t understand why.Report

              • Avatar Jaybird in reply to Nevermoor says:

                The problem is not that rich people can afford higher tier services.

                It’s that poor people cannot afford the services that could possibly save their lives (these same services that rich people *CAN* afford) and people who insist on two tiers of service are saying that poor people should just hurry up and decrease the surplus population.Report

              • Avatar Nevermoor in reply to Jaybird says:

                What does it even mean not to “insist on two tiers of service”? Can you tell me what that system even looks like? Or are you just concern trolling?

                I suspect if there is a life-saving service not in tier 1, I’d actually be wondering whether there was a reason not to include it.

                Also, since no one with your theoretical concerns seems willing or able to answer this question, I’ll try again: what life-saving services are not being provided by Medicare?Report

              • Avatar Jaybird in reply to Nevermoor says:

                Or are you just concern trolling?

                Snort.
                Were you here when I was accused of wanting people to die?
                This is something that *IS* going to happen.

                I’ll try again: what life-saving services are not being provided by Medicare?

                I know I’ve heard of horror stories about the stuff that Medicare doesn’t do or doesn’t cover (and I know that I’ve heard this stuff on NPR) and a quick google got me this.

                It’s a handful of hard-luck stories from people who, surely, aren’t representative of anything.Report

              • Avatar Nevermoor in reply to Jaybird says:

                What does it even mean not to “insist on two tiers of service”? Can you tell me what that system even looks like? Or are you just concern trolling?

                Response: ignore the first part and snort. The Jaybird experience! (I’ll wait to hear what you actually think, if anything, before discussing that part further)

                As for the other thing, these are case-by-case questions. Why doesn’t Medicare cover stem cell transplants? Because they’re too expensive? Because they don’t work? Because there’s a different better treatment? I certainly don’t know. But I’d want to before forming an opinion on whether Medicare should cover them. And I’d certainly want to before concluding this was a problem with low-grade services. And, most importantly for your two tiered argument, EVEN IF that procedure is considered officially worse than another one (or officially ineffective), people should still be able to pay their own money for it if they want. Which is–GASP!–a liberal endorsing a two-tiered system.Report

              • Avatar Jaybird in reply to Nevermoor says:

                Okay, fine.

                What does it even mean not to “insist on two tiers of service”? Can you tell me what that system even looks like?

                To acknowledge that we have one and that it’s not going to change no matter how much political will is spent on it.

                To go back to the original comment that spurred all this crap, “to reconcile oneself to it”.

                As for the other thing, these are case-by-case questions.

                I’m glad we agree they exist.

                If we can agree that doing this on a national level is more likely to result in case-by-case questions, we’re golden.Report

              • Avatar DensityDuck in reply to Nevermoor says:

                Haw. Remember how you got all mad that we wouldn’t give concrete examples of specific things that Medicare didn’t cover and people thought it should? And here Jaybird does just that, and we get:

                “Why doesn’t Medicare cover (thing)? Because they’re too expensive? Because they don’t work? Because there’s a different better treatment? I certainly don’t know. But I’d want to before forming an opinion on whether Medicare should cover (thing).”

                So. All abstract together, it seems.Report

              • Avatar Francis in reply to Jaybird says:

                I find this comment utterly bizarre.

                First of all, the entire discussion about two tiers of service has no basis in reality. Employment-based health care varies widely in networks, co-pays, deductibles, and covered medications. Then we can layer on Medicare, Medicaid, the VA, Tri-Care, what Senators and Congresspersons get, the ACA bands, the actual policies issued in the 50 states in each ACA band, and true out-of-pocket payors. Two tiers? How about thousands?

                Second, the number of people truly rich enough to pay out of pocket is microscopic. What rich people do is get super-premium coverage from their employer. The ACA did a neat thing in taxing those policies as income (which it is, of course).

                The churn for low-income Americans between coverage under the ACA and under Medicaid is unfortunate. But that’s where the votes were. Between needing every vote in the Senate and a very unusual Supreme Court decision, Medicaid ended up in an odd place with states being empowered to opt out of covering their own citizens.

                Non-expansion states are, today, telling their worst-off: Go Die, Already. What the Republicans are proposing doing is to take so much funding out of the plan that the remaining states who want to do the right thing are forced to tell some of their worst-off: Sorry, You’ve Been Triaged.

                As you feel free to tell Kazzy how well he’s doing in writing comments, let me feel free to share my comments about yours: you consistently commit the fallacy of the excluded middle. According to you, health care policy discussions must be phrased in terms of balancing the coverage of ex-Presidents with that given to illegal immigrants.

                If you get people to debate you on those terms, more power to you. But it’s still a fallacious argument. 11 million illegal immigrants plus 4 ex-presidents is still only 3% of the population. The rest of us are talking about the other 97%.Report

              • Avatar Jaybird in reply to Francis says:

                If you get people to debate you on those terms, more power to you. But it’s still a fallacious argument.

                Depends on the fallacy.

                For example, it certainly gets rid of the “NOBODY IS SAYING THAT! THAT’S A STRAWMAN!” argument.

                If we’re saying that what we need is a system that is very good at taking care of the needs of most people and understands that that means that some people who could theoretically be treated will be denied care that, had they sufficient means, they could theoretically purchase is something that’s going to happen… then great.

                I’d be down.

                I’m just saying that we will be surprised by where the edge cases show up and what we will have expected to have been covered.

                According to you, health care policy discussions must be phrased in terms of balancing the coverage of ex-Presidents with that given to illegal immigrants.

                One of the fun tricks to use back before the PPACA was passed was to ask about whether Undocumented Dreamers should get “free” health care in a single-payer system.

                You wouldn’t believe what I was accused of.

                Or, hell, maybe you would.Report

              • Avatar gregiank in reply to Jaybird says:

                There are always edge cases. There existence doesn’t prove anything about anything.

                Were you accused of sophistry?Report

              • Avatar Jaybird in reply to gregiank says:

                “Edge cases” is a term that was used above.

                In the case above, everybody agreed that stuff like “the flu” should be covered. Everybody agreed that stuff like “boob jobs” should not be covered. The “edge case” was that of insulin pumps being given out rather than blood drop tests and needles.

                As such, the edge case wasn’t the edge where some poor child is born with some super-rare disease, but the edge between “obviously, this ought to be covered” and “obviously, this shouldn’t be covered”.

                With that in mind, allow me to repeat what I said in the comment that you’re responding to:

                I’m just saying that we will be surprised by where the edge cases show up and what we will have expected to have been covered.

                Report

              • Avatar gregiank in reply to Jaybird says:

                And again, there will always be edge cases and choices about what to cover. There are in any and every health care plan in the world, in the US before the ACA, with the ACA, after the ACA and when all our care is provided by Star Fleet Medical.Report

              • Avatar Jaybird in reply to gregiank says:

                And I do not disagree with that point one whit.

                I hope you keep it in mind the next time you feel a tug saying “Jeez… that should be covered!”Report

              • Avatar gregiank in reply to Jaybird says:

                That has been happening for a some decades already actually. I’ve had that happen to people in may family. So that ain’t breaking news to me.Report

              • Avatar Francis in reply to Jaybird says:

                My main assumption is that health care will quickly become a positional good.

                good god, why would you ever make that assumption?

                When I get sick, I just want to get better, preferably as soon as possible. I don’t much care what someone else’s care is, I just want mine (a) to work and (b) not to cost too much.

                There’s this weird idea floating around in certain conservative and libertarian think tanks that health care really be a “market” if we just get the federal government out of the way.

                The fact that health care shows very few characteristics of being a market and mostly shows market failure does not disturb this thinking.

                A positional good? Health care is by definition a zero sum game? That’s absurd. Basic dentistry for all does not deprive Hollywood stars from getting super-fancy teeth. The people who get access to the care for the first time are both living better and not depriving anyone else from paying for premium services. Not enough dentists? We can always make more.Report

              • Avatar Jaybird in reply to Francis says:

                good god, why would you ever make that assumption?

                Because, when I was growing up, I referred to my grandparents’ medicare as “medicaid” and they sat me down and gave me a talking to explaining that they were on medicare, something that they *EARNED*.

                There’s some status points in there. I can’t claim to understand it.

                A positional good? Health care is by definition a zero sum game?

                Also there’s the issue of whether “Medicare-For-All” will provide the same level of service as “Medicare-For-Some” and there’s reason to fear that, maybe, it won’t. The people who don’t get Medicare right now might well be better off… but the people who do have reason to be worried.

                I mean, if the supply of health care is, by definition, limited.Report

              • Avatar Francis in reply to Jaybird says:

                The field of economics is not defined by the misunderstandings of the elderly, or their grandchildren. I would happily step on the toes of your grandparents if that would get the votes for a more rational system.

                I get the impression, both from this conversation and the one we had over marijuana deregulation, that you don’t actually put any effort into understanding the underlying issues. You come up with wild ideas — use 30 year old tech! fire everyone who won’t sign a new Rule — and then appear to be offended when commenters here tell you (a) other people have spent years of their lives looking into these issues and they are actually hard problems not likely to be solved by random ideas coming from people who haven’t put in the effort and (b) your ideas bear no real relation to how the world works.Report

              • Avatar DensityDuck in reply to Francis says:

                “and then appear to be offended when commenters here tell you (a) other people have spent years of their lives looking into these issues and they are actually hard problems not likely to be solved by random ideas coming from people who haven’t put in the effort”

                I’m pretty sure that Jaybird would accept your proposed solution.

                What he wants is for you to think about why it’s your proposed solution, because the reasons why you proposed it will help us guess at what you’ll do when it doesn’t actually solve the problem.Report

              • Avatar Nevermoor in reply to Jaybird says:

                I went back to your linked comment and I think I understand our disconnect.

                We, here, are talking about insurance, not about government-provided health care (i.e. the doctors are not going to be government employees). So if the government provides medicare-for-all, the issues are going to be about what procedures get covered. Cosmetic plastic surgery? No. Chemo for cancer? Yes. But there are edge cases. @densityduck highlighted a fair one: what consumables do you give diabetics for free? That’s a cost/benefit consideration (pumps are more expensive, which means you may need to raise taxes more, but if they also reduce complications they may largely pay for themselves, so you may not need to raise taxes a ton), and one I’m sure Medicare has grappled with. What it doesn’t have anything to do with is your iron triangle point in the linked comment.Report

              • Avatar Jaybird in reply to Nevermoor says:

                We, here, are talking about insurance, not about government-provided health care

                Which very much goes back to my original comment insofar as it’s creating incentives for more people to go to the doctor without creating incentives to become a doctor.

                If all we’re talking about is the government cutting checks, we’re going to find that the same thing happens to health care as happened to, say, college tuition.

                But there are edge cases.

                If you create more demand without creating (or incenting) more supply, you will move where the edge cases are.

                What it doesn’t have anything to do with is your iron triangle point in the linked comment.

                If you’re arguing that you can get it done fast and get it done cheap, I think that you’ll find that it has everything to do with my iron triangle point.Report

              • Avatar Nevermoor in reply to Jaybird says:

                Right now the government provides health insurance services that are good and cheap. I don’t know what “fast” means in the context of health insurance, but if it means “doctors know how to use it and can rely on payment when promised” then it’s fast too.

                If you disagree with that, please tell me why.

                Do you actually think there’s a lack of people who want to become doctors and nurses? If so, why is it so damn hard to get into even the worst medical schools?Report

              • Avatar Oscar Gordon in reply to Nevermoor says:

                If it’s hard to get into a school, then you are discouraging a large population of interested students from even trying to become a medical professional.

                And this isn’t a case of, “well those folks would be marginal at best”.Report

              • Avatar Nevermoor in reply to Oscar Gordon says:

                Right, which is why I find concerns about supply of medical professionals to be dramatically overblown. We could easily create more doctors than we currently do, if that was really a problem. There are plenty of bright young folks who are desperate for the opportunity.Report

              • Avatar Kimmi in reply to Nevermoor says:

                nevermoor,
                Jesus, it ain’t fast. We have programs to get the most out of Medicare, because it ain’t fast, simple or logical.

                Economics is a bitch. Medicine is more of one. I can tell you outcomes for a variety of acute issues that vary based on how many minutes you are away from an ER (We’re about 5ish minutes away). If you’re 30 minutes drive, well, you may be a goner. If you’re a full hour out, your odds of survival have plummetted.

                Doesn’t matter about having enough doctors. Gotta have the money to support them.Report

              • Avatar DensityDuck in reply to Jaybird says:

                I don’t think it’s supply and demand, even.

                I think it’s more about the way that every argument that We Need Healthcare Reform Now is either A) ill-analysed statistics or B) a raft of edge cases.

                And there will always be edge cases. Always someone who would have lived with Tier 2 treatment, but died because they only got Tier 1 treatment.Report

              • Avatar Francis in reply to Jaybird says:

                I don’t know enough about health care financing to know whether that’s true or not. Over at Balloon Juice, Richard Mayhew / David Anderson blogs a lot about health care financing. Based on my reading, the industry is plagued both by single individuals whose care costs millions per month and by an entire system of providers who get paid more than they would under any European system.

                By the way, the word to describe the practice of medicine / law / engineering by people who don’t want to learn new things is “malpractice.” No state regulatory agency is going to tolerate such conduct. Separate but equal has a bad history in this country, so I honestly don’t see the wisdom of recreating it on the federal level.

                England, France, Germany and Switzerland, among others, manage to deliver very high care virtually universally at a total cost that is a fraction of the US system. Before we start building an entire new system around laziness and dysfunction, I suggest we learn from the experience of other countries.Report

              • Avatar Jaybird in reply to Francis says:

                Based on my reading, the industry is plagued both by single individuals whose care costs millions per month and by an entire system of providers who get paid more than they would under any European system.

                I have no doubt of this.

                I heard of a nightmare case where a guy experiencing some mental health issue checked himself into a clinic for a short while, and they demanded that he stay longer than he wished to. Like, they got a doctor to have him committed “for his own good”. They wouldn’t let him go until he threatened to call and cancel his own insurance.

                By the way, the word to describe the practice of medicine / law / engineering by people who don’t want to learn new things is “malpractice.”

                So a doctor who isn’t using current year bleeding edge techniques is engaging in malpractice?

                Even if using the bleeding edge techniques from 2007?

                Man, no wonder poor people can’t afford health care.

                England, France, Germany and Switzerland, among others, manage to deliver very high care virtually universally at a total cost that is a fraction of the US system. Before we start building an entire new system around laziness and dysfunction, I suggest we learn from the experience of other countries.

                Stay tuned. You’re not going to believe what happens to England, France, and Germany over the next five or so years. It’s not going to be “man, we should be more like *THEM*!” kinda stuff.

                Though you never know. We had people saying “But they have such great health care!” about Cuba for the last 50 years…

                As for Switzerland, well. Switzerland is Switzerland. I doubt it will scale.Report

              • Avatar Nevermoor in reply to Jaybird says:

                so now your objection is to professionals engaging in continuing education?

                Are you serious?Report

              • Avatar Jaybird in reply to Nevermoor says:

                …Why do you think I’m “objecting” to it?Report

              • Avatar Nevermoor in reply to Jaybird says:

                So a doctor who isn’t using current year bleeding edge techniques is engaging in malpractice?

                Even if using the bleeding edge techniques from 2007?

                Man, no wonder poor people can’t afford health care.

                Are you not?Report

              • Avatar Jaybird in reply to Nevermoor says:

                There’s an excluded middle in there.

                It seems to me that there’s a lot of medical care that can be dispensed by a trained professional that will be helpful using techniques and knowledge from years and years ago.

                You get the flu? Here’s some treatment, get lots of fluids, get a flu shot next year.

                You break your arm falling off your bike? Here’s a cast.

                We don’t require Dr. House in every hospital in the country. Just having doctors who are good enough to deal with 80% of their patients and know enough to kick the other 20% on to the big guns downtown would cover SO MANY PROBLEMS for SO MANY PEOPLE.

                And me acknowledging that is not the same thing as me objecting to professionals engaging in continuing education.Report

              • Avatar Nevermoor in reply to Jaybird says:

                What if we learn something about how to treat the flu?

                Continuing education is a cornerstone of any profession. And, of course, the medical profession ALREADY HAS GPs who can fix simple things and refer complicated things. So I utterly fail to understand where you’re going with this, other than to further defend your incoherent idea that we should forget 30 years of medical developments to really shaft poor people, because reasons.Report

              • Avatar Jaybird in reply to Nevermoor says:

                I’m not married to the 30 years. Change it to 20. Change it to 10. Change it to 7, I don’t care.

                If what we’re talking about is something as simple as telling patients “we’ve discovered that an intensely spicy meal with ghost peppers is an effective cure for constipation”, sure. I’m not talking about doctors not telling patients things and not giving patients advice.

                I’m talking about keeping up with new treatments and making new therapies available the moment they arrive.

                If they’re cheap? Sure! Why not have it be covered. Aspirin crushed up and mixed into applesauce for everybody!

                If they’re expensive?

                We’re back to talking about brand new therapies being made available to anybody and everybody within weeks of them making it past the FDA… and expecting every medical professional to offer it, lest they engage in “malpractice”.

