Elizabeth Warren Releases Medicare For All Plan, Math Debate Ensues
Elizabeth Warren talks to the the audience at a town hall held at Hibernian Hall in Roxbury on October 13, 2018 in BOSTON, Massachusetts. (Staff Photo By Chris Christo/Boston Herald)
Elizabeth Warren has released a proposal outlining the particulars of her “Medicare for All” healthcare plan.
Ending her months-long silence on how to pay for moving the entire nation into a government-run healthcare system, Elizabeth Warren on Friday laid out a detailed plan that relies on trillions of dollars in new taxes on the rich and corporations, big pay-ins from employers and aggressive cost cutting.
With her proposal, Warren becomes the first of the Democratic candidates to fully describe how a Medicare for all plan would be paid for. Her chief rival on the party’s left, Sen. Bernie Sanders of Vermont, who has campaigned in favor of a government-run medical plan for years, has outlined various options for financing, but has not committed to one.
Particulars can be found on Sen. Warren’s campaign website here. Her funding outline can be read here.
I really want someone to explain to me how heavy taxes on corporations does not instantly translate to a tax on the middle class through higher prices on consumer goods and/or lower levels of compensation to employees.
Politicians and pundits really need to stop pretending that corporate taxes are somehow magically not pass through costs.Report
The obvious argument is that the biggest increases are offset by health insurance premiums going away.
Not saying skepticism isn’t warranted, but, “These tax increases will just be passed on as additional consumer costs!” isn’t necessarily true. It also depends on the way the taxes are structured (for instance, pretty sure that wealth taxes wouldn’t be passed on to consumers, and it’s not clear they’d see much of a hit from financial transaction taxes either).
Of course, we’ll never actually find out if this plan works as advertised because even under the most optimistic of outcomes in the Senate, it won’t get 50 Democratic votes.Report
Listen, unless you are taxing the people making profit off of the corporation, you are just levying a tax on the customers and the employees.
Any tax that impacts the profit of the corporation is going to pass through, one way or another until an actual person is paying it. And since the majority of actual people are in the first 4 quintiles, that’s who will be paying those taxes.
Yes, even a wealth tax, levied against a corporation, will be passed on. It may not happen right away, but it will happen.Report
Not only will it not happen right away, a significant fraction (not all necessarily but a lot) will actually be assessed to the people collecting the profit. Like, that’s ownership stakes in a corporation is valuable: the ability to share the profits.
In practice, the question will be, “How much of the costs will be passed on to consumers, and how much of that will be offset by reduced out-of-pocket (and total economic costs) of healthcare?”Report
“…be assessed to the people collecting the profit”
That is not a corporate tax. If it is a tax levied against a person, it isn’t a tax on the corporation. Who is paying the tax matters.
Let me put it this way. Corporations do not pay taxes. Full stop. They collect taxes for the government from employees and customers, but they do not pay taxes. Any money a corporation pays towards satisfying a tax it will pull from an actual human.
The magical thinking is that somehow, the people in control of the corporation will allow the corporation to pull that money mostly out of their pockets, rather than from people who are not in control of the corporation.Report
Corporations generally have limited discretion in terms of the prices they set! This doesn’t change if they specifically face taxes on profits.Report
You are too smart to believe what you just wrote.
Corporations have dozens of ways to raise prices without seemingly like they have, just like they have ways of reducing employee compensation.
If you want corporations to absorb the cost of taxes without taking that money from an actual human, you have to change the incentives corporations have, which means changing how things like how Wall Street behaves.Report
They do.
And they have limited (not zero, but limited) freedom to use those. Like, if they could do that to increase profits, they’d be doing it already, right?
If the actual plan were implemented we’d see a ton of competing effects and it would probably lead to a modest increase in out-of-pocket costs (from the total of taxes, increased prices for goods and services, and reduced health care expenditures) for the modal family.
But I don’t think we’d see all those corporate taxes passed on to consumers.Report
That’s an awful lot of “don’t think”, and not any, “here is some historical data of corporate tax increases coupled with consumer price and employee compensation data showing that corporations or their leaders clearly ate the bulk of the impact”Report
Ah, good to know that oil companies can’t reap enormous profits because they have limited discretion! I guess we can quit worrying about that now.
Back in the real world, what limits a company’s prices are its competitors, who will undersell it and take market share. If you add $1.00 a gallon gas tax to all the oil companies, pump prices go up by $1.00 a gallon by that evening.
Fortunately Warren’s tax won’t apply to foreign companies, so we’ll all buy cheap Chinese products and Iraq oil and wonder why nobody we know still has a job.
Or look at it this way. Since none of the companies can turn a profit because Warren decided to grab all their profits, their return on investment to stockholders becomes nil and everybody’s IRA’s plummet to nearly nothing, along with every states’ employee pension plans.
There’s a reason that Democrats have held power in Washington for about a century without doing something this stupid.Report
No shit Sherlock.
And that’s the point of taxing profits, capital gains, and wealth, instead of adding a $1.00/gallon gas tax.Report
Err.. I think his point is that if the wealth/corporate tax is hitting all the companies then all the companies will probably raise prices/cut wages by roughly the same amount. There won’t be any competitive pressure to prevent it because all the companies will be absorbing the same new tax cost.
But, this is kind of a moot argument isn’t it? A new tax on corporations will result in them cutting compensation, losing profitability, raising prices or going out of business. Now only 2 of those outcomes really will hit the rich at all cutting profits and cutting wages and in the latter case wages will go down enormously more for the non-rich than the rich and in the former case there’ll be plenty of non-rich (but not poor) people who get the bit too (anyone who owns a pension plan or a 401 k for instance).
A lot of this cost is going to fall onto the shoulders of the non-rich. Probably even most of it will fall on the shoulders of the non-rich- there’re a lot more of them.Report
Yes but even though they’re all absorbing the same cost, if they raise costs or cut wages they can still be undercut or outbid by competitors.