                Especially since the vast majority of medical treatments given in this country, including the one mentioned in the post that inspired these comments, are fairly tried-and-true therapies that don’t need to be bleeding edge to be effective.Report

              • Avatar Kimmi in reply to Jaybird says:

                Jay,
                If we suddenly got a new drug tha tfixed depression better and with less side effects, then hell yes, they should switch. These are the sorts of things that ought to go out as broadband bulletins from the CDC or something. (okay, not the cdc for that specific thing).Report

              • Avatar Brandon Berg in reply to Francis says:

                Switzerland

                What specific aspects of the Swiss health care system do you think the US should emulate? My understanding is that under the ACA, they’re already quite similar. The Swiss health care system works via a mandate to purchase private health insurance and subsidies for low-income individuals. The major difference that I can see is that deductibles are more highly regulated in Switzerland, with the maximum deductible allowable by law limited to about $1500, but if anything, that should increase costs.Report

              • Avatar pillsy in reply to Brandon Berg says:

                What specific aspects of the Swiss health care system do you think the US should emulate?

                The most relevant differences that seem to be that everybody gets their insurance through the Swiss equivalent of the exchanges, and that the government sets reimbursement rates.Report

              • Avatar Oscar Gordon in reply to Brandon Berg says:

                I could be wrong, but I thought Swiss insurers who provide base coverage are tightly regulated and non-profit. For-profit insurers can only provide coverage for services above the base level.Report

              • Avatar Kimmi in reply to Francis says:

                Francis,
                Are you okay with leaving everyone in West Virginia to die of heart attacks and strokes?
                Because Europe has a lot better connectivity for rural locations than America does.

                It’s okay if you want that, truly it is.Report

              • Avatar LeeEsq in reply to Jaybird says:

                Jaybird, there are countries with universal healthcare that manage to do quite a bit of medical innovation in research. Switzerland and Israel are good examples. Costa Rica is poorer than the United States by several hundreds of magnitude but has universal healthcare, does some stellar research in pancreatic cancer, and is a hotbed for medical tourism.

                Your entire line about 1987 healthcare is a fantasy that bears no resemblance to actual reality. There is not a bit of evidence to support the hard line free market position that all medical research and advancement would cease if we had universal healthcare paid for by taxes.Report

              • Avatar Jaybird in reply to LeeEsq says:

                I always enjoy “We should be more like Switzerland or Israel” discussions, but I’m not sure that there aren’t a lot of things tied together in the culture.

                There is not a bit of evidence to support the hard line free market position that all medical research and advancement would cease if we had universal healthcare paid for by taxes.

                The argument is not “IT WOULD CEASE!”

                It’s “it would stop acting like someone is pouring nigh-endless money into it and start acting like it needs more funding to do more stuff.”Report

              • Avatar Don Zeko in reply to Jaybird says:

                Is your argument that there’s something in American culture that makes us unsuitable for UHC that is distinct from the culture of France, the UK, Canada, Germany, Japan, Australia, Spain, Italy, New Zealand, etc etc etc? If so, what do you think it is? If not, where am I getting you wrong?Report

              • Avatar Jaybird in reply to Don Zeko says:

                Is your argument that there’s something in American culture that makes us unsuitable for UHC that is distinct from the culture of France, the UK, Canada, Germany, Japan, Australia, Spain, Italy, New Zealand, etc etc etc?

                Yes, I think so.

                If so, what do you think it is?

                Hrm. That’s a toughie. If I had to guess, I’d say that a lot of it is some weird “bootstrap” attitude, some weird Protestant attitude about people getting what they deserve, and, at this point, an entrenched élite who have received their health care as part of their remuneration packages for as long as they remember (and remember their parents doing the same).Report

              • Avatar LeeEsq in reply to Jaybird says:

                The United Kingdom, Anglo-Canada, Australia, and New Zealand had the same bootstrap attitude. Adding Germany and Switzerland, they also had some the same Protestant beliefs about people getting what they deserved. Australia, Canada, and New Zealand even had their own forms of white racism. They still managed to create UHC in their country.Report

              • Avatar Jaybird in reply to LeeEsq says:

                “Why do you think this happened?”
                “Some combination of X, Y, and Z.”
                “Other countries had Y!”Report

              • Avatar Nevermoor in reply to LeeEsq says:

                They have (generally) reality-based conservative parties. We have one who wants to make healthcare as terrible as possible (while whining that it still isn’t terrible enough). There’s your actual difference.Report

              • Avatar Brandon Berg in reply to LeeEsq says:

                There is not a bit of evidence to support the hard line free market position that all medical research and advancement would cease if we had universal healthcare paid for by taxes.

                In principle, this is correct. How health care consumption is funded, as such, has very little to do with the incentive to develop new health care technologies. In fact, insofar as universal health insurance increases demand for new treatments (by increasing the number of customers who can pay full price), it can act as a spur to innovation.

                However most (all?) European countries do reduce the incentive to innovate via price controls. Pharmaceutical revenues in the US exceed revenues in the the EU and Japan combined, despite the greater population and GDP of EU + Japan. A major concern of mine is that the US moving towards a single-payer health care system will facilitate the imposition of price controls, leading to lower profits and less incentive to develop new drugs.

                Yes, I’m well aware that many pharmaceutical companies are based in Europe and Japan, and I have no idea why so many seemingly intelligent people believe that this is in any way relevant. A pharmaceutical company’s market is not limited to the country in which its headquarters are located, so demand, or lack thereof, from the American market has just as much effect on a Swiss pharmaceutical company’s incentive to research new drugs as it does on an American company’s. Conversely, American companies’ incentives are affected by European price controls just as much as European companies’ are.Report

              • Avatar pillsy in reply to Brandon Berg says:

                On the other hand, I’ve never been particularly moved by the argument that US healthcare consumers should be all that enthusiastic about paying extra to let the EU, et c., free-ride on the innovation we fund by paying through the nose for drugs.

                Even if the shift towards price controls in the US slows drug development and innovation [2], the costs of slowed innovation will be spread out across the entire world of healthcare consumers, while the savings will be reaped almost entirely by American consumers.

                [2] Not unlikely.Report

              • Avatar Oscar Gordon in reply to pillsy says:

                To that end, how much do EU, etc countries with price controls spend on pharma research grants? If the EU offers a tiny amount of money to labs for drug discovery, and passively relies on the US to fund breakthroughs, then US price controls would be a problem if other countries don’t step up.

                On the flip side, having more public funding for drug research could be good since it could (ideally) set research targets for low profit drugs.Report

              • Avatar pillsy in reply to Oscar Gordon says:

                I think we’d see a rough couple of years in the pharmaceutical industry if the US adopted pretty-much-everywhere-else-style controls, and then things would shake out with other countries having somewhat higher rates while the US has significantly lower ones.

                Of course, if we did have reimbursements fixed that way, it might provide a push towards making our regulatory agencies more concerned with allowing for competition (as regulators in other countries tend to be). A more libertarian-minded poster than myself might argue that we should do that first.Report

              • Avatar pillsy in reply to Jaybird says:

                Having private expenditures cover some things that universalized care doesn’t is pretty ubiquitous in healthcare systems that aren’t the US [1] . It’s usually not focused on essential care, nor does it seem like it would have to be.

                Having one of the tiers of care being “current state of the art” and the other being “stuff from 30 years ago” is a ludicrously bad idea.

                [1] And supplemental, private insurance plans to go along with Medicare are very much a thing here.Report

              • Avatar Jaybird in reply to pillsy says:

                Having one of the tiers of care being “current state of the art” and the other being “stuff from 30 years ago” is a ludicrously bad idea.

                I was trying to figure out a way to capture the magic of patent protection offered to pharmaceuticals to medical care in general (and figure out a way to still run with doctors who find themselves less and less willing after every passing year to retrain every six months with the latest and greatest).Report

              • Avatar pillsy in reply to Jaybird says:

                Sure, but this is a problem that other systems, and for that matter a chunk of ours, have solved. FSVO of “solved”–it works pretty weirdly in the UK, frex, but it’s a thing there. It even comes as a (fancy) employment benefit.Report

              • Avatar Jaybird in reply to pillsy says:

                If we are saying “we would rather have those problems than these problems”, then I am 100% down with our decision to switch to socialized medicine.Report

              • Avatar pillsy in reply to Jaybird says:

                Well, when you get right down to it, most people are just asking to have the problems their parents or grandparents have with health insurance, not the problems the British have.

                I wouldn’t want an American NHS (unless literally the only other choice was the nonsense we have now), and any half-bright Congressional staffer or AEI intern could straight wreck a proposal for one over the course of a lazy summer afternoon.Report

              • Avatar Stillwater in reply to Jaybird says:

                Why do you think patent protections would be jeopardized by the US moving to a two-tier universal healthcare system? I don’t see the connection between the two things.Report

              • Avatar Jaybird in reply to Stillwater says:

                I’m not arguing that it would be.

                I saw the set of incentives created by patent protection (both in developing new drugs and in the cost benefits to generics) and was trying to figure out a way to apply that to more stuff than just drugs.Report

              • Avatar DensityDuck in reply to Jaybird says:

                Although given the FDA’s cussed insistence on fucking things up, I expect they’d invent a category for “orphan techniques” and allow some dork to put a patent on sticking a Q-tip up your noseReport

              • Avatar Brent F in reply to DensityDuck says:

                That’s a legal impossiblity. One, the FDA has no authority over patent law, two, by long standing common law tradition, medical techniques are inherently unpatentable, they are an exercise of professional skill, not an invention.Report

              • Avatar DensityDuck in reply to Brent F says:

                It’s a legal impossibility now. Jaybird is wondering is that’s something that’s true because truth, or something that’s true because tradition.Report

        • Avatar gregiank in reply to Jaybird says:

          It is a fact of life people will troll any idea. So yeah. But bring on two tiers.Report

      • Avatar gregiank in reply to CJColucci says:

        Yup, i’d take that in a second. So would most people on the liberal side who want Uni HC. No problem.Report

      • Avatar Burt Likko in reply to CJColucci says:

        I second that: those on the left side of the aisle are immensely more concerned about raising the floor of the basement than they are about the existence of a second story.Report

        • Avatar DensityDuck in reply to Burt Likko says:

          How do we know that we’ve raised the basement floor as high as it can possibly go, though?

          After all, if a second story exists then we could, quite obviously, raise the basement floor further.

          Oh, the basement floor is high enough already? What about my grandmother, who died in the basement even though there were things on the second story that could have saved her? What if that happens to ME–do you think that *I* should go die in the basement? Do you HATE ME PERSONALLY SO BAD THAT YOU WANT ME TO DIE IN THE BASEMENT?!Report

    • Avatar InMD in reply to Jaybird says:

      I think the former is really the tougher battle in the political world as it currently exists. Even Bernie voted for the ACA.

      The Republican party, or at least it’s leadership in Congress does not seen to understand how most people experience healthcare in this country, or deliberately avoids discussing it by referring to some mythical group of people who are choosing to opt out (something I don’t think is really possible as long as ERs are treating uninsured people).

      Of course it also isn’t clear to me that most voters are sophisticated enough to understand the nuances of our system. I suspect most vote out of fear of losing what they have or paying more for less.Report

      • Avatar Jaybird in reply to InMD says:

        “Most voters”.

        If I counted up the voters who had employer-subsidized health care and added the ones who were on Medicare, I wonder how close I’d get to “most voters”. (If I added the ones on Tricare, how much closer would that get me? Across the 50-yard line?)Report

        • Avatar InMD in reply to Jaybird says:

          I suspect that would get you there by the numbers. Excepting the ‘keep your government hands off my Medicare’ crowd I’d guess most people know who in particular they’re beholden to. But is there an appreciation for how employer, HIX, Medicaid, and Medicare interact, and the big holes in the webbing that anyone could fall through?

          I’m not so sure.Report

        • Avatar Michael Cain in reply to Jaybird says:

          Employer-subsidized including worker’s comp, plus Medicare, plus Medicaid, plus the parents of kids on CHP+, plus Tricare and the VA, plus the folks who get care at state- and locally-funded clinics,… At that point, I’d be surprised if you didn’t have 90% of voters.Report

        • Avatar PD Shaw in reply to Jaybird says:

          Health Insurance Coverage (2015):

          Employer-sponsored: 49%
          Medicare: 14%
          Other Public: 2%

          Medicaid: 20%
          Nongroup: 7%
          Uninsured: 9%

          KaiserReport

      • Avatar LeeEsq in reply to InMD says:

        I think my brother Saul has it right, Most Republican politicians are sincerely against the welfare state and do not believe that providing universal access to healthcare is something that they government should do. They also believe that people should be subject to the free market rather than protected from the vagaries of life through the welfare state. They are intelligent enough to know that will be a politically loser argument if said directly on the campaign trail. Even during the 19th century, many Americans were angry when Grover Cleveland argued that its not the government’s job to take care of the people in times of distress or need. Its even going to be more unpopular when we have a welfare state in place and certain expectations.Report

      • Avatar Dave in reply to InMD says:

        Of course it also isn’t clear to me that most voters are sophisticated enough to understand the nuances of our system. I suspect most vote out of fear of losing what they have or paying more for less.

        Yep.

        It’s why you’ll have a hard time finding people complaining about the ACA and addressing things other than health insurance.Report

    • Avatar Nevermoor in reply to Jaybird says:

      Who isn’t reconciled to two tiers of medical care? The ACA already had at least four (and fully allowed people to go over and above the top tier). And, of course, the ACA is the compromise position as it preserves market-based insurance (having been developed by conservative think tanks).

      But yeah, BSDI.Report

      • Avatar DensityDuck in reply to Nevermoor says:

        “Who isn’t reconciled to two tiers of medical care? ”

        Are you happy with the thought of rich people having insulin pumps while everyone else has to make do with needles?Report

        • Avatar Nevermoor in reply to DensityDuck says:

          Sure beats rich people having insulin pumps while poor people go blind / can’t get health insurance.Report

          • Avatar Stillwater in reply to Nevermoor says:

            The majority of lefties/Libs would agree with you, given that the only way to achieve a fully comprehensive two tiered system would require socializing the increased healthcare costs. But DD does have a point here. A small one. Shouting very loudly from the cheap seats will be some cohort of woke intersectionalists waily waily waily-ing about how a two tiered system codifies subjugation and victimizes oppressed marginalized populations who only just yesterday didn’t have access to insulin at all.Report

          • Avatar Jaybird in reply to Nevermoor says:

            I agree with this 100%.

            It’s just that, two years later, we’ll find ourselves wondering why (new treatment) costs money.

            Are you arguing that only rich people should be allowed to not die of provably preventable causes?Report

            • Avatar Nevermoor in reply to Jaybird says:

              No. I’m not.

              I’m admitting that money buys things, and suggesting that fact is insufficient reason to object to improvents in the status quo.Report

              • Avatar Jaybird in reply to Nevermoor says:

                I’m not objecting to improvements in the status quo.

                I’m making the (I thought obvious and trivial) observation that whatever we end up with will suck and people (ON BOTH SIDES!) will hate different things about it that they won’t be able to change, not even in theory.Report

            • Avatar North in reply to Jaybird says:

              Generally the rest of the developed world gets by with euphemisms and the majority of the populace doesn’t know nor give a rip.

              I think you’d be on more solid ground if you dialed it back to the McMegan line that “the US is the last moneypot for medical development and if it socializes medicine then we won’t have any more near as many future medical advances.”Report

        • Avatar gregiank in reply to DensityDuck says:

          Two tiers aren’t the issue as long as the lower tier provides good care.Report

          • Avatar dragonfrog in reply to gregiank says:

            Except that two tier systems are generally the reason the lower tier doesn’t provide good care – because everyone with power to change the lower tier, experiences and is affected by only the upper one.

            So, two tier systems aren’t the issue as long as they don’t behave as two tier systems unfailingly do.Report

            • Avatar Nevermoor in reply to dragonfrog says:

              There’s ALWAYS a two tier system, though. Someone with lots of money is always going to be able to spend it to obtain better services than the government provides by default.

              I’m not sure why I should be worried about that, when I can instead worry about shoring up the bottom tier. It’s why liberals don’t hate the existence of private schools, or think it is unfair that prison inmates can buy stuff while incarcerated.

              We aren’t actually the communists (certain) conservatives imagine.Report

              • Avatar DensityDuck in reply to Nevermoor says:

                “I’m not sure why I should be worried about that, when I can instead worry about shoring up the bottom tier. ”

                Welp. Insulin pump therapy leads to demonstrably better outcomes than needles alone, so it’s entirely possible to say that not paying for insulin pumps means that people will go blind.

                My point being that when Jaybird says “we need to get used to a two-tier system”, the way I interpret that is “we need to get used to the idea that the government healthcare plan will explicitly not have The Best Possible Outcome as a goal”.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                That would be an argument for including insulin pumps in tier 1 (I honestly don’t know if bronze ACA plans pay for insulin pumps, but I sort of assume they do). That’s not an argument for having some rule forbidding people from buying more expensive pumps if they can afford to (for example, someday there’ll be pumps with more advanced intelligence than current models, but if they cost 10x as much for 1.1x the effectiveness, do they need to be free for everyone? It’s a question to consider).

                My point is that we need to look at alternatives and status quo.Report

              • Avatar DensityDuck in reply to Nevermoor says:

                “That would be an argument for including insulin pumps in tier 1 ”

                sic transit the two-tier service.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                So tier 1 is, by definition, terrible?

                Is medicare terrible?Report

              • Avatar Jaybird in reply to Nevermoor says:

                This comes down to the “on an absolute level” vs the “on a positional level” distinction.

                On an absolute level, Tier 1 will be awesome.

                On a positional level, Tier 1 will not be Tier 2.Report

              • Avatar Nevermoor in reply to Jaybird says:

                So let’s do that. I’ll even stipulate that someone will want Tier 1 to be better, basically all the time. Someone else will want Tier 1 to be cheaper, basically all the time.

                But no one serious will propose laws to prevent people with money from going above the system.Report

              • Avatar switters in reply to Jaybird says:

                And this is important why, Jaybird. You are acting like any people being unhappy with an amendment to or replacement of a law is enough of a reason not to make an amendment/replacement.

                Your argument sounds a lot like “Well, if people will still be shrieking about multiple tiers when we move from a one multiple tier system to another multiple tier system” then of course we shouldn’t move, I mean people will still be shrieking. But that can;t be your argument. So what is it?Report

              • Avatar Jaybird in reply to switters says:

                You are acting like any people being unhappy with an amendment to or replacement of a law is enough of a reason not to make an amendment/replacement.

                I am not arguing that we should not make an amendment/replacement.

                I am, in fact, arguing that Socialized Medicine is inevitable.

                Also, I am arguing that it will have two tiers… and the two tiers won’t be “life saving stuff vs. boob jobs” tiers either.

                “So are you saying we should keep things the same as they are now?”

                “Should? I don’t understand the question. I am arguing that socialized medicine is inevitable. Also that it will have two tiers.”

                “Liberals/Progressives will *JUMP* at the chance for that!”

                “Sure they will.”Report

              • Avatar DensityDuck in reply to Nevermoor says:

                “So tier 1 is, by definition, terrible?”

                Tier 1 covers Treatment X.

                Someone invents Treatment Y, which is better than Treatment X in every possible measure except cost.

                Should we expect that Tier 1 will now cover Treatment Y despite the increased cost?

                I’m keeping my hands over the gauges here, because the point of this is not to twiddle the cost knobs around so that we can make vague statements about long-term outcomes.

                “there are things which are better but not covered by Tier 1” is not the same thing as “Tier 1 is shitty”. Socialized medicine depends on understanding and accepting that.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                I agree. It’s a case-by-case decision that cannot be reduced to a principle from the limited information in your hypothetical. Which means people are sure to disagree on specific cases. Yet, somehow, Medicare seems to manage these questions reasonably well, given how much people like Medicare.

                I suspect, given our priors, I’ll want a more generous and expensive tier 1 than you. But that just means that political debate is a never-ending adventure, not that we somehow can’t provide insurance in a two-tiered system (because, again, OBVIOUSLY we would have a two-tiered system).Report

              • Avatar DensityDuck in reply to Nevermoor says:

                “It’s a case-by-case decision that cannot be reduced to a principle–”

                (slap) No, keep your hands away from the knobs. You’ve got all the information you’re getting.

                “I suspect, given our priors, I’ll want a more generous and expensive tier 1 than you.”

                That’s fine–but you’ll also need to reconcile yourself to the fact that when someone says “we can’t afford that in Tier 1”, it can be for reasons that aren’t “I hate poor people and want them to die”, “dummies should work harder if they want better”, and so on.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                And, so?

                This is something both the government and insurers already do.Report

              • Avatar pillsy in reply to DensityDuck says:

                Should we expect that Tier 1 will now cover Treatment Y despite the increased cost?

                Is treatment Y way better and a bit more expensive, or is it a bit better and way more expensive?

                I mean, we could (and maybe should) formalize that by agreeing on a way of measuring the incremental improvement in outcomes. It’s not quite enough to acknowledge that there’s a difference between “not the best” and “shitty”: there needs to be some agreed-upon method of distinguishing between the two.

                (And then we’re going to totally throw that method away when dealing with adorable children who have really rare diseases. Fortunately really rare diseases are really rare by definition.)Report

              • Avatar Morat20 in reply to pillsy says:

                Insurance companies have this particular conversation *all the time*. They use it for multiple tiers of drug pricing, for instance.

                It’s funny the amount of time we’re arguing over problems that, well, have working solutions.

                Universal healthcare has a few dozen, over the Western world. Multiple-tier access and pricing has…a lot more! Not just all those countries with universal care, but even the insurance plans you pick from here in the US cover those things.

                (Bronze, Silver, Gold….different variations of deductible, network size, prescription coverage).

                It’s amazing the time we spend arguing about whether solutions exist to problems that are, bluntly, already solved.

                We’re not breaking new ground. We’re just trying to figure out which canned solution is best, and what minor (given the scope) modifications would work best. Yet we treat it like a jump into the utter unknown.Report

              • Avatar pillsy in reply to Morat20 says:

                Yeah, I was trying to allude to that—perhaps too subtly.

                Then again, maybe DD was doing the same (too subtly for me to catch on to, in any event).Report

              • Avatar DensityDuck in reply to Morat20 says:

                “It’s amazing the time we spend arguing about whether solutions exist to problems that are, bluntly, already solved. ”

                Oh, so you definitely totally accept a two-tier system of healthcare?

                What about (thing)? “Oh, that should be covered.”
                What about (thing)? “Oh, that should be covered.”
                What about (thing)? “Oh, that should be covered.”
                What about (thing)? “Oh, that should be covered.”
                What about (thing)? “Oh, that should be covered.”
                What about (thing)? “Oh, that should be covered.”
                (and so on).Report

              • Avatar Davebo in reply to DensityDuck says:

                So much for honest conversations.

                It’s almost like I’ve seen this before.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                What does Medicare cover that you don’t think it should? What doesn’t it cover that you do think it should?

                This isn’t abstractable, no matter how much you seem to wish it were.Report

              • Avatar DensityDuck in reply to Nevermoor says:

                “What does Medicare cover that you don’t think it should? ”

                I’m not the one who’s asking for it to cover more things.

                What is your response to people who ask “why doesn’t Medicare cover (thing) without which I shall suffer and possibly die?”Report

              • Avatar Troublesome Frog in reply to DensityDuck says:

                Oh, so you definitely totally accept a two-tier system of healthcare?

                I’m not understanding how our current system differs from a two-tier system. The arguments seem to be that people won’t accept an increase in the number of tiers when in reality, a two-tier system would be a whole lot less tiers than we currently have.

                It’s not like we’re talking about replacing a system where rich and poor alike get exactly the same thing care and trying to tease out what the consequences of this strange new system would be.Report

              • Avatar DensityDuck in reply to Troublesome Frog says:

                “The arguments seem to be that people won’t accept an increase in the number of tiers…”

                It’s not that they won’t accept an increase in the number of tiers; it’s that they’ll be angry to learn that after hearing how we needed healthcare reform so that (thing) wouldn’t force people into bankruptcy, (thing) is part of the Tier 2 coverage.Report

              • Avatar Troublesome Frog in reply to DensityDuck says:

                So hypothetical promises that we can’t specify here won’t be kept? We can’t say what treatment X is, but we can be certain that treatment X will be promised to the masses and then denied?

                This is not making any sense to me. We have a system with a bunch of tiers and a bunch of treatments that people can’t afford the lower tiers don’t get. Is the worry that if we rejigger the system so the lower tiers get substantially more but not everything, they’ll reject the system? Is this a “perfect being the enemy of the good” type of thing?Report

              • Avatar Oscar Gordon in reply to Troublesome Frog says:

                As a society we seem much more tolerant of the faceless corporate drone denying us something than we are the faceless bureaucrat, even if the denial is made for the exact sameReport

              • Avatar Nevermoor in reply to Oscar Gordon says:

                A theory proven by the near universal hatred for Medicare, and definitely not just an unsupported opinion presented as fact.Report

              • Avatar DensityDuck in reply to Troublesome Frog says:

                “So hypothetical promises that we can’t specify here won’t be kept? ”

                The people asking us to reform healthcare are asking for exactly those promises!

                “We have a system with a bunch of tiers and a bunch of treatments that people can’t afford the lower tiers don’t get.”

                …and then you say…

                “Is the worry that if we rejigger the system so the lower tiers get substantially more but not everything, they’ll reject the system?”

                If the whole reason you’re rejiggering the system is because the lower tiers can’t afford things, then it looks pretty derpy to end up with a system where the lower tiers still can’t afford things. It looks less like reform and more like rearranged deck chairs. Maybe there’s slightly more deck chairs because of a more efficient arrangement, but there are still people who can’t sit down, and your stated reason for tearing things apart was to help the people who couldn’t sit down.

                Which gets me back to what Jaybird was talking about in the first place. The harder job, in healthcare reform, is not dealing with the people who Hates Socialized Medicines Forever. It’s dealing with the people who see healthcare reform happen but still can’t pay their doctor bills. Or, maybe, it’s figuring out how we can be Good Kind Empathetic Rational Well-Meaning Inclusive Persons who nonetheless will look a single mother in the eye and tell her to buy her own chemo meds.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                If the whole reason you’re rejiggering the system is because the lower tiers can’t afford things, then it looks pretty derpy to end up with a system where the lower tiers still can’t afford things.

                C’mon. I know you’re smarter than this and don’t actually think in conservative bumper stickers.

                Let’s assume that the AHCA passes and there are 24 million people who can’t afford 1,000,000 things. And we pass a system where those people get onto tier one and therefore can’t afford 100 things. That’s not “derpy,” it’s progress. Health care isn’t an abstraction.Report

              • Avatar DensityDuck in reply to Nevermoor says:

                “And we pass a system where those people get onto tier one and therefore can’t afford 100 things.”

                And if one of those 100 things is the thing they need to live?

                “That’s not “derpy,” it’s progress.”

                I can progress from seventy feet underwater to seven, but if I can’t swim I’ve still got problems.

                And again. You’re arguing as though I’m saying “it should be perfect or it should not happen”. I’m saying that the thing you propose does not address people’s stated reasons for wanting it, and that has a strong likelihood of turning into “okay well you did the thing but it didn’t fix the problem, now you HAVE to do this other thing, and this OTHER thing, and this other thing…”Report

              • Avatar Nevermoor in reply to DensityDuck says:

                If one of the 100 things is something “they” (as in everyone) needs than it better be in Tier 1.

                If not, then you’ve reduced the problem from millions of people to fewer than millions of people, which is a pretty good policy.

                Again, in discussing the problems with Medicare–which actually does this stuff–so far I’ve seen one link to one treatment that may-or-may-not be necessary for one woman, but that Medicare apparently only approves sometimes (including maybe for her, or maybe not). From that you weave a conclusion that Medicare-for-all would be “derpy” (but do so insistent on staying at an abstract remove).Report

              • Avatar DensityDuck in reply to Nevermoor says:

                “If one of the 100 things is something “they” (as in everyone) needs than it better be in Tier 1.”

                What if it’s not “everyone”? What if it’s just one person? Why should that person die just so that there can be 100 not-covered things instead of 99?

                Or is it that when you say that you’re on board with two tiers, you mean that Tier 1 is “everything but boob jobs” and Tier 2 is “boob jobs”?

                “If not, then you’ve reduced the problem from millions of people to fewer than millions of people, which is a pretty good policy.”

                if your policy goal is “reduce the number of overall uninsured”.

                The people asking for healthcare to be reformed aren’t, generally, saying “reduce” in any other context than “to zero”.

                “From that you weave a conclusion that Medicare-for-all would be “derpy” (but do so insistent on staying at an abstract remove).”

                I guess you missed all the posts where I said that I supported single-payer and medicare-for-all? I get that you argue with fake people inside your head, but there are words here on this page that are directly opposite from what you said here.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                If you waive away the fact that numbers are different, and everything everyone has said in response to this answer, then this is a strong point.

                I supported the ACA, which definitely didn’t reduce anything to zero. Because it made things better than they were. I oppose the AHCA because it makes things worse. I would support Medicare-for-all (subject to solving the transition shock) because I believe it would make things better than now. None of those solutions eliminates all pain and suffering and sadness in the world. Which is true of literally everything anyone has ever done.

                But you keep right on misinterpreting that and making the same comment over and over again. .

                Also, words: “If the whole reason you’re rejiggering the system is because the lower tiers can’t afford things, then it looks pretty derpy to end up with a system where the lower tiers still can’t afford things.” I take from this more recent comment that you’re either retracting that point or it was a rambling unrelated to anything we are actually discussing.Report

              • Avatar DensityDuck in reply to Nevermoor says:

                “None of those solutions eliminates all pain and suffering and sadness in the world. Which is true of literally everything anyone has ever done. But you keep right on misinterpreting that and making the same comment over and over again.”

                That’s because you still focus on “I want to reduce the pain and suffering and sadness”, and yet you also say that you’re OK with some of it not being reduced. So…what’s wrong with the system we have now, then? It is, after all, one of the best.

                And I can hear you fumping about “well what’s YOUR solution then, you say you favor Medicare For All but what ARE the reasons other than improving outcomes”, and my answer is that there are benefits from a national healthcare program that don’t have anything to do with improving outcomes. It’s about improving the freedom of movement between opportunities; if I can’t be sure that I’ll get healthcare coverage for a particular condition then I’m not gonna move to a better place (or to leave a bad one.) I don’t, actually, think that a MfA system will give us better outcomes than we’ve got right now.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                The system we had pre-ACA (and would go back to post-AHCA) would be one of the worst in the world, not one of the best. The ACA system, though much better, is also FAR more expensive than other countries while not providing excellent outcomes (your link, for example, concludes that care is dramatically more expensive and outcomes might be a teeny bit better. That’s a problem).

                So the reason to move to MfA is that it would almost certainly reduce cost substantially (you’d win at least 10% on admin overhead right off the bat, while likely also reducing fees paid for services dramatically), increase access dramatically (the “fA” part), and provide exactly the sort of benefits you describe while also freeing Americans from things like medical-bankruptcy (though the ACA already did a lot of that work). These are all good things, even if none of them are perfect. And it’s ok not to pretend that the result will be perfect, especially in the early stages, to support the change.Report

              • Avatar pillsy in reply to DensityDuck says:

                I’m saying that the thing you propose does not address people’s stated reasons for wanting it, and that has a strong likelihood of turning into “okay well you did the thing but it didn’t fix the problem, now you HAVE to do this other thing, and this OTHER thing, and this other thing…”

                And maybe we can, and maybe we can’t. Some of the complaints will seem pretty fair, and some of them won’t, and I doubt there will be universal consensus on which is which.

                Some people will die even if you spend that billion dollars. Other people will die because some routine-ass procedure that doesn’t cost much at all gets screwed up. And so on.

                But fewer complains is better. More met needs is better.

                Fewer heart-rending unbelievably-bad-luck sob stories is better.

                Meeting moral obligations to more people seems obviously better to me [1], all else being equal, even if, for various reasons, we can’t meet our obligations to everyone.

                [1] I mean, once you accept that there are moral obligations to be met.Report

              • Avatar DensityDuck in reply to pillsy says:

                “Fewer heart-rending unbelievably-bad-luck sob stories is better.”

                Yes, it definitely is.

                But if you’re motivated to change things because you heard heart-rending unbelievably-bad-luck sob stories, and your proposed change knowingly and intentionally will not handle all those stories, well. What are you even doing this for, then?Report

              • Avatar Oscar Gordon in reply to pillsy says:

                I’m not sure why so many people seem to be having a hard time understanding @densityduck ‘s point here, almost as if everyone is trying to talk about anything but what he’s addressing.

                There is a, if not large, then certainly vocal (with access to popular national platforms) contingent of HC reformers that are lobbying, agitating even, for a vision of HC reform that is without a doubt unsustainable, and if the rest of the groups lobbying for SP or UC don’t clearly address that those folks aren’t being realistic, those agitators could tank reform efforts by being a “perfect is the enemy of the good” set.

                Every movement has such people, and they have to be told to go fume quietly in the corner while the adults get work done.Report

              • Avatar Stillwater in reply to Oscar Gordon says:

                The irony – or perhaps confusion – here is that DD said he supports single-payer even while he’s criticizing a two-tier advocate for failing to address political/policy obstacles which pertain to his preferred system as well. Seems like ankle biting to me.Report

              • Avatar DensityDuck in reply to Stillwater says:

                “DD said he supports single-payer even while he’s criticizing a two-tier advocate for failing to address political/policy obstacles which pertain to his preferred system as well.”

                I’ve already solved those obstacles, at least in my own mind, by the expedient of declaring them not relevant to the goals which I think a single-payer system ought to strive for.