The companies that do will be taking reduced profits as a result, but that’s the basic mechanism of competition.
And that’s why there’s doubt. And I haven’t seen actual studies that dispel that doubt; indeed what I have seen (not at all complete but more than anybody else has brought to the table) is more doubt.Report
The flaw in the logic is easier to see when you turn it around.
Consider:
Consumer prices go up, affecting everyone, so there is greater pressure to demand more wages. Wages go up, which puts pressure on prices to increase as well, becoming an inflationary spiral without end.
Inflationary spirals do occur, but not all the time. Not every market-wide price increase triggers a uniform response across the board.
Because no, not all sellers of labor (AKA “workers”) or sellers of goods (AKA “corporations”) are in identical positions relative to the market.
If all parties were in identical positions, there really wouldn’t be any way to gain competitive advantage.
Some buyers and sellers are more willing to absorb price increases, some have other investment options and so on.Report
Sure, but the base point- that these corporate tax cuts will pass on to middle class people- is still sound. Except for the very small fraction that might be applied against profits (and every company involved will make sure that is by far the smallest component) all the rest of the tax will land on the shoulders of ordinary people. It’s still a tax on the middle class- it’s just going to be a roundabout one.Report
When and how have corporate tax cuts ever been passed on to the middle class?Report
Objection! Relevance!Report
Tax cuts would probably be disbursed even less readily than tax increases are passed on. My assumption is they get spent on share buybacks and increased profitability. Both of those trickle out to the middle class through their stock ownership (401k’s, pensions insurance etc) but the companies gobble up as much of them as they can.
But can we be real? The corporate tax has always been a shitty mechanism for raising revenue compared to VAT’s or income taxes. It’s complicated and distortion causing. I’ve always thought the argument for taxing capital gains as normal income and axing the corporate tax all together (with suitable regulation to nail smart asses trying to treat their personal income as corporate income) is a pretty good one. Which is yet another reason this idea of the corporate tax being a huge revenue generator for Warrens medicare for all plan is a shitty one.
But Warren isn’t trying to make this policy, it’s pretty obvious it’s only a political ploy. I don’t hold that against her personally. I imagine once she’s in office she’d toss this dumpster fire of a plan. My problem is if this crap sandwich of a proposal is the best she can do for covering her ass on screwing up in embracing M4A then she’s a really risky bet for the general.Report
In this case, the tax is set to 98% of current cost paid to insurance company. So, cost-wise it is a 2% decrease. That is how it does not instantly translate to higher prices.Report
I really want someone to explain to me how heavy taxes on corporations does not instantly translate to a tax on the middle class through higher prices on consumer goods and/or lower levels of compensation to employees.
Fixed investments are sunk costs. If this abomination passes into law, corporations which have made investments in the US can’t just take their factories (or whatever) and go home. The factories are built, and the only option is to suck it up, pay the ransom, and remember to build factories somewhere else next time.
That last bit is a big part of why the corporate income tax is a bad idea. Investors only care about after-tax returns, not pre-tax, so if Elizabeth Warren jacks up corporate income taxes, investing in the US becomes less attractive relative to the counterfactual scenario in which she was paying attention in economics class. So there’s less investment, and consequently less growth in labor productivity and wages.
But because fixed investments are sunk costs, this process of attrition takes a long time, on the scale of decades. Higher corporate income taxes will lead to slower wage growth, but not instantly.
The same is true in reverse, as well. Corporate income tax cuts make a country a more attractive place to invest, which translates to more investment and higher wages, but this process takes a long time, and is very difficult to measure without the ability to observe the counterfactual world where the corporate income tax rates remained high. Furthermore, it might not happen at all if investors are concerned that the tax cuts will be rolled back by a populist demagogue like Warren. You don’t make long-term investments based on a tax cut that’s only going to last a few years.
This is why the “The Corporate Tax Cuts Didn’t Work” narrative that the media is pushing is nonsense. First, the expected effect over two years is quite small. Second, we can’t know what would have happened in the absence of the corporate tax cuts. And if they are in fact not working as intended, the most likely reason is the fact that the leading Democratic candidates are all promising to roll them back.Report
Here’s my math: Mostly we pay for health insurance already. Bringing in the now-small fraction who don’t have it will cost something, one way or another. I think it’s worth it. I also expect that the tax will be pretty strongly progressive. So I’m ok with that, and I don’t need to know more.
Finally, this will get tweaked by Congress endlessly, or maybe even ignored. It just doesn’t matter that much, and I’m not interested in these details.Report
So we’ll have people who oppose Warren because her plan wouldn’t work, and people who support her because although they know her plan wouldn’t work, they don’t think it would be implemented anyway? The 2020 campaign is upon us, and you expect your candidate to win with that? Her ads and media appearances would have to be listed as in-kind contributions to the Trump campaign.
* If I was a bookie and someone insisted on betting the Miami Dolphins will win Superbowl 55, I’d take their money, but I might feel a bit guilty about it if I didn’t give them a little push back first.Report
LOL you support Trump, George.Report
Indeed, but I can still feel guilt about not warning fellow citizens that they’re making politically bone-headed decisions about how to unseat him, kind of like you might feel if Republicans had tried to beat Obama in 2012 by going all in for Ron Paul and a return to gold and silver backed currency, a primary choice which would mostly benefit Democrats who make Lolcat memes.Report
Yes George you’re obviously deeply concerned that people would never support someone who promotes unworkable plans.Report
Oh, I love it. “But if we win, we get…. nothing” is going to get so many people to the polls.
Admit it. You guys want Trump to win in a landslide.Report
It worked well for Trump and a Mexico pays for a wall. The wall plan he put forth ignored tons of practicalities and most people thought he would switch to something sane and practical after the election.