                My concern is conversations that go like this:

                Jaybird: “you’ll have to get used to a two-tier system”
                People: “well of course that’s what we’ll have”
                Me: “what about (thing)”
                People: “well of course that’ll be in Tier 1”
                Me: “what about (thing)”
                People: “well of course that’ll be in Tier 1”
                Me: “what about (thing)”
                People: “well of course that’ll be in Tier 1”

                And what I conclude is that these people do not, actually, want a two-tier system. As I keep saying, they’re imagining that Tier 1 is “everything but boob jobs” and Tier 2 is “boob jobs”. And I feel like they don’t have a backup plan for when the two-tier system rolls out and we immediately hear stories about how so-and-so contracted boneitis and that’s not covered under Tier 1 and they’re gonna have a medical bankruptcy and we need reform.

                And they say “well yeah but it’ll help some people“, and hey, that’s great, but the stated goals of the healthcare reform movement are not “maybe we’ll help some of you”. The motivation is not “make things better on average for typical people who don’t have weird problems”.Report

              • Avatar Stillwater in reply to DensityDuck says:

                For my part, I don’t think that line of reasoning is persuasive except as an argument for single payer where (presumably) those types of concerns don’t obtain. So two things: within your single payer system there will almost certainly be a private insurance option for folks who desire it and can afford it unless those type of market opportunities are prohibited by law. I don’t see that happening. Do you? (Would you desire such a prohibition?) So even on your preferred model there will be two tiers.

                The other thing is that in single payer there will be edge cases in which provision of services will be denied unless spending is unlimited. But that’s the type of unsustainability Oscar was referring to. So even on your own model hard political decisions need to be made regarding what services will be denied to specific individuals. So it seems to me the types of problems you’re challenging Nevermoor to account for apply just as much to universal single payer.Report

              • Avatar DensityDuck in reply to Stillwater says:

                “even on your preferred model there will be two tiers.”

                A setup where Tier 1 is “everything that has any medical benefit whatsoever” and Tier 2 is “boob jobs” is not meaningfully divided into two tiers.

                “So even on your own model hard political decisions need to be made regarding what services will be denied to specific individuals.”

                I’m willing to make those decisions.

                I don’t think that’s true of someone who tells me that there’s a Fierce Moral Urgency to provide medical care. I think that people who talk about Fierce Moral Urgency are remarkably good at coming up with reasons why in this case we need to stretch the rules just a little bit, this one time.Report

              • Avatar Stillwater in reply to DensityDuck says:

                A setup where Tier 1 is “everything that has any medical benefit whatsoever” and Tier 2 is “boob jobs” is not meaningfully divided into two tiers.

                I’m not sure why you’re so insistent on the boob job thing. Imagine it more like Canada, where there’s a foundational single payer system constrained by cost and therefore a form of rationing of healthcare provision determined by whatever constraints they’ve imposed, and a private insurance system which (perhaps) has no spending caps and therefore covers every conceivable medical situation.

                Boob jobs have nothing to do with it.Report

              • Avatar DensityDuck in reply to Stillwater says:

                “I’m not sure why you’re so insistent on the boob job thing. Imagine it more like Canada, where there’s a foundational single payer system constrained by cost and therefore a form of rationing of healthcare provision determined by whatever constraints they’ve imposed…”

                I’m not the one who’s upset about rationing by cost.

                But I’m not the one who you’ll have to convince that the New Improved (But Still Rationed) System represents real reform that was worth fighting for.

                “Boob jobs have nothing to do with it.”

                The reason I keep bringing up boob jobs is that whenever people talk about how they’re totally OK with there being two tiers of healthcare coverage, it turns out that their idea of “Tier 2 uncovered private-spending care” is, well, boob jobs, and Viagra, and things where the knobs of the Example Machine were spun to reductio ad absurdum levels.

                Like, I’m pretty sure they don’t imagine that Lipitor would be put in Tier 2 because “just eat less fat, fatty, and you’ll be fine once you aren’t so fat”. Or that insulin pumps would be put in Tier 2 because “needle injections combined with proper diet and exercise regimens result in acceptable long-term outcomes”. Or that proton therapy for tumor reduction would be in Tier 2 because “it’s still considered experimental whereas chemotherapy is a well-understood protocol”.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                For the ten thousandth time, Medicare has spent a long time making these decisions. Do you think it is doing anything seriously wrong? If so, what?Report

              • Avatar Dark Matter in reply to DensityDuck says:

                Tier 1 is “everything I need”.
                Tier 2 is “things I don’t need”.

                Fertility treatments are a great example, better imho than boob jobs.

                I’m perfectly willing to back UC if we have something which can be reasonably (mis)called a “death panel”.

                One way to do it is to give every treatment a rating (say, a ratio created by dividing benefit by money), and then putting as much money in the pot as we want to, and then seeing what we can afford. Fund everything above a certain line and don’t fund anything below it.

                But wherever that line is, people will die, and their relatives will scream to the media that it’s not fair.

                My feeling is that you’re right. UC proponents envision that *everything* will be covered. I remember Nancy Pelosi explaining it that way to some of her backers.Report

              • Avatar pillsy in reply to DensityDuck says:

                I think that people who talk about Fierce Moral Urgency are remarkably good at coming up with reasons why in this case we need to stretch the rules just a little bit, this one time.

                They are. They just aren’t remotely unique in that.

                Every one who wants the reform along the lines we’re talking about, even if the reform program goes as well as is feasible, is going to be bitterly disappointed with some aspect of it.

                Some of them are going to be people with type I boneitis who don’t have a promising treatment covered because it’s too expensive.

                Some of them are wondering why we’re spending billions of dollars a year on dodgy treatments for type II boneitis when spending the money on better insulin pumps would help a lot more people in a much more significant way.Report

              • Avatar pillsy in reply to Oscar Gordon says:

                Every movement has such people, and they have to be told to go fume quietly in the corner while the adults get work done.

                Those people will be out there, but when they come, I’m going to go out on a limb and say that they aren’t going to be coming from where DD thinks they are.

                It’ll be about whether it’s OK to have any sort of direct payments from patients at all or whether it’s OK to have anyone but the “rich” support the plan.

                That, I predict, is where the fracture points on the left will be: “How dare you suggest that a poor person should have to make a $5 copay?” or, “What do you mean a 10% premium from someone making median income?”

                I.e., it’ll be another front in the fight over economic inequality, wages and (effectively) taxes. Not so much “if one life be saved” stuff.Report

              • Avatar Oscar Gordon in reply to pillsy says:

                You might be right, but the larger point is still valid; those damn ankle biters can distract and rob a movement of much needed momentum. Best to acknowledge their existence and put on the mid-calf leather boots, instead of walking around in Birkenstocks.Report

              • Avatar Morat20 in reply to Oscar Gordon says:

                So the correct response to anti-fa is, in fact, a punch to the face?

                By the peaceful protesters?Report

              • Avatar Stillwater in reply to Oscar Gordon says:

                Not really, at least if DD is your example of ankle biting. Tho I concede he’s distracted you. 🙂

                Add: you and I clearly understand different things by that term.Report

              • Avatar pillsy in reply to Stillwater says:

                If the DM lets you play a kender, they deserve what they get.Report

              • Avatar pillsy in reply to Oscar Gordon says:

                I would be the last to deny the existence of the ankle biters.Report

              • Avatar Troublesome Frog in reply to DensityDuck says:

                I can progress from seventy feet underwater to seven, but if I can’t swim I’ve still got problems.

                I’m trying to figure out how what you’re arguing here can’t be reduced to, “There has been no economic progress since the Dark Ages because there are still things that some people don’t get to have. All of our efforts were wasted.”

                Or maybe, “I don’t get why you’re so happy about the polio vaccine. There are still dozens of cases per year, so the system still sucks if you’re one of those people.”

                Or is there some reason why it’s just healthcare provisioning where comparing two sets of outcomes is a logical impossibility?Report

              • Avatar DensityDuck in reply to Troublesome Frog says:

                “I’m trying to figure out how what you’re arguing here can’t be reduced to, “There has been no economic progress since the Dark Ages because there are still things that some people don’t get to have. All of our efforts were wasted.””

                I’m not arguing that.

                The people who say “of course insulin pumps should be in Tier 1″ are arguing it.

                The people who say “yes” to every “should (thing) be covered” are arguing it.

                The people who say “the purpose of healthcare reform is to make sure that everyone gets the healthcare they need” are arguing it.

                Because if you’re saying that the current system is immoral and needs to change because not everyone gets all the doctoring they need, then you cannot go in saying “we’re going to set up a system that we know will not give everyone all the doctoring they need”, because that isn’t in concordance with the moral imperative you’re taking as justification.

                “Or is there some reason why it’s just healthcare provisioning where comparing two sets of outcomes is a logical impossibility?”

                If you go out to buy bread but come back from the store with a hammer, then you haven’t achieved your goals, and saying “well I went all the way to the store and bought something” doesn’t make it so.

                ******

                And so I guess after all this yak we see the answer to Jaybird’s question, and the answer is “no”. Democrats and Progressives will not, it seems, be able to reconcile themselves to a two-tier system of medical care. They’ll destroy Medicare-For-All by insisting that it cover everything, and while it burns to the ground they’ll yell at each other about how they let Perfect Be The Enemy Of Good-Enough.Report

              • Avatar switters in reply to DensityDuck says:

                “Because if you’re saying that the current system is immoral and needs to change because not everyone gets all the doctoring they need, then you cannot go in saying “we’re going to set up a system that we know will not give everyone all the doctoring they need”, because that isn’t in concordance with the moral imperative you’re taking as justification.”

                This is about as ridiculous as anything ever written here.

                I believe we have a moral obligation to set up a system to identify and imprison murderers. According to DD though, unless my plan is 100% effective, I cannot propose it. Awesome, you just ruled out every solution to every problem ever proposed.Report

              • Avatar Oscar Gordon in reply to switters says:

                Man, good thing no one ever proposed such a system, and quite specifically sold the idea of an inherently imperfect system that would fail towards not catching 100% of murdererReport

              • Avatar Stillwater in reply to Oscar Gordon says:

                Are you talking about the ACA? If so, that’s not fair. It was never billed as a 100% solution to healthcare problems. It was designed with a few primary goals in mind: preserve Medicare; mandate guarantee issue and community rating; set a medical loss ratio floor; bend the cost curve; expand Medicaid and the private market; etc.

                It was a highly imperfect bill along a whole slew of vectors. I don’t think anyone would dispute that.Report

              • Avatar switters in reply to Oscar Gordon says:

                Oscar,

                I’m having trouble parsing this. If your claim is that the ACA was sold as the 100% solution to countries health care ills I would strenuously disagree. I heard “don’t make the perfect the enemy of the good” so often it nearly induces a gag reflex at this point.

                Im sure there were those who claimed it would solve all health care problems, but they were a pretty insubstantial minority, right?Report

              • Avatar DensityDuck in reply to switters says:

                “I believe we have a moral obligation to set up a system to identify and imprison murderers. According to DD though, unless my plan is 100% effective, I cannot propose it.”

                Hey cool analogy bro, but for it to be really representative the cops would have to say things like “we know that your wife was murdered, but unfortunately we think it would be too expensive to chase the criminals and so we aren’t going to investigate at all. You’re welcome to hire a private detective though.”

                (Kim: Yes, I know. Shut up.)Report

              • Avatar switters in reply to DensityDuck says:

                “but for it to be really representative the cops would have to say things like “we know that your wife was murdered, but unfortunately we think it would be too expensive to chase the criminals and so we aren’t going to investigate at all. You’re welcome to hire a private detective though.”

                You understand that is what police forces do, every day in every jurisdiction, right. Albeit a bit more diplomatically.

                Even your back up position – “beware of passing this law, because people who don’t think its 100% effective will keep agitating to make it better,” while completely true, is just banal.

                Maybe analogies aren’t your thing.Report

              • Avatar Francis in reply to DensityDuck says:

                Oddly enough, there are about a half-dozen models for the delivery of health care, including Canada, England, Switzerland, France, Germany and Singapore, that a vast majority of Democrats / Liberals / Progressives / Leftists would prefer to the existing system.

                But since employer-based health care is so deeply embedded in our society and tax code, Obama and the Congress realized that they didn’t have the votes or support for such a radical change.

                Without a single Republican vote, they substantially raised taxes, pumped hundreds of billions into Medicare, and imposed stiff regulations on employer-based health insurance policies.

                Yet it’s the Democrats who will burn the system to the ground?

                The ACA could use some tweaks to work better; the AHCA will actually burn the system to the ground if the CBO is to be trusted. It is way past the time to continue absolving the Ryan-led House of its utter failure to govern.Report

              • Avatar Stillwater in reply to DensityDuck says:

                Democrats and Progressives will not, it seems, be able to reconcile themselves to a two-tier system of medical care. They’ll destroy Medicare-For-All by insisting that it cover everything,

                DD, I’m not sure we’re using the term “two-tier system” the same way. The way I understand the term, a two-tier system is a public single payer system (like Medicaid and Medicare) and a private health insurance system. Structurally, we already have a two tier system, and progressives/liberals/lefties/lots of righties merely want an expansion of one tier already existing in the current HC system.Report

              • Avatar DensityDuck in reply to Stillwater says:

                I’ve never meant it any other way. The question is, do the people talking about how they’ll die without the ACA understand that the thing killing them might not be in the “public health coverage” tier?Report

              • Avatar Stillwater in reply to DensityDuck says:

                I still have no idea what you’re actually arguing. Nevermoor, TFrog, switters, others, me, we’ve all responded to your comments yet you persist in thinking there’s an issue which hasn’t been addressed. I don’t know what it is, to be honest. Politics is an issue in any major policy change. Everyone agrees with that. Hard choices need to be made regarding provision of covered services. Conceded. Everybody admits these things.Report

              • Avatar Troublesome Frog in reply to DensityDuck says:

                Because if you’re saying that the current system is immoral and needs to change because not everyone gets all the doctoring they need, then you cannot go in saying “we’re going to set up a system that we know will not give everyone all the doctoring they need”, because that isn’t in concordance with the moral imperative you’re taking as justification.

                So it really is the case that any law that’s passed in furtherance of an objective is not in concordance with that objective if it doesn’t satisfy it 100%?

                If it’s wrong that we allow children to be uneducated, proposing public schools would not be in concordance with that imperative because they eventually graduate and we could potentially teach them more.

                If it’s wrong that people get murdered, putting together a police force with any budget less than 100% of our economic output is not in concordance with the murder imperative because we could still potentially spend more money stopping murder.

                If it’s wrong that there’s no way to transport goods from place to place, building roads is not in concordance with that imperative because some goods will still not be movable and we could always demand teleporter research.

                If the argument is that there’s a slippery slope that will eventually cause those crazy leftists to spend 100% of our output on healthcare, I’m not clear on why it already hasn’t happened with schools or policing.Report

              • Avatar DensityDuck in reply to Troublesome Frog says:

                “So it really is the case that any law that’s passed in furtherance of an objective is not in concordance with that objective if it doesn’t satisfy it 100%?”

                If “people don’t have care” represents a failure state, then a proposal that doesn’t drive coverage to 100% is a proposal that’s failed before it even gets off the ground.

                One way to solve this is to explicitly not make improved coverage a goal. But I keep asking “how are you going to sell that to people who want 100% coverage”, and you keep replying by turning up the knobs of the example machine until they snap off and saying “see? THAT is how!”

                You all keep writing as though I’m the one you need to angrily denounce until I agree with you. But–and I can’t believe that I need to keep writing this down, I can’t believe that people keep ignoring it–I’m not the one saying that lack of coverage is a problem. I’m not the one retelling sad stories about people dying from Totally Preventable Things. I’m not the one talking about medical bankruptcies. I’m not the one describing people setting up crowdfunding accounts to pay for surgery.

                I am not the one making a case for reform based in moral imperatives.

                I understand that you’re yelling at me because I’m here.

                “If it’s wrong that we allow children to be uneducated, proposing public schools would not be in concordance with that imperative because they eventually graduate and we could potentially teach them more.”

                Wow. This is what you come at me with? No wonder you dopes can’t figure out what I’m saying!

                “If the argument is that there’s a slippery slope that will eventually cause those crazy leftists to spend 100% of our output on healthcare, I’m not clear on why it already hasn’t happened with schools or policing.”

                I’m going to give you the benefit of the doubt and assume that you are just not paying attention to the ongoing arguments about how we’re spending more on college and policing than ever before, getting less result than we ever got before, and how the solution is to spend more money on these things.Report

              • Avatar Jaybird in reply to DensityDuck says:

                There’s always something interesting going on when someone makes a statement X and the responses come:

                How come you’re opposed to the proposition in statement X?
                Statement X isn’t going to happen!
                We’re already doing statement X now!
                Nobody is opposed to statement X!
                Statement X is really a merely trivial observation…Report

              • Avatar Stillwater in reply to Jaybird says:

                What’s statement X in this debate?

                As far as I can tell, it’s this: DD thinks a two tier system creates edge cases in which private tier healthcare may not be available in the public tier.

                That’s descriptively accurate, and as far as I can tell true by definition. DD thinks it constitutes a fatal problem for a two tier system. Other people disagree.Report

              • Avatar Jaybird in reply to Stillwater says:

                Well, the statement for X that first came to my mind was something like “Democrats/Progressives are going to have to reconcile themselves to there being two tiers of medical care”.