What Waren has put forth is more sane and practical than Trump’s two pager on how he is going to make Mexico pay for the wall.Report
It’s not more crazy than even pre-Trump GOP promises about tax cuts paying for themselves. Probably less.Report
And yet we’re building a mile of wall a day. Amazing.
The wall is going to cost an estimated $25 billion or so, depending on who you ask, but Democrats dismiss it as unaffordable. Warren’s plan is going to cost an estimated $20.5 trillion (with a ‘T’) but somehow we’ll pay for it with corporate bake sales or something.Report
How many miles long is the border, George?Report
Same as it ever was, but the length of the border that isn’t protected by a huge wall is dramatically shrinking, to the extent that the 2019 migrant crisis is said, by some, to have ended. However, having Mexico through migrants into horrendous internment camps had a lot to do with that. Thanks Mexico!
Trump’s folks think they’ll double the roughly 650 miles of existing barriers by 2020. Mostly they were upgrading existing stretches that just had vehicle barriers or regular fencing. As of last month, there were 74 new miles built, 159 miles under construction, with 276 miles in pre-construction, mostly focused on critical locations.
A wall is no harder than a two-lane road tipped up on its side. I’m pretty sure the US has more than 2,000 miles of paved roads.
Of course Elizabeth Warren probably wants to tear down the barriers we’ve already erected, just so 600 million people can walk in and sign up for Medicare for All.Report
She’s trying to massively increase demand (i.e. access). Since there’s nothing in there that increases supply, this means large increases in price or serious queueing.
Much worse, if we assume she’s not firing hundreds of millions of people we’re also going to see EXTREMELY large tax increases, 52T in 10 years is 5T a year.
It’s a payroll tax. That means it’s strongly regressive. Also the rich simply don’t have the money to pay for a program of this size.Report
Warren’s time at Harvard was spent writing papers that generated interest, sometimes headlines, by using really odd metrics to reach unexpected conclusions. But the reason other academics in business or economics don’t use odd metrics is that they usually generate spurious results that can’t be defended. So Warren’s papers, while sometimes eye-brow raising for their oddity, have always shown weak thinking that relied on gimmicks for shock effect. So she looks interesting at first, king of like “M Night Shyamalan is the next Steven Spielberg!” But after three or four films everybody realizes that all he has are formulaic “big reveal” gimmicks. Warren’s pitch is essentially “If we ignore the obvious things that nobody else ignores, we get this surprising result!” That works until the audience gets more interesting in catching the tricks than in getting taken in by them.Report
New taxes on the rich and aggressive cost-cutting? Wow, what a bold and innovative strategy. Truly this is a candidate who brings a new energy to the public debate over how The Rent Is Too Damn High.Report
The math usually shows that in the three point balance of time-quality-cost that time is the metric that will eventually suffer as healthcare is socially tinkered with.Report
Usually yes. It’s also the easiest to manage if health outcomes in countries where the tinkering has taken place are anything to judge by.Report
I guess it is easy when you have fewer doctors and more customers to adjust the wait times out a bit.
https://www.globenewswire.com/news-release/2019/10/03/1924518/0/en/Fraser-Institute-News-Release-Despite-high-health-care-spending-Canada-ranks-last-on-number-of-hospital-beds-wait-times.htmlReport
https://medicalxpress.com/news/2018-09-swedes-world-class-healthcarewhen.htmlReport
Ultimately, you either pay, wait, or die. People can have any proportion of the three they want, and we can argue about how we want to balance them, but just pointing out that one variable will increase under Plan X doesn’t move the ball much.Report
I don’t want this concept of “we” to make the choice I want the customer to make the choice of the broadest options available of time-quality-cost.Report
That assumes a choice. If you can’t pay, and you don’t have the option of waiting while someone else pays, you die.Report
Let’s review.
Since economics isn’t a priority subject in this country, people don’t understand the parameters very well.
The first parameter to be tinkered with is quality. People who prefer social controls demand the minimum quality standards MUST be regulated.
The regulations accumulate and then this starts impacting costs.
Both of these parameters are being distorted in attempts to socially control the outcomes.
High costs become problematic, so the social controllers then MUST control costs.
Now in the time-quality-cost balance, quality and cost have become rigid.
The only parameter left to adjust is time.
Now let’s get to the math. Statistically has the time parameter ever done anything other than increase with the parameters set as described?
Not only have you raised the costs involved, you have extended the time to treatment parameter.
Add to the issue the percentage of healthcare workers that would defect such a clusterfish of a system.
So you pay more wait longer, and then you die, unless your some priviledged socialist vanguard type.Report
This isn’t even mentioning all the nefarious crap that the will to power folks would attempt if they did get control of the system.
Controlling speech by denying healthcare looks pretty obvious.Report
I don’t know that nefarious will to power folks get up to would necessarily be more or less nefarious than will to power folks get up to today.Report
Let me just say that if I needed a important service, that i would prefer it in a non-captured market as compared to a captured one.Report
The math and results from the rest of the world doesn’t measure up to your prediction Joe.
Health care results in the rest of the developed world are comparable if not better than the results here in the US for a larger proportion of the population.
So your last sentence, at least, appears erroneous. They pay less, wait longer and get as good or better healthcare results for more people.Report
I could point you to Sauls link below that compares the healthcare spending in the US as a percentage of GDP to other nations.
Part of the reason I linked below to Warren admitting to cutting 2 million jobs, wasn’t because I care whether or not those two million people have a job or not, it’s because it is a good indicator that the social controllers are on the path to control costs.
As I said above the first part that becomes rigid is the quality, then that drives up the cost. I think that is where we are now, attempting to control the spending, which will make that parameter rigid. Again that only leaves time as the parameter that can adjust.
We will likely see ‘cost cutting’ or ‘reform’ ad nauseam for the next 20 years as the wait times extend.
Maybe you have a iron clad case that cutting 2 million people from a field doesn’t lead to long wait times. I mean I could see some automation and streamlining clearing a few of those positions, but I think that is a lesser parameter in what we are seeing.