                While, I can’t really prove that such a statement would set off a shitstorm, I can look for evidence, if you’d like.Report

              • Avatar Stillwater in reply to Jaybird says:

                Is medicare-for-all a two tier system in your view?Report

              • Avatar Jaybird in reply to Stillwater says:

                With the first life-saving (or significantly life-improving/extending) treatment that (rich person) gets that (person on tier 1) fails to get, yes.Report

              • Avatar Stillwater in reply to Jaybird says:

                Jaybird, it’s a two tier system before that rich person, with private insurance receives a treatment the public tier doesn’t provide. It’s a two tier system precisely because it provides both public healthcare and private insurance.Report

              • Avatar Stillwater in reply to Jaybird says:

                Well, in that case …. every liberal/progressive I know and every liberal/progressive in this discussion would love Medicare for all in a two tier system. Are you and DD on board? Let’s get this done!

                {{For some reason I feel like the liberals/progressives aren’t the problem, here… }}Report

              • Avatar Jaybird in reply to Stillwater says:

                Hey, I think it’s inevitable.

                If it were done when ’tis done, then ’twere well it were done quickly.Report

              • Avatar DensityDuck in reply to Stillwater says:

                “every liberal/progressive I know and every liberal/progressive in this discussion would love Medicare for all in a two tier system. Are you and DD on board? Let’s get this done!”

                Sounds good to me. I’ll let you field the questions about “why doesn’t the government cover (thing)”, though, because all along you’ve been saying you have the best answer for that.Report

              • Avatar Kimmi in reply to DensityDuck says:

                I don’t mind when the bleedin’ heart libs start saying “why won’t you cover this?”. I MIND when the conservatives fall for some stupid drug company’s propaganda, and start saying the same fucking thing. I expect better from them.Report

              • Avatar pillsy in reply to Jaybird says:

                You’re getting a spectrum of answers because there is a spectrum of “Democrats/Progressives” who have different (if perhaps not extremely different) perspectives on this just commenting on this very thread.

                I don’t know if this is tantamount to saying that X is trivial, but I will cop to saying X is happening now.

                I am also going to stick with my contention that differing availability of essential care between private and public markets isn’t likely to be a serious threat to the pro-reform coalition (though there will be others).

                But maybe I’m wrong. I think we’ll know in the next 5-10 years.Report

              • Avatar Jaybird in reply to pillsy says:

                I am also going to stick with my contention that differing availability of essential care between private and public markets isn’t likely to be a serious threat to the pro-reform coalition

                Best of luck to them!Report

              • Avatar Stillwater in reply to Jaybird says:

                Jaybird at T1: “Two tier system is inevitable.”

                Jaybird two seconds later: “Two tier system is impossible!”Report

              • Avatar Joe Sal in reply to Stillwater says:

                “The problem with parsing need, is the problem with parsing need”

                “your in good hands with skippies rationality (insert blue hands logo here)”Report

              • Avatar Jaybird in reply to Stillwater says:

                Not exactly a paraphrase of my position, I’d like to point out.

                It’s more that I think that there will be a two tier system where my part of town will have a lot more doctors willing to accept the first tier (and that there will be no shortage of second tier doctors).

                And, at the end of the day, the system we have is defined by culture rather than by law, and so changing the law is most likely to result in a system a lot like the one we have now. Only codified into law.

                Maybe we’ll pass some laws saying that doctors *MUST* accept some percentage of Tier 1 patients. Surely that will fix it.Report

              • Avatar Nevermoor in reply to Jaybird says:

                Another problem that doesn’t seem to exist in other countries.

                If everyone has Tier 1 insurance, only a few doctors will have sufficient tier 2 customers/expensive enough services to not accept it.Report

              • Avatar Morat20 in reply to Stillwater says:

                What’s weird is he doesn’t note that this is the pre-ACA system.

                Insurance had stuff it paid for, stuff it didn’t. Didn’t have cash and it wasn’t covered? Sucks to be you.

                And whether or not you could get insurance was yet another tier.

                “Oh no, under two tiers some things might not be covered”. Yep. But pre-ACA we had like…60 tiers, one of which was “No money, no coverage, no healthcare at all” and some were “Some money, we rescind your coverage instantly if you get sick” and some was “We cover some stuff, not others” to varying degrees.

                So the amazing massive problem of “How do we, as a society, handle the notion that our health insurance might not cover everything” can be summed up “Like we did before, only there’s a lot less examples?”

                I mean we all lived through the ACA and pre-ACA, right? We’re not talking some hypothetical martian society?Report

              • Avatar Jaybird in reply to Morat20 says:

                What’s weird is he doesn’t note that this is the pre-ACA system.

                I didn’t think I had to.

                I just am not seeing the moral urgency of switching to a system more or less identical to the one we have now. Is it because Sweden is doing it?Report

              • Avatar pillsy in reply to Jaybird says:

                Is this another deontology/consequentialism thing?Report

              • Avatar Don Zeko in reply to pillsy says:

                As far as I can tell it’s mostly just a demonstration that playing a bunch of semantic games is easier than actually learning something about a subject.Report

              • Avatar Jaybird in reply to pillsy says:

                One of the biggest things I’ve noticed in any sufficiently progressive discussion is that we have a moral imperative to have pretty much exactly what we have right now, only with more people getting exactly what we have right now, for cheaper. (See, for example, college degrees.)

                And we’re not going to end up with that.

                Some people will be better off. Hurray!
                Others will be worse off. Well, you have to understand…

                The amount of health care, more or less, will remain the same because this isn’t going to create more doctors, nurses, nursing assistants, hospitals, so on and/or so forth.

                We’ve got a problem *NOW* with doctors moving from an “accepts Medicare” paradigm to a “doesn’t accept Medicare” paradigm. Medicare-for-All ain’t gonna address that.

                It’s going to accelerate that and make it worse.

                But I accept that it’s inevitable. Hell, I think we should probably hurry it up and institute it.Report

              • Avatar Nevermoor in reply to Jaybird says:

                We’ve got a problem *NOW* with doctors moving from an “accepts Medicare” paradigm to a “doesn’t accept Medicare” paradigm. Medicare-for-All ain’t gonna address that.

                [Citation needed]. As a simple illustration, many more retailers refuse to accept Discover cards (which few people hold) than Master cards (which many people hold).Report

              • Avatar Jaybird in reply to Nevermoor says:

                Here’s something from 2015.

                Maybe it’s gotten better since then. After Medicare-for-All, maybe it’ll get even better than it’s surely gotten since 2015.Report

              • Avatar pillsy in reply to Jaybird says:

                After Medicare-for-All, the costs for refusing to take Medicare will be much higher, and the ability to offset those costs by accepting private insurance will be much lower, if not strictly non-existent.Report

              • Avatar Nevermoor in reply to pillsy says:

                Yep. I should have made clearer that I was challenging the truth of the last sentence I quoted, which is my fault.Report

              • Avatar Dark Matter in reply to pillsy says:

                After Medicare-for-All, the costs for refusing to take Medicare will be much higher, and the ability to offset those costs by accepting private insurance will be much lower, if not strictly non-existent.

                Only if you take all comers.

                If we go down this path I expect a boom in Concierge Medicine.Report

              • Avatar pillsy in reply to Dark Matter says:

                That’s the biggest risk. I think it underestimates the extent to which providers would be thrilled if they could know how much they’re going to get paid, when they’re going to get paid, and, frankly, that they’re going to get paid at all.

                (The biggest weakness of the ACA, I think, is that it tied outcomes to reimbursement in a way that makes one of the worst problems in our health care system even, like, more bad.)Report

              • Avatar Dark Matter in reply to pillsy says:

                (The biggest weakness of the ACA, I think, is that it tied outcomes to reimbursement in a way that makes one of the worst problems in our health care system even, like, more bad.)

                IMHO the biggest weakness is it doubles down on the parts of the system which make it expensive. It was insurance reform, we need medical reform.

                Infection rates for hospitals and doctors are hidden. Costs are hidden. Success rates. Etc, etc.

                Force the publishing of all of them and we’d at least have potential solutions that involve markets, at the moment we don’t and can’t.

                Without markets we have rationing and/or money cannons.Report

              • Avatar pillsy in reply to Jaybird says:

                The flaw in your argument is that you seem to believe that, in order to get better outcomes for people who aren’t covered now, they need as much care as people who are currently covered and can get treated.

                But the thing is people who are covered often get way more treatment than they need, in the sense that they get treatment that has little or no benefit. If you think, “Currently health care is basically a free market where people aren’t going to spend a lot of money on care that has little or no benefit,” this will strike you as, at best, counter-intuitive, and perhaps you will hit on the idea that health care is basically a positional good.

                But healthcare isn’t basically a free market in the US, so that reasoning doesn’t obtain. It’s a bunch of (shitty) heavily regulated cartels, government paid systems, and socialized systems that have been tossed into a burlap sack, beaten vigorously with a hammer, and slathered with “I Can’t Believe It’s Not a Free Market” capitalism-substitute spread.Report

              • Avatar Jaybird in reply to pillsy says:

                But the thing is people who are covered often get way more treatment than they need, in the sense that they get treatment that has little or no benefit.

                We’re going to run with that pretty hard in the coming years.

                But healthcare isn’t basically a free market in the US, so that reasoning doesn’t obtain.

                Fair enough. I’m remain pretty sure that doubling down will get the same results as the other fifty billion times we’ve doubled down.Report

              • Avatar DensityDuck in reply to Stillwater says:

                “DD thinks a two tier system creates edge cases in which private tier healthcare may not be available in the public tier.

                That’s descriptively accurate, and as far as I can tell true by definition. DD thinks it constitutes a fatal problem for a two tier system.”

                I don’t think it’s a fatal problem. I don’t, actually, think it’s a problem at all. As you point out, we’re already living in a world where (some) people can’t afford (some) healthcare.

                Or, I should say, I don’t think it’s a fatal problem for me.

                But when someone says “we need to reform healthcare because some people can’t afford healthcare“, then for that person it is a fatal problem that (some) healthcare is unaffordable.

                The only way out of that problem is to put every conceivable medical treatment in the “paid for by the government” category. And if someone says “okay fine, we’ll just do that”, then their answer to Jaybird’s question is “no, I refuse to reconcile myself to a two-tier healthcare system”.

                Or you say “well, okay, we’ll define some level of Baseline Health, and ensure that the government tier fits that level”. And then you can go figure out how to not-racist-ly tell poor black diabetics that needles and diet and exercise provide sufficient blood-sugar control, while rich white diabetics buy insulin pumps.Report

              • Avatar Troublesome Frog in reply to DensityDuck says:

                If “people don’t have care” represents a failure state, then a proposal that doesn’t drive coverage to 100% is a proposal that’s failed before it even gets off the ground.

                “People don’t have care” doesn’t represent a failure state, though. “People have less care” is simply not as good as “people have more care.” This isn’t hard to understand. Having airlines is better that not, even though some flights are late. Having polio vaccines is better than not, even though people get polio.

                I’m going to give you the benefit of the doubt and assume that you are just not paying attention to the ongoing arguments about how we’re spending more on college and policing than ever before, getting less result than we ever got before, and how the solution is to spend more money on these things.

                It’s almost as though when deciding how much to spend on a particular public service, there’s a variety of preferences and beliefs, and we ultimately end up with a solution that does some of it but not all of it. Like in absolutely everything government does.

                But since there’s clearly a disagreement and some people aren’t being educated to the absolute maximum and not every murder gets solved, that’s a failure. Clearly no different from having no cops or education at all. If only we had skipped the whole thing, we’d be better off.Report

              • Avatar DensityDuck in reply to Troublesome Frog says:

                ““People don’t have care” doesn’t represent a failure state, though. ”

                Welcome to the Republican Party, sir.

                It’s not worth discussing the rest of your post because you insist that I’m saying that we shouldn’t have medicare-for-all because it’s “not perfect”. I’m not saying that. I’ve ever ever once said that. I think it will be better than what we have now, hugely so, and I can’t understand why there’s so much resistance–from the progressive Democrats, in fact!–to the idea.

                What I am saying is that after it happens, you’ll still hear stories about people dying from things we could’ve treated, you’ll still see GoFundMe drives to pay for surgery, you’ll still see poor people making do with crutches and wheelchairs while the rich buy new legs. Medicare-for-all will not solve the problem of people being unable to pay for medical care. If you’re selling it based on the idea that it will, you’re telling a lie. If you think that people won’t expect it to, you’re a fool.Report

              • Avatar Dark Matter in reply to DensityDuck says:

                I can’t understand why there’s so much resistance–from the progressive Democrats, in fact!–to the idea [of medicare-for-all]

                Medicare-for-all may mean “worse than what we currently have for the seniors”.

                You’re not adding more doctors to the system, you’re probably not adding more money, you’re just adding more people.

                Scarce resources will need to be shared with the new people, i.e. uninsured or under-insured sick people that you’re bringing into the system. It is reasonable to wonder if the new people will crowd out the current ones, or at a minimum if unintended side effects will negatively affect the current winners.

                For example Medicare-for-all may mean Medicare can no longer underpay for things, or that doctors will focus on treating “healthy” medicare patients rather than sick ones.Report

              • Avatar Kimmi in reply to DensityDuck says:

                DD,
                All I wanted out of the ACA is a decent catastrophe system, and no more delisting women for failing to disclose a C-section 20 years ago as a “preexisting condition.”Report

              • Avatar DensityDuck in reply to pillsy says:

                “Is treatment Y way better and a bit more expensive, or is it a bit better and way more expensive?”

                (smack) No, you may not play with the knobs.

                The intent of this line of questioning is thus:

                Given the number of arguments for the ACA that espouse the moral necessity of providing healthcare, does this not imply that a plan which does not provide The Best Possible Healthcare Available should be considered immoral? And if so, is it possible to accept a two-tier system of healthcare?

                People here are saying “well OF COURSE we will accept a two-tier system of healthcare” but based on the Moral Necessity Of Treating Edge Cases style of argument used in discussions over the ACA, I get the feeling that people’s idea is that Tier 1 is “everything” and Tier 2 is “Viagra and boob jobs”.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                I love how the conservative with the incomplete abstract hypothetical is criticizing the liberals with the existing set of coverages for being abstract about what Tier 1 should look like.

                For time #8927: just about exactly like Medicare, except to the extent Medicare doesn’t cover problems exclusive to the sub-65 set right now.Report

              • Avatar pillsy in reply to DensityDuck says:

                (smack) No, you may not play with the knobs.

                Why not? Playing with the knobs is the best way to defend putting something in Tier 2 instead of Tier 1.

                Given the number of arguments for the ACA that espouse the moral necessity of providing healthcare, does this not imply that a plan which does not provide The Best Possible Healthcare Available should be considered immoral?

                I don’t see why it would, any more than, “We should ensure people don’t starve,” entails giving everyone the best possible food.Report

              • Avatar DensityDuck in reply to pillsy says:

                “Playing with the knobs is the best way to defend putting something in Tier 2 instead of Tier 1.”

                The point is not to play with knobs. The point is to explain to someone who lives with Tier 2 treatment but dies with Tier 1 treatment why they don’t get to live.Report

              • Avatar pillsy in reply to DensityDuck says:

                The point is not to play with knobs. The point is to explain to someone who lives with Tier 2 treatment but dies with Tier 1 treatment why they don’t get to live.

                “It’ll cost a billion dollars, and you’ll still end up dying next Thursday instead of tomorrow.”Report

              • Avatar DensityDuck in reply to pillsy says:

                ““It’ll cost a billion dollars, and you’ll still end up dying next Thursday instead of tomorrow.””

                That’s a week I wouldn’t have otherwise, and a billion dollars is only three bucks from everyone in America. Are you really saying that you won’t give three dollars so I can have a chance to say goodbye to my family?

                (You see how this goes, right?)Report

              • Avatar pillsy in reply to DensityDuck says:

                Sure, someone might say that, but I bet they’re a lot more likely to say that when it’s, “Well, it’ll cost $9 000 to let you live until 2032 instead of dying tomorrow,” and a lot less likely to say it when, “We can spend 17% of the US GDP to keep you alive for another hour and a half.”

                I wouldn’t spend a billion dollars of other people’s money (let alone my own, if I had it!) to extend my life a week. Hell, I don’t even forego extra cheese when I order pizza.Report

              • Avatar DensityDuck in reply to pillsy says:

                “Sure, someone might say that…”

                If we need healthcare reform because there’s a Fiercely Urgent Moral Need for it, then they’ll say it and we’ll be obligated by morality to listen and act on it.

                If we need healthcare reform because American healthcare is inefficient and wasteful then OK, that’s good too, but I don’t think that’s what this person has in mind. I’m pretty sure she isn’t thinking about bending the cost curve. I’ve got the sense that her goal is not to decrease the year-on-year rate of increase.

                I don’t, actually, disagree that healthcare reform is necessary. I don’t even think that single-payer is bad (if nothing else it gives us a way to negotiate costs without being part of an employer-provided plan, which will actually address the cost of care).

                But I’m not the one out there in the street cornering Senators with stories about cancer. I’m not the one on Twitter posting about my treatment for mental illness being described as a preexisting condition. I’m not the late-night TV talk show host telling us about his son.

                I’m not the one being told “fuck you, I got my health”.Report

              • Avatar Kimmi in reply to DensityDuck says:

                DD,
                Yeah, that is most people’s conception of Tier 1. Everything medically recommended (NO Mammogram every year unless medically warranted. NO test me for everything batteries for no reason other than I worry too much).Report

              • Avatar DensityDuck in reply to Kimmi says:

                If nothing else, having a Tier 1 gives doctors a great basis for motions to dismiss malpractice lawsuits. “I did everything that was medically necessary for me to do. If you think extra tests would have spotted something or additional intervention would have prevented a bad outcome then take it up with the US Government, not me.”Report

              • Avatar Kimmi in reply to DensityDuck says:

                DD,
                Please note: Actual practice will probably be “come back next time for a better diagnosis. Here’s Generic Answer 1.”

                … ya know, like it is now.

                Yeah, it’s probably going to be “I told you you could buy more tests, and I gave a 5% likelihood that they’d catch something of Y degree of severity.” People don’t get numbers, but the doctors can at least claim to have done something well.Report

              • Avatar DensityDuck in reply to Kimmi says:

                Yep; I have a feeling that single-payer healthcare is not actually going to look all that different from what we have now, it’ll just be that your insurance card says “Medicare” instead of “Aetna”, and if you’re paying for something yourself it’ll be very clear what that is and how much it costs.

                Which, y’know, won’t be a bad thing, but neither will it be the disease-free Eden that some folks imagine Cuba to be.Report

              • Avatar pillsy in reply to DensityDuck says:

                Well, if you’re right, the whole Tier 1/Tier 2 system is even better than I’d previously thought, and I hypothetically pity the hypothetical folks who get that fancy private insurance or pay out of pocket for Tier 2.Report

              • Avatar dragonfrog in reply to Nevermoor says:

                Come to Canada, sit in a pub at happy hour and say that nobody is worried a two-tier health system will result in the deterioration of the lower tier. You will have no shortage of conversation partners all night.

                That said, as @gregiank says below, an upper tier that consists of things like private rooms, elective cosmetic surgery, is not so worrisome.Report

              • Avatar Jaybird in reply to dragonfrog says:

                an upper tier that consists of things like private rooms, elective cosmetic surgery, is not so worrisome.

                The upper tier that I am imagining consists of more things than private rooms and elective cosmetic surgery.Report

              • Avatar Nevermoor in reply to dragonfrog says:

                Did I say that? I said you worry about making tier 1 good, not preventing tier 2.Report

            • Avatar gregiank in reply to dragonfrog says:

              Two systems can be like they use in Germany where everybody has solid UHC provided by highly regulated insurance companies but people can buy more HC if they wish. I don’t have a problem with that. The goal of UHC should be to get everybody to have access to good health care of their choosing. But there will always be elective procedures or experimental procedures or even some things which aren’t covered but people should be able to buy if they wish.Report

    • Avatar Saul Degraw in reply to Jaybird says:

      I think we already have.

      Most Democrats understand the sheet power it took to get the ACA in place and most of us are not fully pleased with the resultReport

    • Avatar North in reply to Jaybird says:

      Yeah, every Democrat and every liberal to the right of the very fringe of the political spectrum would take that deal in a heartbeat.Report

      • Avatar Morat20 in reply to North says:

        Yeah, it’s kind of weird he assumed no liberal would take that.Report

        • Avatar Nevermoor in reply to Morat20 says:

          No weirder than other BSDI examples.

          David Brooks just spent 8 years writing articles of exactly the same form as Jaybird’s comment, often with the benefit of pleading with President Obama to support a policy he already explicitly supported just so the issue could be framed as both sides being intransigent.Report

      • Avatar Jaybird in reply to North says:

        I’m sure that we’ll see “Socialized Medicine is on the table? SOLD!”

        I have no doubt of that.

        I just deeply suspect that we will see people argue that any possible treatment that would save the life of an ex-president is a treatment that should be available for undocumented dreamer… and, if it is not, such would be a betrayal of the promise of Socialized Medicine.

        I don’t doubt for a second that Democrats/Progressives would *LEAP* at the chance at Medicare For All. It’s that they’d rankle at the thought that there would be life-saving treatments not covered by Medicare and yet available to the Rockefeller types… thus demonstrating that they would not, in fact, be willing to reconcile themselves to there being two tiers of medical care.Report

        • Avatar switters in reply to Jaybird says:

          Exactly. That’;s why all the noise from the left about healthcare focuses on all the tummy tuck and botox treatments the rich are getting that they should be prohibited from getting, and not on the lifesaving care people are priced out of receiving. So yeah Jaybird, I agree, lets ignore the latter problem to make sure the former never becomes one.Report

          • Avatar Jaybird in reply to switters says:

            You may notice that in the examples given above (and not by me!), the assumptions are that the 2nd Tier will involve private rooms and/or cosmetic surgery.

            The edge case example was the difference between fancy-schmancy insulin pump regulators and blood tests/needles.

            That ain’t where the edge cases are going to be.Report

            • Avatar switters in reply to Jaybird says:

              OK – Let me restate your position, as I think i better understand it now. Let’s disregard the discussion about whether the orphan without insurance should have life saving care delivered until we either work out all the edge cases Jaybird identifies or guarantee him that people will be quiet about those that remain. You still understand why someone might think thats a bit ridiculous, right?

              Or are you just pointing out that in a country of over 300 million, someone will always be there to complain about whatever is enacted. Cause you could have made that point much more directly. And much more efficiently.Report

              • Avatar Jaybird in reply to switters says:

                I’m not asking for a guarantee.

                I’m saying “X is going to happen.”

                And, for the record, there’ll be more complaining than the trivial amount of people who are the type that would find some way to complain if you brought in bagels for the team to share.Report

              • Avatar DensityDuck in reply to Jaybird says:

                “Clearly you didn’t spare a moment to think that some of us might be gluten-free?Report

              • Avatar North in reply to Jaybird says:

                I’ve followed the argument Jay and if we were talking policy in a vacuum perhaps you’d be right but the weakness of your position is that pretty much the entire industrialized world except the US has had socialized medicine for ages and the outcome you’re fretting about hasn’t come about.

                It’s not even mysterious why it hasn’t come about. People get rare/hard/expensive to treat condition and the national system says “Sorry, can’t swing it” and the desperate patients say “But look there’s this gold plated/experimental/rich option we could try!” and the national system says “Sorry can’t pay it for you”. There’s some hubbub and in the most sympathetic cases the media run some heart aching stories and people get exercised about it and call their politicians. Then the politicians puff and huff then go off into an office with the National System administrators and say “We need this gold plated option for everyone!” Then the administrators say “Yes sir, here’s what it’ll cost.” The politician turns pale, gets swirly eyes, comes out, says some political stuff about compromises and tax rates and the masses move on. The marginal patents are sad (and it is sad), but they were going to be sad anyhow, and then they have non-cutting edge care as biology proceeds along its tragic course and their families are not mired in penury to pay for it.
                Then the pollsters ask “what do you think of your national health services” and the masses grumble and says “oh it has all kinds of problems” and then rate it around 65% or so and the tiny fringe of people talking about getting rid of socialized medicine get looked at like the guy peeing on the lamp post in downtown and talking to his teeth.

                So I struggle to see why it would be different in the US if there was some sort of universal socialized medicine.Report

              • Avatar Jaybird in reply to North says:

                That looks like “reconciled to two tiers of care” to me.

                Hey, if we’re cool with that, then I’m cool with that.

                I’m just not a fan of the “you’re just concern trolling and besides everybody else already does that” form of argumentation.Report

              • Avatar pillsy in reply to Jaybird says:

                Why do you think people wouldn’t be cool with it, though?

                That’s why what everybody else does is relevant: because pretty much everybody else does it and is cool with it.Report

              • Avatar DensityDuck in reply to pillsy says:

                “Why do you think people wouldn’t be cool with it, though? ”

                If I don’t get (thing) I die. I can’t afford (thing). If you tell me that you support a plan that doesn’t cover (thing) then you want me to die. Why do you want me to die?

                Oh, what is (thing)? Imagine the most expensive medical treatment that you can think of. That’s (thing).

                Now if you’re okay with letting me die–me, who hasn’t done anything to you, who hasn’t done anything to deserve death, who just got unlucky in the lottery of existence–then so be it. You heartless bastard. How can you live with yourself? Are you even a human, really? Don’t you have any sense of empathy? There’s a word for people like you–psychopath.Report

              • Avatar North in reply to DensityDuck says:

                Because your hypothetical sick person isn’t numerous enough, not even including their friends and family, to change policy. The rest of the people who’re sympathetic aren’t sympathetic enough to actually pay for it. So your hypothetical doesn’t add up to enough “people” to count as “people not being cool with it”.Report

              • Avatar DensityDuck in reply to North says:

                “Because your hypothetical sick person isn’t numerous enough”

                I dunno, 43000 a year adds up after a while.Report

              • Avatar North in reply to DensityDuck says:

                I think the link is broken.Report

              • Avatar North in reply to DensityDuck says:

                Well this link is talking about the ACA and what repealing it would do. Jay and I were talking about Socialized universal healthcare and why the pressures to cover more won’t lead to unsustainable coverage creep. The ACA and the American healthcare system is an entirely different bag o’ cats.Report

              • Avatar DensityDuck in reply to North says:

                Your claim is that we can make a “small numbers” statement about why it’s okay to declare certain health issues as not worth covering. My reply is that “small numbers” can still be (and probably will be) tens of thousands of people, and you’re going to get the same “you’re talking about human lives” arguments used against your socialized universal healthcare system as you see against ACA repeal.

                Like, there are many good reasons to prefer a single-payer healthcare system, but those reasons aren’t the ones that people demonstrating in the street about Healthcare Reform consider meaningful…and those reasons are also not what is being used to sell us on the idea. We don’t see “here’s a person whose healthcare premiums went up only ten percent and have higher deductibles or reduced reimbursements”, we see “here’s someone with rare cancer”, “here’s someone with a preexisting condition”, “here’s someone whose baby was born without a torso”.Report

              • Avatar North in reply to DensityDuck says:

                Yes, other nations socialized medical systems make this argument and by and large it’s accepted. That addresses Jay’s point.

                To your point, yes- people can and do hold up the rare cases but they also hold up the not rare cases. People getting sick from non-exotic medical events and being financially ruined or dying where in one of the nations with socialized medicine they would avoid the first and potentially the latter.

                In the US and the rest of the west there are people who A) Have exotic medical catastrophes and B) have non-exotic but still serious medical catastrophes. In the US(pre-ACA) groups A and B would suffer ruin and death unless they’re independently wealthy enough to secure their care. In the rest of the west, though, group A still suffers the same (barring being independently wealthy) but group B generally does not. That is a significant difference.Report

              • Avatar DensityDuck in reply to North says:

                “In the US and the rest of the west there are people who A) Have exotic medical catastrophes and B) have non-exotic but still serious medical catastrophes.”

                And what Jaybird and I are saying is that you’re going to have people who are definitely sure that they are Group B who the system nonetheless insists on assigning to Group A. And to those people, the reformed system looks exactly like the old one. Which means that, in the end, maybe healthcare reform isn’t actually about providing the best care possible to everyone, but the good-enough-est care to the good-enough-est number of people.

                Which isn’t a whole hell of a lot different, in practice, from the nightmare dystopia “free market healthcare” system we’ve got now.Report

              • Not just people who think they are misclassified as (A) or (B), but doctors who help with the misclassification. Anecdotally…

                When I was 45, I was diagnosed with low bone density. Following most of 20 years of normal density decrease, I now technically have osteoporosis. Never broken a bone, despite things like being thrown off a horse, bicycle spills, etc. Every time I change GPs, they read my file as far as the density measurement and class me as (B): serious, but non-exotic, and fixable. Then they want to repeat all of the various tests that I’ve had over the years in order to identify the non-exotic cause: hormone imbalances, kidney disease, assorted forms of cancer, etc.

                After arguing with them enough times, I found a world-class specialist here where I live and paid out-of-pocket for the tests he wanted in order to do a thorough diagnosis. Bottom line? I’m a (C), for whom low bone density is normal and not a significant health risk. To roughly quote the specialist, “We know what the distribution of bone density looks like in the population, so we know that there are people like you out there, but we see so few of you because despite the low density your bones don’t break. Don’t worry about it. You probably shouldn’t take up pro football as a second career.”

                Since the diagnosis, I’ve never had to change health insurance under conditions where I had to do a medical history. I did buy a ten-year term life insurance policy and included the bone density in the application. The agent told me that he got a call from the underwriters who said that they had no idea whether low bone density in a 50-year-old male was a risk factor, so had ignored it.Report

              • Avatar Kimmi in reply to DensityDuck says:

                DD,
                Preexisting conditions were OUT OF CONTROL. Specifically, they were being used to cheat people out of money. If you didn’t list a c-section (thirty years ago!) as a preexisting condition, you’d not be able to receive care for the flu. They’d take your money and kick you off the plan.

                … this happened.Report

              • Avatar Stillwater in reply to Kimmi says:

                Agreed. Denial of coverage based on pre-existing conditions was certainly out of control. I knew many people who were +/- trapped by their employment situations because either that person or their spouse had an uncoverable PE. I knew other people who were denied coverage in the individual market because of PEs.

                Another thing which was out of control, tho, was rescission based on fraudulently not noting every condition listed in the fine print which qualified as a PE on an insurance application.

                The purpose of guarantee issue at community rating was motivated by exactly those concerns. (The AHCA radically changes the ACA’s community rating requirements.)Report

              • Avatar DensityDuck in reply to Stillwater says:

                This (along with national cost negotiation) is why I support single-payer. Not because it’s going to deal with the kind of edge-case “I’d DIE without (thing)” situations, but because it reduces the ball-and-chain effect where preexisting-condition fuckery leaves people with no good options for coverage outside of staying with their current employer.Report

              • Avatar Jaybird in reply to pillsy says:

                Why do you think people wouldn’t be cool with it, though?

                In America? Well, for one thing, there’s going to be a huge chunk of voters who will find that their positional good has shifted in a worse direction.Report

              • Avatar pillsy in reply to Jaybird says:

                So, wait, the people who can afford the expensive stuff are going to be mad… because they can afford the expensive stuff?

                I’m still not really following the argument.Report

              • Avatar Jaybird in reply to pillsy says:

                The people who get the expensive stuff as part of their remuneration package will find themselves now, along with everyone else, as part of Tier 1.

                And if they want to be part of the second tier, they can pay for it themselves.

                Or, hey, maybe jobs will still find some way to offer Tier 2 insurance as part of their packages. I imagine the people who work the types of jobs that will get offered those packages will be just as happy as now.

                Maybe even happier.Report

              • Avatar North in reply to Jaybird says:

                You can’t possibly be carrying a brief for the historical anomaly that led to so much healthcare being linked to employment in the US. You didn’t move that far from libertarian and you’re not running for office.Report

              • Avatar Jaybird in reply to North says:

                I’m not talking about what I’m cool with.

                I’m trying to explain why a lot of voters will suddenly find themselves in a less enviable position positionally after the historical anomaly is rectified… and be surprisingly upset about it.Report

              • Avatar North in reply to Jaybird says:

                Well, if socialized universal healthcare was instituted, and if the pay raises they would get from their employers no longer being able to lump healthcare in as part of their compensation package was not larger than the tax increase they had to pay to support the socialized healthcare they might be angry. But it’s a hard hypothetical because a populace that elected a majority to institute socialized universal healthcare would have to have some kind of beef with their employer plans already.Report

              • Avatar Jaybird in reply to North says:

                I don’t think that the populace is best described as having such clear-cut intention either time.

                But we’ll see.Report

              • Avatar pillsy in reply to Jaybird says:

                Or, hey, maybe jobs will still find some way to offer Tier 2 insurance as part of their packages.

                Probably! That’s something else that happens in many of those other places we talk about.

                It works better as a status marker when it’s not something most people get just for having a job.Report

              • Avatar North in reply to Jaybird says:

                Yep, and everyone outside the US is cool with it, or at least not uncool with it enough to make any serious effort to change it which is functionally the same as cool with it.Report

              • Avatar Jaybird in reply to North says:

                And for many decades, we had a system that everyone was cool with it, or a least not uncool with it enough to make any serious effort to change it.Report

              • Avatar gregiank in reply to Jaybird says:

                Ummm everyone wasn’t cool with what we had. HCR has been an issue for quite a while if you remember. Tens of millions of people weren’t thrilled with it at all.Report

              • Avatar North in reply to Jaybird says:

                And then, lo and behold, it got so uncool that a person running on changing it got elected with a super majority and then he changed it.Report

              • Avatar Jaybird in reply to North says:

                “And that’s where I’m going to end the story.”Report

    • Avatar Stillwater in reply to Jaybird says:

      Republicans/Conservatives are going to have to reconcile themselves to there being Socialized Medicine
      Democrats/Progressives are going to have to reconcile themselves to there being two tiers of medical care

      The problem right now is that, even with the ACA, we have a three-tiered system: good healthcare provided by expensive private insurance, less good healthcare provided by gummint, and no healthcare at all other than cash pay or the ER. A two tier system in which everyone has access access to healthcare would be a huge improvement. Unfortunately, the House GOP isn’t holding up their end of the bargain: the AHCA not only rolls back the progress in creating a two tier system under the ACA, it further entrenches the three-tier system.