InMD down below suggest that maybe we will have a German type HC system in 40 years, the problem is that we are on track to reach Currency Value Zero within 30 years.
That will be enough time for most of our free market small business techniques to be forgotten, and that wheel will have to be reinvented as a considerable amount of people perish around a decaying carcass of horrid ideas.Report
That’s one possible way to balance the inescapable pay-wait-die equation, though if you’re suggesting that it is the only way or the most likely way, you haven’t shown your work. I’m not sure whom you are disagreeing with, since my point was that in any conceivable system — or collection of non-systems — you pay, wait, or die, and you don’t seem to disagree with that.Report
My position is that there should be the MOST degrees of freedom in the system. We aren’t starting at that point. Quality has become rigid.
I can’t tell if we are talking past each other in priors.Report
We probably are because I have no idea what you mean.Report
“Health care results in the rest of the developed world are comparable if not better than the results here in the US for a larger proportion of the population.”
Statistics, please.
And do make sure you understand them. You’re going to throw “infant mortality” at me without knowing that the EU definition of a dead baby is different from the US definition of that term. And you’re also probably going to bring in “life expectancy” without knowing how that’s calculated (hint: it is not “how many years do you expect the average person to live”, it’s actually quite a bit different from that.)Report
I think this is a good call. Pillsy is right that the M4All probably has a snowball’s chance of hell in passing the Senate (unless a miracle happens and we don’t need to depend on Manchin) but there is nothing wrong with going big or going home. I find a lot of the Republican smears on this disingenuous. The big question is will takes go up in a way that is more than the amount many or most people pay on their portion of employee healthcare or the ACA, co-pays, deduictables, out of pocket expenses, etc.
The other big question is whether anything but universal healthcare can survive a right-wing assault in the courts. The answers seems to be no considering that the 5th Circuit is posed to void all of the ACA out their never give up Bolshevik fanaticism.Report
The best thing for M4A is for ACA to get gutted in the courts. One of the three legs of the ACA (individual mandate) is quite wobbly. I tried to warn some of my conservative friends that they needed to help make ACA work. The healthcare funding/market issues needed addressing one way or the other. That if ACA fails, single-payer would be virtually guaranteed. There is little serious question that a single payer system would pass constitutional muster.Report
We need to deal with the fact that some far right organization is going to argue that M4A and by extension the entire American welfare state is unconstitutional because argle-bargle limited government. I’d like to believe that no Court is that crazy but we don’t know. Plus even if the entire ACA is gutted, the Republicans and more conservative Democratic politicians are not going to collapse.Report
They have been arguing such argle-bargle for some time and not getting much of anywhere. I guess it is possible that it can change.
There is little dispute that the federal govt. can collect a variety of taxes and ways. That the federal government can spend is not really in dispute. Maybe this or that way a tax or spend gets shot down, but it seems there are enough buttons, knobs, and switches to fiddle around any issue that comes up.
True, if the ACA is gutted Republicans and conservative Democrats are not going to collapse, but our medical system probably will in under a decade. The forces in play pre-ACA causing 10% per year premium and 100% co-pay spikes will return. We will shortly see the adverse selection death spiral come back. It will be bad. I do not want to see that happen. However, if it does M4A will quickly gain popularity. Maybe at that point we get a do-over on ACA with bi-partisan support, but I think only state guaranteed coverage will be acceptable to enough people.Report
Warren Plan: Health coverage for all, paid for with taxes;
Republican Plan (Unchanged since 1932): [shruggy face emoji]Report
Don’t propagate the Republicans claim that they don’t have a hand in making this mess. In fairness, Saint Reagan signed EMTLA. EMTLA broke fundamental rules required for capitalist markets. It virtually guaranteed the death spiral of most of the healthcare market. It was a hack that looked sensible at the time, but we have been chasing that structural issue since.
We can go back to pre-EMTLA where federal government is mostly ambivilent as to how care is paid for. To world where you show up at the ER with a gunshot wound and get asked to show ability to pay before walking in the door. It would work. It would be a functional system. It would not break markets. I am pretty sure that collectively we still find that morally repugnant, we did enough in the mid-80s to for Republicans to support EMTLA.Report
Erstwhile brother Doc Saunders wrote this on the twitters.
The entire thread is worth reading. Especially *THIS* tweet:
A 40% cut to my practice's revenues means we close. Full stop. It is extremely difficult to see staying open, at least with the hours we currently provide, with a complete loss of all profitability and steep cut to provider salaries.
— Daniel Summers (@WFKARS) October 16, 2019
In addition to that, Popehat linked to this article the other day:
And my take on that was this:
Today the vets. Tomorrow the doctors.
When health care is a right, the people who could give it to you but do not because you can’t afford it are, by definition, withholding something that you have a right to.
Which makes *THEM* the bad guy. Not the person calling them out.
This ain’t gonna solve the problem. I appreciate that the problem is a problem that requires solving and I appreciate that this is an attempt to solve the problem but this will not solve the problem and will, instead, make the problem worse.Report
Why won’t solve the problem? Well over a dozen countries have publicly funded healthcare systems that solve these exact problems. I have heard breezy explanations like “Americans are too individualistic”, but nothing really substantive.Report
Well, because I take Doc Saunders at his word and that he will close. That tells me that the doctors that stay open will have longer (perhaps even *MUCH* longer) lines to see them.Report
The Warren plan starts rates at 110% of medicare rate, vs. Sanders 100%. It then has adjustments upwards for various forms of “challenging cost structures”. Just from the start most Dr’s should also see some cost relief in form of radically simplified coding, billing and reimbursement. (That is a healthy chunk of the estimate referenced below in 2M job loss.)
Possibly those are rates are too low. It is certainly something that should be studied, monitored, and adjusted as part of implementation. We should absolutely hear out folks like Doc Saunders to make sure we get it right, or at least as best we can.