      Whether the Dem/liberals will get on board with a two tiered system remains to be seen, since I believe there are real opportunities for Senate Democrats to negotiate with GOP Senators to achieve a more politically stable health care system which expands the two tiered system even further than currently exists. Functionally, I think Dem CCers on the Hill are much more moderate than the Democratic base while the GOP CCers are (probably) much more ideologically right-conservative than the GOP base, so a failure to make progress on institutionalizing a comprehensive and stable two tier system would most likely result from GOP ideological/retail political intransigence. I mean, take a look at the AHCA for an indication of the where the House GOP House would like to take things. It’s not pretty.

      Btw, this is probably a good time to dust off a sound bite from my Rush listening, Dems-are-socialists hating fathter in law: he criticized the ACA on all the standard rightwing talking points then wondered aloud why we, as a society, couldn’t have medical care like they have at the VA, or like Medicare? I told him those were socialized single payer systems. Dejectedly, he said, “huh really?”Report

      • Avatar Jaybird in reply to Stillwater says:

        I’ve come to the conclusion that Socialized Medicine is pretty much inevitable.

        There will be a huge fight from the insurance industry, of course… there will be a *HUGE* push for retraining former Insurance people to make them into Single Payer Paperwork Simplification people, but we’re going to quickly find that people in this part of town see their outcomes improve a little bit and people in that part of town see their outcomes decrease a little bit.

        Most of the people who will be involved in the conversation at a national level come from this part of town.Report

        • Avatar Stillwater in reply to Jaybird says:

          I’ve come to the conclusion that Socialized Medicine is pretty much inevitable.

          Looks like we may be going the other direction. Word on the street is that Orrin Hatch (at least) is on board with the AHCA Medicaid cuts.

          paraphrasing Kissinger: tax cuts are a powerful aphrodisiac.Report

          • Avatar Jaybird in reply to Stillwater says:

            Yeah, but the tax cuts that most of the families in the middle will see is somewhere around $200/year… or 4 bucks a week.

            Of course the people at the top will see somewhere around enough money to pay for the lobbyists agitating for the tax breaks and, after all the various benefits and amenities are paid for, they’ll walk away with an additional 4 bucks a week themselves.

            But, at least, the insurance agencies create jobs.Report

    • Avatar Mike Schilling in reply to Jaybird says:

      As opposed to the system we have now, where paupers and billionaires get exactly the same standard of care?Report

  4. Avatar LeeEsq says:

    Ezra Klein recently pointed out on Vox that the Singapore model requires a lot of government intervention and provided healthcare to work. The government of Singapore docks part of your pay and makes you put in your HSA, they choose what drugs people can get based on cheapness of price and effectiveness, most doctors are state employees, and nearly all hospitals state run. The HSA is also for the more low cost procedures like mending a broken bone or curing the flu. High cost treatments are paid for in a more socialist manner.Report

    • Avatar DensityDuck in reply to LeeEsq says:

      So, Medicare For All plus VA For All.Report

      • Avatar Nevermoor in reply to DensityDuck says:

        I think the country would obtain huge long-term benefits from simply reducing the age of entry into Medicare from 65 to 0 and by reducing taxes sufficiently to pay the difference.

        It’d be a huge shakeup, in that most health insurers would either go out of business or have to dramatically reduce their size, since they’d only be able to sell supplemental policies, but the government is MUCH better at cost efficiency in this space than private companies so we would need to increase taxes by substantially less (on aggregate) than people would save in insurance costs (on aggregate). Obviously, who individually wins and loses would become a very difficult political question.Report

        • Avatar Burt Likko in reply to Nevermoor says:

          We get there by lowering the age of entry every five years or so. While a lot of private insurers are not interested in supplemental coverage because right now it’s a difficult way to profit. Ratcheting towards more inclusive coverage over time will let more of the supplemental insurers figure out how to make money at it.Report

          • Avatar Nevermoor in reply to Burt Likko says:

            Maybe. But that assumes a functioning legislature over decades.

            Otherwise you have things stalled out at some intermediate age that makes no sense, and people start seeing windfalls at 35 or 40 (because you’d have to kick up taxes when you started kicking down the age).

            I think the better way would be to insert Medicare into the exchanges (plus allowing employed folks buy in) and let it eat the private insurers’ lunch for a couple years until they cry uncle. Or, of course, just tear the bandaid off with a year’s notice.Report

            • Avatar InMD in reply to Nevermoor says:

              @nevermoor @burt-likko

              There’s already an obvious way to do this, which is opening up Medicare Advantage (part C) to the under 65 population. That’s administered by private insurers and subject to heavy regulation. You could then phase out Medicare parts A and B (outdated fee for service model) over time.

              All of the big insurers are already in the MA game to some degree. What would die off would be smaller plans with sicker populations (the ACA has already killed a lot of those anyway because of coverage mandates and minimum spends on care).Report

              • Avatar Nevermoor in reply to InMD says:

                Except medicare advantage is a bad program (relative to regular medicare).

                So that would seem to be shooting yourself in the policy foot to benefit insurers (an unworthy goal if ever there was one).Report

              • Avatar InMD in reply to Nevermoor says:

                By what metric?Report

              • Avatar Morat20 in reply to InMD says:

                IIRC, higher costs and lower patient satisfaction versus traditional Medicare. (It has a very high churn rate).

                OTOH, that might be a lot better than what a lot of people have now.Report

              • Avatar Michael Cain in reply to InMD says:

                Availability, among others. Along the urban Front Range in Colorado, there are lots of choices for Medicare Advantage plans. In some of the rural parts of the state, none. In rural areas where the plans do exist, they tend to be significantly more expensive than the plans along the Front Range.Report

              • Avatar Nevermoor in reply to InMD says:

                I seem to have lost a comment here, but my understanding is that Medicare Advantage costs the government more per member than Medicare, despite the point being that it is equivalent coverage. In large part because insurance companies have dramatically higher overhead costs than the government.Report

              • The PPACA gradually lowered the extra amount paid to Advantage plans. IIRC, in 2018 the insurers will get the same amount per client as the government spends per client in the traditional program. The CBO scoring said that in the long term this would reduce Advantage enrollments by about three million people as the insurers exited high-cost areas.Report

              • Avatar Nevermoor in reply to Michael Cain says:

                Got it. If it’s cost neutral and supposedly-equivalent (wasn’t there something about minimum actuarial value too?) I have no problem with allowing the competition.

                I guess I just haven’t updated my understanding of this one post-ACA debates.Report

      • Avatar LeeEsq in reply to DensityDuck says:

        With an added level of political illusion to make it seem much more free market than it actual is. Even if you create an illusion of free market healthcare, I think most Republicans in Congress will oppose it. They really seem to think that the only way to affordable healthcare is through the free market or are simply willing to deal with the consequences of a free market healthcare system because the abstract is more important than the practical.

        I was in an argument on Facebook about the merits of licensing physicians or more accurately why most people would prefer to see degrees and licenses on the wall rather than trust their instincts when it came to selecting a doctor or dentist in the free market without licensing. A couple of libertarians brought up the standard arguments against licensing on how it isn’t necessary, the starter of this thread was about how a man managed to practice as a doctor for thirty years without a license, including how licensing hurts the poor by decreasing supply and increasing costs. I pointed out that we can also get poor people healthcare by biting the bullet and adopting an actual socialized universal healthcare system like every other developed nation on the planet. The two other posters would not have it. No socialism, the solution is the free market.*

        I think the entire Republican Party believes the same and would rather get rid of all licensing so people would have to choose between Bob’s Neurology and an actual neurologist who knows what she is doing. I posted this story of a woman arrested for practicing dentistry without a license as an example of why getting rid of licensing might not be a good idea but the two anti-licensors would not have it.

        *My argument for licensing is that most people do not want to shop around for their doctor or dentist and use the license as short hand for competency. You go in see it and know your probably getting somebody with average competence. The anti-licensors argued that why wouldn’t people shop around for their health when they shop around for lesser things like TVs or furniture. People don’t shop around because their health or life or that of a loved one is on the line. They don’t want to take any risk even if that means reducing demand to ensure a high average level of quality and competency.

        I’m also unimpressed at the licensing hurts the poor arguments because people who make this argument never take their case to actual poor people. They want to impose it from above without actual consultation. They are remarkably like the Far Left who fail to understand that most people don’t want public ownership of the means of production and will go forward with their plans to get rid of capitalism and consumerism no matter what.Report

  5. Avatar Joe Sal says:

    Excellent post as always Dennis.
    I don’t agree with the principles of it, but it presents the case well.Report

  6. Avatar Nevermoor says:

    John Podhoretz, like many conservatives, forgets the lesson of my personal favorite quote:

    The law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges, to beg in the streets, and to steal bread. -Anatole France

    I’m sure the 24 million people losing coverage are rugged individualists yearning to be free from health care mandates, and not people who will gladly pay a reasonable portion of their income but cannot pay many hundreds of dollars a month (or, of course, who have pre-existing conditions–due to their personal moral failings, naturally).

    I’ll also observe that I wish conservatives could support government programs that don’t help them personally. I’m having very complicated reactions to the conservative reactions like this one that reach the right conclusion on a specific issue, but purely out of self interest.Report

    • Avatar Don Zeko in reply to Nevermoor says:

      An awful lot of those 24 million have Medicaid, so the mandate has nothing to do with it. They’re getting single payer coverage now and the AHCA would take it away. The fact that Podhoretz hasn’t bothered to learn the basic contours of what the ACA is tells you all you need to know about the value of his argument.Report

  7. Avatar dragonfrog says:

    I… question your representation of solidarity as a conservative value (under the current right / left structure, anyway).

    Solidarity is the absolute core of socialism. If you posit socialists as a subset of conservatives – you’re venturing far afield of the current usage of the terms in North America.Report

    • Avatar Pinky in reply to dragonfrog says:

      Interesting. Let me come at it first from a Catholic perspective, parenthetically noting that Catholicism isn’t the same thing as conservatism.

      The idea of solidarity is typically balanced with subsidiarity, which is a preference for something to be handled at the lowest possible level. That’s entirely compatible with conservatism. It has the family, then the community, then the local government, then upwards, handling things as they are able. A person can favor universal health care without supporting federalized or even government-run health care.Report

      • Avatar dragonfrog in reply to Pinky says:

        The idea of subsidiarity seems like it could be a bit of an unconscious FYIGM trap.

        That is – if my middle class, non-traumatized family in its prosperous economically diverse community in its resource-rich province can handle healthcare, then healthcare can be handled just fine at that level – including for your barely-working class family weighted down by intergenerational trauma in its collapsing former mill town in its province notable for depleted fisheries and closed mines.

        And if you can’t handle it as well as we do, doesn’t that say more about your personal moral failings than about my understanding of economics?Report

    • Avatar Burt Likko in reply to dragonfrog says:

      What if the phrase had been “commutarianism”? A venerable and powerful strain of conservatism is the notion that fellow members of a community have a moral obligation to look out for one anothers’ welfare in some way. May would prefer that this be handled at the municipal or church level, rather than by the national government, but application of federalism is a different question than the existence of a moral obligation to other people.Report

      • Avatar dragonfrog in reply to Burt Likko says:

        I’m sure many would prefer that their wealthy community fund socialized healthcare to those within the community, and that the impoverished reserve next door fund its own healthcare. I don’t know what I’d call those folks.

        @pinky I’d consider Christian Socialists to be a subset of all socialists, for all that they may on the whole have some more socially conservative views on matters of sexuality and the like.Report

      • This is a good point, but one that has become badly dated.

        Confining myself to just the US…

        As the country has become richer overall, expectations have moved higher, and more and more communities are effectively left behind. In many states (perhaps most, by now), rural areas are no longer able to afford to provide what is considered a necessary and proper K-12 education. Here in Colorado, we have rural school districts who get 80% of their funding from outside the district. As a country we transfer money from richer states to poorer states to subsidize health care for the poor. California pays 50% of its traditional Medicaid costs, Mississippi only 30%.

        Not just geographic inequality, but temporal inequality. At $100K for a course of treatment, many inner-city neighborhoods and small rural towns could afford state-of-the-art cancer drugs for someone once every several years. Bad timing and you’re the one who goes without. One of the often-ignored features of Social Security is the temporal factor. Lots of studies around to demonstrate that if you depend on personal savings, whether you can have a comfortable retirement is a function of when you were born — a stock-market crash at the wrong time wipes you out with inadequate time to recover.Report

      • Avatar LeeEsq in reply to Burt Likko says:

        Communitarianism has never really been part of American culture outside some small and specific groups because the social structure to support communitarianism was never there. Americans tended to define themselves around the individual and communitarianism was seen as foreign and Catholic as opposed to American and Protestant.Report

  8. Avatar North says:

    A fine article Dennis, though, there hasn’t been a conservative party (as you define conservative) operating in this country for my adulthood at the very least.Report

    • Avatar Mike Dwyer in reply to North says:

      @north

      I don’t think it’s ‘un-conservative’ to be leery of universal healthcare, given that opinions are varied on how well it works in other countries. Afterall, conservatism shouldn’t be about saying No, but rather just taking things slow and measured.

      What IS a problem for conservatives though is to prefer a deeply flawed private system that makes the lives of Americans less better in many cases.Report

      • Avatar Morat20 in reply to Mike Dwyer says:

        I don’t think it’s ‘un-conservative’ to be leery of universal healthcare, given that opinions are varied on how well it works in other countries.

        Unfortunately they all have one thing in common: Cheaper than ours, better coverage than ours, and better results than ours.

        American has by far the worst healthcare system in the First World.Report

        • Avatar Pinky in reply to Morat20 says:

          A lot depends on your metrics. Too much for you to say “by far”.Report

          • Avatar Nevermoor in reply to Pinky says:

            By what metric is America not by far the worst? We cost twice as much, for worse results, and until recently about half of personal bankruptcies were related to medical costs (a problem that the GOP just voted to resurface).Report

            • Avatar DensityDuck in reply to Nevermoor says:

              “By what metric is America not by far the worst? ”

              We could get into the specifics of what metrics you’re talking about, how they’re measured, how the measurements change with demographics (not to mention the very definitions of the terms used), the motives behind the spending that we do…but I don’t actually think that you’re interested in having a conversation here.Report

              • Avatar Nevermoor in reply to DensityDuck says:

                So there totally are some but it’s a secret? Gotcha.

                Here, for example, is what I’m talking about. Note the black line in exhibit one, then realize that it’s % of GDP (so deflating the difference because our GDP is high).Report

              • Avatar Pinky in reply to Nevermoor says:

                If those stats are correct, that would indicate that a ridiculously obese nation spends more on health care and dies early! My suppositions have been jarred. Seriously, we’ve been talking about health care a lot in this country over the last decade. You should be familiar with how our eating and driving habits hurt our numbers. You should also know about our quicker treatments, the discrepancies in how countries calculate infant mortality, and how much we enjoy shooting each other. And a bunch of other things.Report

              • Avatar Nevermoor in reply to Pinky says:

                So still nothing, gotcha.

                Are you suggesting we are the only fat country on earth? Are you suggesting our MRIs are super-expensive because we’re fat? Or are you just trying to obfuscate?

                Only time will tell…Report

            • Avatar dragonfrog in reply to Nevermoor says:

              By what metrics is America’s health system not the worst? The only metric that matters, of course – stock valuation. Have you ever tried to invest in a Canadian hospital? They’re not even publicly traded! Madness!Report

      • Avatar Stillwater in reply to Mike Dwyer says:

        What IS a problem for conservatives though is to prefer a deeply flawed private system that makes the lives of Americans less better in many cases.

        I hear ya. I’ve often thought that the biggest problem conservatives have is conservatism. 🙂

        {{Actually, I agree with the ideological critique you’re making up there.}}Report

      • Avatar North in reply to Mike Dwyer says:

        Sure Mike, but when considering healthcare questions one can only go off a limited number of action data points (talk being entirely valueless):
        -In 1993 the Republicans frenetically opposed the Democratic Party’s proposed single payer plan offering that is the Liberals would only vote down their single payer plan then the Heritage market plan (aka Romneycare, aka Obamacare) would be discussed as an alternative. The single payer plan foundered and the Heritage Plan was swiftly yanked away leading to no reform and conservatives rejoicing like Tuscan raiders.

        -In 2009 the Dems proposed the ACA whereupon the Republicans attempted to pull a ’93 repeat only with with the Heritage plan standing in for single payer and a mumblemumblesomething standing in for the alternative. They were enraged and furious to discover that Dems were uninterested in reprising that chain of events again and thus the ACA was born.

        -And now, in 2017, they propose to repeal every bit of the ACA they can repeal without 60 votes in the Senate and replace it with a coupon for Denny’s and a tax cut for the wealthy.. to be followed by another even bigger tax cut for the wealthy.