However, setting the opinion of a doctor against multiple systems that appear to be working, I am going to side with evidence and say that it is POSSIBLE. We just have to figure out how to get there from here. Maybe the plan does not understand something properly, maybe the doctor does not understand something properly.Report
Most of what I’m working with is the evidence I’ve shown above (and talked about in the past) and the inferences I’m making (which, believe me, I try to make explicit).
Hey, maybe Doc Saunders should feel relief that he’s no longer obliged to pay for insurance for himself/his staff. Maybe the plan is possible! Maybe he doesn’t understand what will happen to his practice under your proposed plan.
But I am inclined to believe the Doc more when he talks about what he, himself, will do in response to the plan than I will to the person explaining how awesome the plan would be because it’s similar to what England does.
Because I know that the Doc ain’t doing wishful thinking. (And I see that suicides for Vets, for example, are up… due to such things as not only money, but social esteem.)Report
I have seen it widely discussed that many medicare and medicaid services pay below a fair rate but above an incremental rate, resulting in private reimbursement rates subsidising federal reimbursement rates. To me this means that the federal rates are too low and private rates too high. So the correct point would be somewhere in between to reach the same service and cost levels. This has been one of my gripes about Sanders plan. It sets the rate at 100% of medicare rates, which looks too low. Warren at least ups that to 110% of current rates, which is at least acknowledging the reality. Is 10% over enough? I don’t know.
If the good Doc is taking a 30% haircut, the new efficiencies may not cover that and rates need to be improved or other ways to reduce his costs. Maybe they will and he will discover that when we get closer to a full plan and can gauge all gives and gets. I don’t know, but these are questions that are going to take time and effort to research and do correctly. There is a lot more to be nailed down before such a thing is even close to completely baked.
Clearly there is disconnect somewhere between Doc Saunders, his understanding of proposed single payer systems, the single-payer proposals on the table, and existing functional single-pay systems. That disconnect should be found and addressed.Report
Again, all I’m going on is what the good doc himself has said.
Hey, maybe he’s wrong!
But he’s actually got skin in the game. He’s what is generally considered to be a “good” person (as opposed to folks like me) so I don’t think that he’s saying what he’s saying out of spiteful greediness. And I’m more willing to believe him when he says “if this happens, I’m closing down” than someone else who promises “if we change, we’ll be more like Europe!”
But, hey, maybe you’re right. We could finally be like Europe.Report
Maybe he is not wrong.
We are not Europe and a lot of folks like to ignore that fact. Anything we do needs to be aware of those differences. That is one reason I was all in on the ACA. It got us to near universal coverage and significantly tried to respect those differences. It was still very privately managed and still quite market-ish in what looked like a workable way.
Nearly anything I attempt to do I look around for someone who has done that thing or something like it before. If I find that a bunch of people have done it, I assume I can do it and then try to see if I can get them to share with me what they can on doing it. If someone then comes to me and says it is impossible because of X, I am going to assume that X is addressible in some fashion. X didn’t stop others from doing it. If it was just one other that did the thing, I might buy that it was a special case. Hell, with an appropriate reason I would buy that it won’t work because I am special case, but that case needs to be made.
Personally, I could not give two craps about more or less like Europe. If doing M4A means not looking at success and fails in Europe, fine… lets just look at Canada, Taiwan and South Korea. We just need to get a system that “works well enough”, in time we may even get back to being the “best”. There seems to be different types of systems that work better than what we got. Let’s pick one and start making it work, what we got is ain’t working and prospects of tweaking it into working shape looks very unlikely.Report
Just as no battle plan survives contact with the enemy, no health care plan will survive contact with Congress. Regardless of the merits, we just won’t get the Full Bernie or the Full Warren, or the Full Whatever-Kamala-is-Pushing -This-Week. Even the Full Biden will be an enormous political lift. There are lots of workable ways to skin the health care cat, and any candidate’s Big Bold Plan is a starting point for negotiations and nothing more. I wouldn’t pick a candidate based on detailed differences in their health plans.Report
Just from the start most Dr’s should also see some cost relief in form of radically simplified coding, billing and reimbursement.
I know a guy who, before he retired, built a chain of pediatric dental practices that only accepted Medicaid patients. This is what he told anyone who asked. “It works because Medicaid is the only dental plan we accept. Instead of two people per office dealing with insurance companies, we have one person per several offices.”Report
I noticed that when I went to the dermatologist two weeks ago. At 10am on a random Tuesday the office had 1 doctor, 1 nurse, 1 receptionist multitasking data entry, and 2 people on the phone going back and forth on billing related things. They told me it would probably be a month or more before I saw my part of the bill(100%) because the back and forth with the insurance usually takes that long and my cost will be determined by that back and forth.Report
I am sensitive that there will be new problems, but on net are things better or worse after attempting to mitigate those problems. Cars are a slam dunk for net good. Cars brought new problems like going faster than our jumped up monkey brains are designed to handle and splatification. We mitigate those risks with technology like crosswalks and memes like “look both ways before crossing”.
Just saying there are problems without setting those against the gains is not a fair argument for the status quo. Just as not discussing financing a M4A plan is not a fair argument against the status quo.Report
Here’s MattY:
“Providers accept lower unit prices (but more volume)”
“Providers accept lower unit prices (but more volume)”
“Providers accept lower unit prices (but more volume)”Report
They’re losing money on every sale, but making it up in volume!
Only someone from Harvard could believe such things.Report
Nonsense.
She is providing exactly Trump’s plan, word for word.
In case anyone forgot, Trump’s plan was that he would provide great insurance for everybody, without any increase in cost.
A sensible, bipartisan reasonable plan, don’t you think?Report
She’s saying she’s going to take away everybody’s private health care plans, even the ones labor unions fought long and hard for over countless decades. I hope she has a plan to win that doesn’t require any union votes.Report
If you read the plan she has a one for getting union votes. It mandates some if not all of the union payed for health spending goes directly back to the employees paychecks. More money in your paycheck has a long history of being desirable, even by union members.Report
So what was the point of all the unions negotiating to get those great health benefits when they could have just asked for more money, instead?
In her plan, the extra money from the union workers’ paychecks is spent on massively increased prices for everything, while their fabulous union health plan is replaced by the same one she’s offering to Guatemalans who walked across the border two weeks earlier.
Trump will get to point that out and hammer it home, repeatedly. Any Republican would. That’s probably why Bill Clinton, Al Gore, John Kerry, Barrack Obama, and Hillary Clinton didn’t run on a plan like that.
As I’ve said before, you never start a sales pitch by saying you’ll take away something the customer really loves, or really depends on, because they’ll pigeonhole the salesman and product as some kind of fast-talking thief running a scam.
“First, we’re going to take out your existing windows and rip the siding off your home. Then we’re going to take your money and flee to Indiana…”
If they’re offering you something that’s too good to be true, it probably is and you’re going to get reamed by the fine print.
To pull off a sale of that magnitude, your salesmen has to have a large reservoir of trust built up. Elizabeth Warren doesn’t have that trust, as she’s never accomplished anything in her long life except passing herself off as a Native American.Report
You mean the labor union plans that if you strike, the company can kill if they choose too, as GM attempted to do?Report
You’ll notice GM failed to remove or even reform their HC system because the issue is THAT painful and important to the union.
If you’re going to argue for UHC then yes, it means the people with really good access to the system right now will be losers in the new system… so I really have to give Warren points for honesty.
The next step she needs to really make this work is spin “Death Pannels” into something that people will vote for.Report
Warren proposes a financial transactions tax of 0.1 percent of the value of every stock, bond, or derivatives transaction. That raises $800 billion. Then she adds a “systemic risk fee” on financial institutions with more than $50 billion in assets. That’s another $100 billion.
She’s going to slap 20-30 cents of tax on a transaction that only has a penny profit and expects no one will change their behavior? SERIOUSLY?!?
My expectation is that all stock trading is done off shores within a year.Report
Am I reading this right, that the argument is being made that “If we create a national health service, doctors will kill themselves?”
Is this actually an argument?Report
Not really. It’s closer to “stuff that is happening to vets today will happen to doctors tomorrow… and this is what is happening to vets today.”
I see national health services as likely to make things worse for health care workers than make them better.Report
Depends on the approach and the workers. But it seems weird to say that we’ll see the same pattern we see with vets when the way veterinary medicine is paid for is completely different and will get more different under M4A.Report
Here’s the opening sentence to the story:
“Pushed to the brink by mounting debt, compassion fatigue and social media attacks from angry pet owners, veterinarians are committing suicide at rates higher than the general population, often killing themselves with drugs meant for their patients.”
The clause I’m looking at is “mounting debt, compassion fatigue and social media attacks”.
When it comes to mounting debt, I’ll just swap that out for “money in general” and then I’ll look at what Doc Saunders said. As for compassion fatigue and social media attacks, I see M4A neither helping nor hindering either of those… except, of course, if the promise of M4A is that it will make things better for patients and the patients notice that things have not, in fact, become better, I imagine that some of the patients will blame doctors instead of the change.
Just off the top of my head.Report
Vet care is usually paid out of pocket. I imagine that leads to delayed payment, collection agencies, writing off care, people killing off fido since they can’t pay for his chemo and denied care. How does that relate to people having to pay their own health care costs out of pocket. Prob all the same issues for the patients.
But pulling back a bit this is all why D’s explaining their plans in detail is bad politics. They get all the negatives and no positives. Trump and the R’s will offer up a few lies that we all know are lies then just smoothly move on. The entire debate will about D dreams and details. Some of the details may even be poor, i dont’ actually have much of a thought about Warren’s plan yet. I do put a lot of stock in the good doc’s criticism. But if you pay attention he is also for uni HC and on the D side in general about fixing the system.Report
I have a handful of ideas myself about the problems of and solutions for Health Care.
We got into them here (among other places).
I (more or less) stand by them.
When I see a solution that says “we need to create more doctors/nurses/MRI machines!” than one that focuses on “we need to give more people more care!”, lemme know. That’s the one that I think might actually be in the ballpark of solving the problem.Report
Thanks for the pointer.
Your observation that we are going to end up with a two tier system I think is spot on. M4A like most similar systems is going to be “kinda crappy but good enough”. Then there is going to be fancy “whatever you can pay for” system. Care has to be taken on both fronts. We will have to ensure M4A is good enough. We will also have to ensure that the M4A system doesn’t completely kill the pay for system by forcing it to subsidise M4A too much.Report
We’re not going to have a “Gold Level” and a “Platinum Level”.
We’ll have a “You Just Want People To Die!” level and a “This Is Just The Bare Minimum Of What Is Acceptable” level.Report
Why don’t other countries with universal systems have this specific problem?Report
American Exceptionalism.Report
The release valve of the US. The cultural solidarity that comes from everybody knowing that everybody is in the same boat (“at least we’re not like the US!”). Internalized knowledge that a long queue is the price that sometimes you have to pay in order to maintain high quality in a cheap environment. There’s also stuff tied to the FDA (remember when we discussed Epipens?) in there too when it comes to why drug prices are so bad (Insulin is cheaper in Peru than in the US, for example).
There are probably a handful of other dynamics there but those are the big ones that come to mind.Report
“Why don’t other countries with universal systems have this specific problem?”
They do.Report
There’s some push on the right to get rid of “certificates of need”, whereby no health facility can add or expand services without permission from the local or state government. If you want to open the town’s second or third MRI center, you have to get it approved by bureaucrats who get heavily lobbied to stop you by the existing hospitals and MRI centers, who’d prefer to have less competition.