        So, based on their actions, I think it’s pretty sound to say there isn’t a conservative party in the country, as Denis defined it, and there hasn’t been for about 25 or so years. There has, however, been some kind of moral scold/neocon/glibertarian Frankenstein party lurching around with some confused libertarians perched on top of it wondering what the hell is going on.Report

  9. Avatar Francis says:

    Dennis:

    Liberals fail to understand that conservatives don’t see government as a wholly good.”

    please stop. Liberals understand just fine. The implication that liberals are stupid is expected from any number of voices here; I was hoping that you would not join that caucus.

    Jaybird:

    “I’m suspicious that …” Of course you are. You and your gut are the all time truth-tellers of American politics. However, you might want to take note that the ACA does, in fact, treat ex-Presidents differently than undocumented immigrants. You may also want to remember what you wrote earlier today: “I had been thinking about everything incorrectly.”

    The counsel of paralysis is very nice if you’re too adversely affected by the current situation. As to people who were not well served by pre-ACA law, not so much.Report

    • Avatar Jaybird in reply to Francis says:

      I also went on to say “I’ve come to the conclusion that Socialized Medicine is pretty much inevitable.”

      Hrm. Was the interpretation of my comment that I was arguing *AGAINST* socialized medicine by pointing out that it will involve compromise?Report

  10. Avatar Mike Schilling says:

    Liberals fail to understand that conservatives don’t see government as a wholly good.

    And conservatives fail to understand that liberals don’t either. And not just in the obvious cases like when it starts a war over non-existent WMDs or kills someone and then plants a gun on him.Report

  11. Avatar LeeEsq says:

    Like Denis Saunders noted, conservative intellectuals and pundits have been making the case for single payer in the wake of the horror that is the American Healthcare Act. Republican politicians are not and will not listen to them because they are coming from a different ideology altogether, something more brutal and strict.Report

  12. Avatar Saul Degraw says:

    Here is a question. This is the second “conservative” case I have seen for universal healthcare. I am sure there will be more. I often see essays that are “conservative” cases for liberal ideas/ideals.

    What does it take for people to say they are not conservative?Report

    • Avatar dragonfrog in reply to Saul Degraw says:

      Maybe it’s a bit like Catholicism.

      You can disagree with every one of the tenets that distinguish Catholicism from the other Christian faiths, even from Islam, Judaism, Hinduism, Buddhism… But you were baptized as a newborn, and took confirmation at, like, 11, so there’s pretty much nothing that will convince you that you’re not “Catholic”.Report

    • Avatar Pinky in reply to Saul Degraw says:

      Modern political conservatism is classically liberal, and allows for broader thinking and healthy disagreement. Conservatives (ideally) don’t shun.Report

  13. Avatar Damon says:

    Hey, I’ll swap my employer paid health care for a gov’t system. IF I pay the same or less for the same coverage or better coverage. But that’s not gonna happen. Why? Because I’m the type of person who gets the short end of the stick–middle class….where the tax money is. So, no, f that.

    I’d object less to HC for the rest of society if it wasn’t a one size fits all system. Really, some of the mandated coverage seems excessive. MY HC has options, sure, but I gotta pay for it. Want dental? You pay. Want eye coverage, you pay. So, maybe we should have a conversation about whether or not we need to have invetro fertilization covered in the standard plan, or even IF for seniors. Does someone really need dependent coverage if they don’t have any kids?

    Now let’s talk about all that wonder other stuff I pay for and don’t get. Social Security. There’s no way I can live on what SS would pay me. It’s not even a factor in my retirement, it’s such a small part of my component of my retirement income needs (given where I live). It’s almost useless, and given how it’ll have to be tinkered with to keep it solvent, i’ll likely pay a lot more in than I ever manage to get out…so…I get shafted again. Hell, we can’t keep SS and Medicare solvent–let’s add a NEW program.

    “because in the end we are our brother’s (and sister’s) keeper.” Yeah, no. Not only do I reject this assertion philosophically, financially, I’ve been doing that since ’92 and I’m tired of it. Time for folks to stand on their own. I’ve got to find enough money to live on when I quit working and none of the current safety nets are likely be reliable by then. I don’t have any more money to cover others.Report

    • Avatar Francis in reply to Damon says:

      The maximum SS benefit, for a person retiring at 70 in 2017, is $3,538 per month.

      If your retirement demands are so high that $42,000 annually is a “small part” of your retirement income needs, then I expect you’re not going to find much sympathy for your bitching.Report

      • Avatar Damon in reply to Francis says:

        Francis, my rent is half that amount and it’s BELOW market rate. Market rate for housing in my area is @ 30K a year-(that’s for a townhouse). And that’s excluding state income taxes. Did you know that my November power bill was 400 dollars? And I like it cold in the house!

        Yeah, my retirement “needs” very high. Better to say the state’s needs for my money is very high.Report

    • Avatar Nevermoor in reply to Damon says:

      Ooh. Look. A wild FYIGM appears!Report

      • Avatar Damon in reply to Nevermoor says:

        If I didn’t have to pay taxes, I might, might have “GM”. But since taxes take > 40 percent of my money, I didn’t “GM” did I? The state already took it…and they can’t manage that amount in a fiscally responsible manner, they are to be trusted to do the same with more of it? Surely you jest sir!Report

        • Avatar Nevermoor in reply to Damon says:

          And you definitely didn’t benefit from any state services, either! No postal service, police department, or code of laws ever helped you have a secure life, by gawd! The whole thing is so unfair and oppressive that you moved out of the country! Err, wait, no. You just sucked up whatever benefits you get, whine about your taxes, and suggest everyone else should be left out in the cold.Report

          • Avatar Damon in reply to Nevermoor says:

            Oh, I “benefited”. I just, paid, to re-use a SJW phrase “more than my fair share”.Report

          • Avatar DensityDuck in reply to Nevermoor says:

            “No postal service, police department, or code of laws ever helped you have a secure life, by gawd! ”

            heeheeheheeeheehee

            I love seeing people like you post stupid shit like this

            because on the one hand you’re not actually arguing what you think you are. If you want to say “you benefited from society, therefore you play by society’s rules”, well, society bans gay marriage, society puts restrictions on abortion, society doesn’t want Muslims around. I can’t imagine you finding much to admire in an argument that says “you benefit from having police, therefore you can’t criticize what the police do in order to provide that benefit!”

            and on the other hand you’re…not actually arguing what you think you are, because what happens when I say “you’re right, I do benefit from having police, and I’m rich enough to hire my own damn police, so you can go get fucked”Report

            • Avatar Nevermoor in reply to DensityDuck says:

              Oooh, look. If you pretend I say something other than what I said, I said something silly. Strong point!

              (also, a tip: society very much supports gay marriage)

              And I’m sure you actually believe (when not snarking poorly) that people who pay for stuff therefore forfeit the right to complain about what they get back.

              Nice try though.Report

    • Avatar Davebo in reply to Damon says:

      i’ll likely pay a lot more in than I ever manage to get out…so…I get shafted again.

      And I’ve paid more into car insurance premiums, health insurance premiums and homeowners insurance premiums than I ever got out. Tons more.

      That’s the way insurance (hopefully if you’re lucky) works! And Social Security isn’t a retirement investment fund. It’s insurance. Against disability, early death for your dependents and lots of other things.

      If you were considering it a 401k plan you had it all wrong. Don’t believe me. Look on your check stub! FICA stands for Federal Insurance Contributions Act.Report

      • Avatar Pinky in reply to Davebo says:

        Social Security was intended as an insurance program against late death.Report

        • Avatar Davebo in reply to Pinky says:

          Regardless of what it was intended for, and I’d disagree with your claim, what it is, is disability insurance and life insurance that also pays dividends late term should you not become disabled or die at a rate far greater than anything the private sector offers. In the case of the former, it was intended to provide a minimum baseline to retirees should none of the other two come to pass.

          A huge chunk of it’s outlays is Medicare which is indeed more of a retirement benefit than anything else.Report

        • Avatar Nevermoor in reply to Pinky says:

          Right, and even if @damon couldn’t live in his current house as a retiree on $3.5k/month, he wouldn’t be reduced to abject poverty either. Which was the problem SS was designed to solve.Report

          • Avatar Davebo in reply to Nevermoor says:

            Generally, the assumption is that upon retirement you housing costs would consist of insurance and property taxes. If that can’t be covered by $1,500 per month then you probably have too much house or retired before you payed off your mortgage. Some would say that was a irresponsible decision.

            The entire discussion is getting a bit silly IMO.Report

            • Avatar Morat20 in reply to Davebo says:

              Sometimes I think silly is the point. Bog it down in hypothetical after hypothetical, to get to a point where you can say “I guess we can’t do ANYTHING because we can’t solve every possible permutation of every possible problem for eternity right now”.

              A perfect, eternal solution that no one can ever argue…or nothing. Too hard. Move on…Report

              • Avatar Oscar Gordon in reply to Morat20 says:

                Sounds like you understand the game pretty well.

                Although there is value in running down the hypotheticals. Not only does it demonstrate that you have tried to think things through, but it can also identify issues that while not fatal to the big picture effort, can cause problems or give the opposition ammunition to derail your efforts in whole or in part.

                This is why Pelosi’s casual remark about having to pass the bill before we could know what is in it pissed me off, it showed that the people voting for it had no idea what they were voting for, which left them open to future attack on that vast ambiguity.Report

              • Avatar gregiank in reply to Oscar Gordon says:

                Oh god, not that quote. The part you are saying was only a snippet. The meaning of what she said was different than the way you frame it. Not that is matters of course at this point.Report

              • Avatar Nevermoor in reply to gregiank says:

                1000x this. She was saying CRITICS needed to see what the ACA did (by getting it passed).

                Meanwhile, of course, the same GOP that feigned outrage then just did exactly what Pelosi didn’t with the AHCA. Sanford’s op ed on that point is particularly precious.Report

            • Avatar dragonfrog in reply to Davebo says:

              Right, because everyone owns their home, especially those who are relying on social security to see to their needs in retirement.Report

            • Avatar DensityDuck in reply to Davebo says:

              ” If that can’t be covered by $1,500 per month then you probably have too much house or retired before you payed off your mortgage. Some would say that was a irresponsible decision.”

              uh

              wait

              you’re the one saying that we’re getting bogged down in abstractions and refusing to see the reality of people dying and being bankrupted over medical costs

              but if it’s a house, well, that’s on you bro, prob’ly bought too much house, your fault, too bad so sad here’s a nice cardboard box, guess you shouldn’t have been so irresponsible.Report

          • Avatar Damon in reply to Nevermoor says:

            Actually, back in 1995, the max level of income to qualify for housing assistance in my county was 30k. I know because I made that amount and so did my gf….and my rental agent told me that if we’d not declared her income, we could have gotten a 30% reduction on the rental cost…albeit in a ground floor apt.Report

            • Avatar Nevermoor in reply to Damon says:

              I’m not sure what that comment has to do with the abject poverty faced by senior citizens that prompted Social Security in the first place, though I acknowledge it is framed as a disagreement.Report

              • Avatar Damon in reply to Nevermoor says:

                You’re the one who said, “Right, and even if @Damon couldn’t live in his current house as a retiree on $3.5k/month, he wouldn’t be reduced to abject poverty either. Which was the problem SS was designed to solve.”

                I was simply saying that in my county, in 95 ish, making 30k was considered “poor”. Not abject poverty, but enough to quality for gov’t assistance. I’m sure the amount now is over 50K. What has this got to do with SS? That the amount of SS paid, for those living in my county, is probably pretty close to being classified as “poor”.Report

              • Avatar Nevermoor in reply to Damon says:

                Right, but if your other retirement savings got wiped out, you could move to another county and not be reduced to starvation. Which was the pre-SS system.Report

      • Avatar Damon in reply to Davebo says:

        SS is not an “insurance’ program. If it was, payments would be based upon actuary tables and the money would be invested in the market in some form, not as things are now, payouts determined by congress and the money “invested” in treasury securities. It’s a transfer program plain and simple.Report

  14. Avatar Dave says:

    @jaybird

    If I counted up the voters who had employer-subsidized health care and added the ones who were on Medicare, I wonder how close I’d get to “most voters”. (If I added the ones on Tricare, how much closer would that get me? Across the 50-yard line?)

    As far as I’m concerned, you’d still have 50 yards to go because I’d argue the ACA really isn’t about health insurance. Ask any of the “repeal and replace” idiots how their ideas help improve the delivery of healthcare.

    Maybe I’m just a meathead here, but I see the goal of the ACA as facilitating the transformation of healthcare is delivered and paid for in this country. By that, I mean from the transition from the traditional fee-for-service model, which is completely unsustainable especially given demographics drivers, to what they call “value-based medicine” or population health management or outcome based medicine. It’s driving competition in the market among healthcare providers. It’s aligning the incentives between patient and doctors in ways fee for service didn’t through the risk-sharing agreements through the bundled payment plans.

    There is a wholesale shift away from inpatient acute-care setting to the outpatient facilties, both in terms of certain medical procedures and primary care. Providers are going to need to adapt to reach out to those populations and in doing so, they’re effectively retail models, something requiring a far more sophisticated approach vs. just having your patient base come to the medical offices on-campus. I guess the people complaining about the ACA fail to see that because they see the challenges in the insurance markets and say “Ack! Death Sprial”

    So no, don’t expect me to think someone is sophisticated if they think the ACHA is good idea and can’t point to the ways that it can help foster the transformation in healthcare delivery started through the ACA.

    It’s simple…it won’t. It’ll derail it.Report

    • Avatar Kimmi in reply to Dave says:

      Dave,
      The ACA has a target on its back. The changes to medicare reimbursement (particularly the penalties for readmits) don’t. And those are doing a lot to change health care as well.Report

    • Avatar Jaybird in reply to Dave says:

      what they call “value-based medicine” or population health management or outcome based medicine

      This would probably be an improvement over the worst-of-all-worlds that we have right now.

      Except, of course, it creates more uncertainty for the people who are the best off right now… those who are receiving employer-subsidized health care and the ones on Medicare (and, maybe, I’ll have to add in the ones on Tricare).

      If those people happen to make up more than 50% of voters, we find ourselves with a co-ordination problem.Report

      • Avatar Stillwater in reply to Jaybird says:

        If those people happen to make up more than 50% of voters, we find ourselves with a co-ordination problem.

        Only if you assume that every member of that group is motivated solely by pure, narrow, short term self-interest, which is certainly logically possible but practically impossible. Most people realize that their immediate situation is not permanent, that they will get old, that they may become unemployed, etc.Report

        • Avatar Jaybird in reply to Stillwater says:

          There are probably more Purely Altruistic people on the “I Got Mine” side than “False Consciousness” people on the other side… which, again, makes me wonder at what percentage of voters we’re talking about.

          If we’re talking 40%, oh yeah. Those people are effectively irrelevant.

          If we’re talking 50ish? A decent ad campaign might be able to pull it off. Maybe if we increased immigration…

          66%? Never. Never in a million years.Report

        • Avatar DensityDuck in reply to Stillwater says:

          “Only if you assume that every member of that group is motivated solely by pure, narrow, short term self-interest…”

          It’s entirely possible to find people who favor the AHCA because they believe it to be in the whole country’s long-term best interests. (And to find people who favor the ACA from a sense of pure, narrow, short term self-interest.)Report

    • Avatar DensityDuck in reply to Dave says:

      ” I mean from the transition from the traditional fee-for-service model, which is completely unsustainable especially given demographics drivers, to what they call “value-based medicine” or population health management or outcome based medicine. It’s driving competition in the market among healthcare providers. It’s aligning the incentives between patient and doctors in ways fee for service didn’t through the risk-sharing agreements through the bundled payment plans. ”

      This is dandy but it sounds an awful lot like “free market in health care” which, we are told, is horrible and wrong and leads to all sorts of bad outcomes.

      Like, you say “value-based medicine”, I hear “we aren’t paying for (thing) because it’s too expensive”. You say “population health management”, I hear “your cancer is too rare for us to consider its treatments a coverage priority”. You say “outcome-based medicine”, I hear “we tried (treatment) which is all that our Official Standard Of Care requires of us, sorry it didn’t help, if you want anything else you’re on your own”.

      And you can say “but these are all things that healthcare coverage will have to do to be sustainable!”, and I can say yeah, that’s certainly true, but that’s not what this person is looking for, and that person is the contemporary face of The Need For Healthcare Reform.Report

      • Avatar pillsy in reply to DensityDuck says:

        And you can say “but these are all things that healthcare coverage will have to do to be sustainable!”, and I can say yeah, that’s certainly true, but that’s not what this person is looking for, and that person is the contemporary face of The Need For Healthcare Reform.

        Would a similarly situated person get sicker, faster, until she dies in the UK with the NHS?

        Because the UK is about as aggressive as it gets in terms of cost control in its healthcare system, and actually have some stuff in Tier 2 (as we’re calling it) that isn’t just fancy rooms and boob jobs.

        This, of course, leaves aside the fact that this person seems to think she won’t get sicker, faster, until she dies under the current ACA status quo, which (among other things) still leaves patients paying higher out-of-pocket expenses than just about any other system I know of.Report

  15. Avatar DensityDuck says:

    Incidentally, if you want to have two-tier healthcare, you don’t need to argue with me. You need to argue with the guy in this tweet:
    http://twitter.com/jimwalsh_cp/status/862465058361704448Report

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