The theory behind it is probably the same as Bernie’s theory that we only need one kind of soap. Why should a town have two MRI centers?
Sometimes a contrast is drawn between the plummeting cost of LASIK surgery (and the proliferation of LASIK centers that replaced frozen yogurt and Blockbuster Video stores) and the lack of regulation of the industry. Under the CofN model, a town would have the one LASIK center and they would charge a fortune.Report
Glad to see somebody pushing back on the senseless nanny state top down rentseeking restrictions on abortion clinics.Report
LASIK is a great example of why we want a robust two tier system. New cool procedures would show up in the “all the healthcare you care to afford” lightly or no regulated system. Being all markety and as lightly regulated as is reasonable, competition will eventualy drive costs down to the point that makes the cost/benefit analysis by the “crappy but good enough” system is willing to pay for it vs. radial keratotomy. This seems like it should work with anything that is mostly elective. Another example would be various gastric reduction options.
Urgent, emergency or life saving procedures are unlikely to work as cleanly and smoothly though.Report
While you’re not saying it in as extreme a terms as I did, you’re saying that M4A will lead to doctors…getting angry, stressed, possibly killing themselves.
That is the argument here, right?Report
No. I am saying that doctors are going to be getting angry, stressed, and possibly killing themselves and M4A will not alleviate any of the things that will be making them angry, stressed, or want to kill themselves.Report
So its the status quo that is making them angry?Report
Taking Doc Saunders at his word, the status quo is keeping them in business (and getting angry is secondary).
The proposed change would probably result in Doc Saunders being happier in some ways because (and I’m taking him at his word here), he’d be able to do something else entirely.Report
So nobody would be killing themselves?Report
According to comments below, Doctors and Nurses have fairly high rates of suicide… and, yeah, checks out. There’s a wiki page devoted to the phenomenon.
I don’t know what clinics closing would do to the suicide rate of doctors/former doctors.
I imagine that it might nudge the rate for patients in the bad direction.Report
So is the argument now ” “If we create a national health service, patients will kill themselves?”Report
No.Report
It will alleviate or reduce stress around ability to pay, coding, billing, and pricing. Those things will be simpler or out of the doctors control.
I agree that if M4A service prices are set too low it will create a lot stress around cost control.
I am 100% sympathetic that this is huge change. Change is stressful. Huge change is huge stress. What we have is byzantine, broken, and looks to be getting worse. So, to my view change is coming one way or another. Going whole hog on laissez-faire can work, but seems morally unacceptable to a sufficient portion of the country that it won’t fly. M4A looks like an option that can be successful and can work. ACA seemed a middle of the road, still market friendly solution that might work, but is proving unsuccessful. Getting to a competent M4A system is going to be bumpy, painful, stressful project; but it is the best option I see.Report
I think that making us more like Canada or Europe will entail making us more like Canada or Europe.Report
Agreed! Pooping entails pooping! Everybody poops!
To you, is being more or less like Europe a goal in and of itself?Report
IMO if these folks have a Canada or Europe fetish, they should probably buy a one way ticket.Report
Meh, people hear ‘Europe’ and automatically assume UK or Scandinavia. There are continental options we can learn from. IMO healthcare is one of the few areas where being an English speaking country really stunts us.Report
Yeah, i know more than a dozen folks who jump our southern border to get work done there.
One was an obese gal that US doctors wouldn’t touch, she went south and had one of those stomach bands put in and has dropped 130lbs.
In doing so, she saved her job, her knees, ankles, and probably a fair amount of future life.Report
Well, whenever it comes up that we should be more like Europe, I tend to bring up language laws.
There are a lot of ways that we could be more like Europe. Tons.Report
FWIW… I have a different read. Doctors and Nurses are already known to have some of the highest suicide rates. This article starts from a study that indicates that veterinarians do too then riffs on those specific stresses and even has nod to gender inequality. It is new information but not really all that surprising.
There is not really an “It will happen to doctors too”, since it is already happening. Medical provisioning is a high stress, high stakes gig regardless of patient species. High stress, high stakes gigs have significantly higher suicide rates along with other conditions that travel with stress (drug abuse, heart disease, depression.)Report
I think its’ important to note that most voters don’t find the argument that “this is what I want to do but can’t” terribly persuasive. So a more realistic pitch isn’t going to be great campaign stumping.Report
I remember us having this discussion before, and people asking straight-out “what happens when the government-run healthcare plan that pays everything for everyone says something is too expensive to pay for”, and the answer was “well the government doesn’t have a profit motive so we should believe them when they say it’s too expensive”, and then I asked “so it’s okay to tell people they should die if they can’t afford to pay so long as it’s the government doing the telling”, and the reply was “well the government doesn’t have a profit motive so we should believe them when they say it’s too expensive!”Report
Politicians are poorly set up to stand up to accusations of killing people “because it’s too expensive”, and families are poorly set up to believe their dying relative should die.Report
Fascists gonna fascist:
https://www.vox.com/2019/11/1/20943251/fraternal-order-of-polices-impeachment-due-process-sean-hannityReport
https://platform.twitter.com/widgets.jsReport
Huh, did Warren admit that?
https://freedomoutpost.com/warren-admits-cost-of-medicare-for-all-could-be-2-million-lost-jobs/Report
Holy crap! A politician that is honest that efficiency and cutting costs means lost jobs? Wow, what will they think of next?Report
Well, I guess that’s good news. It even improves access. If you like your doctor, your pediatrician, and your gynecologist, they’re all bagging groceries down at Walmart so you can drop in on them whenever you want.”Report
Those job losses are not doctors or nurses. That is medical administration and marketing people. Billing, coding, claims adjusting, policy marketing, etc. However, at the end of the day cutting costs means cutting someone else’s income, often to zero. This is the same if it is private sector cost cutting or government program cost cutting. I am sympathetic that is a lot of people whose industry is going to disappear out from under them. It is horrible and it will likely result in deaths that otherwise would not have occured, but the current system is killing folks that would be saved under a M4A system.Report
Agreed. I have a ton more respect for Warren for admitting that millions of people need to lose their jobs in any plan that is going to lower medical costs.
I also think there’s no way the political machinery has the stomace to inflict this much pain on itself.Report
You are probably right. Americans don’t seem willing to do anything difficult or remotely painful anymore, esp if a politician wants us to.
For fish sake…. we now have adult gummi multivitamins. I recall looking at the price difference vs. regular old pill and it was huge. I am told they are quite popular.Report
She doesn’t really need to admit it. Yes, it’s obvious to _you_, and everyone else, that it will result in cutting a bunch of medical staff that are only needed because medical insurance is a nonsensical pile of nonsense that tries to avoid paying anything so doctors have to constantly run things by insurance companies and then hound them to get payment…because that’s actually lot of cost savings in the assumption…
…but the thing is, Republicans have been sprouting nonsense about medical stuff for so long, and the nation has become so partisan, it doesn’t matter if Republicans _do_ point that out. Democratic voters simply won’t believe it.
And we’ve lost any objective institution that could make it clear. Republicans are going to say it will do this, Democrats will point out that Medicare administration will be expanded to cover the same amount of people so those people can get jobs in that, Ignoring the fact that there, obviously, will be less jobs there. The media, as now trained, will simply report both sides.
In fact, Republicans politicians are so disconnected from reality, I’ll bet even money that ‘This will result in a lot of administrative jobs lost’ will barely even be an argument made against this, and instead it will be a bunch of nonsense about ‘socialism’. Seriously. The fact it’s going to reduce doctor expenses by getting rid of one of the several random staff people sitting around doctor’s offices is barely even going to come up….Republicans won’t say that, because then they’d have to admit we wouldn’t be paying their salary anymore to do stupid insurance bullshit, and things might actually be slightly cheaper.
I guess other Democrats could bring it up, although it would be rather self-defeating if they did…any serious attempt to deduce medical expenses has to look at the sheer insane overhead that having all these insurance companies causes. Even obvious stuff like ‘standardize billing codes’ and ‘make everything go through a standard computer protocol’ will reduce administrative staff!Report
If you mean a generic “voter” with a generic job, then sure.
If your job is working for a hospital fighting with the insurance industry, then you probably understand EXACTLY that it’s your job she’s talking about. This also applies if s/he’s your spouce, parent, or child. Or if your job is servicing people like that.
The scale of this is insane. We’re talking about multiple percentage points of the GDP. If memory serves, my back of the envelope suggested it was more like 3+ million jobs.
We’re a nation mostly balanced 50/50. Those 3 million high wage jobs cut across both sides and land everywhere. If you assume people won’t vote for themselves to be fired, you just lost a lot of blue voters, more than enough to swing elections. Presumably the unions with HC in their contract will also understand they’re getting shafted.Report
The problem has been solved! Elizabeth Warren came out and said the workers displaced from health insurance will simply move into providing life insurance and car insurance.
Now why couldn’t any of you folks think of that? It seems pretty obvious to me, now that she’s pointed it out. I guess that’s why she gets paid the big bucks while we pound away at our keyboards.Report
I point to my ‘This will result in a lot of administrative jobs lost’ will barely even be an argument made against this, and instead it will be a bunch of nonsense about socialism’ point.
We aren’t balanced 50/50 at all. More importantly, we aren’t balanced like that in a balanced way. For one thing, none of the big insurers are located in swing states.
Now, for some idiotic reason, it is hard to figure out how many people are in the health insurance industry total. You’ll often run across the 2.6 million figure, but that’s wrong. Other places will make it clear that’s the total in _all_ insurance, not just health. But I tracked it down:
https://www.ibisworld.com/industry-statistics/employment/health-medical-insurance-united-states
621,505 employees total. So…let’s see how many those are in swing states. We don’t have the exact number of employees per insurance company, but let’s assume it’s basically proportional to the amount of insured people.
UnitedHealthcare Group is the largest health insurance company in the US, covering 49 million. It’s in Minnesota. That state is voting for Democrats. Anthem is the next largest, 40 million. It’s located in Indiana. That state is voting for Republicans. Aetna has 22 million, that’s in Connecticut, that’s voting for Democrats. Cigna is 17 million, also Connecticut. Humana is 17 million, Kentucky, voting for Republicans.
That’s insurers that cover 145 million people total. And let’s recall only about 170 million people even have private insurance.
That’s leaves…15% of the private insurance market that the employees of could hypothetically change how they vote. So…fifteen percent of 621,505 is 93,226. Let’s assume that the larger insurance companies scale better, so the smaller ones employ slightly more people, so let’s say 100,000, to be fair.
I know our last election was just decided by that many people, but that’s an absurdly small amount of people to worry about, politically.
—
But what about the extra staff at medical places, you ask. Because there are more of them. I’m not sure where you got your ~2.5 million estimate (The 3 million minus actual health insurance employees), but it sounds reasonable.
The problem is that loudly talking about how people’s doctor’s and hospitals will be able to employ less people is…not the winning argument, politically, that you think it is. Because while the medical staff will hear it, and perhaps worry about their job, everyone else will hear it too.
And they’ll think…hey, my doctor isn’t going to have pay for extra people…and that’s bad enough for Republicans. But…maybe their thoughts don’t stop there, and they reason…that’s because everyone no longer have to jump through insurance hoops. Which…includes me. Huh. Actually, Medicare for All seems like really a good idea! I hadn’t realized how much overhead insurance companies added!
Like I said, in reality, Republicans are actually going to attack M4A (and in fact already are) using ‘socialism’ and claims it would be incredibly wasteful and all sorts of nonsense. Attacking it based on lost jobs means they have to sit there and explain how it’s so much more efficient that a lot of people would lose their jobs. That is not a winning political argument. Even if it would hypothetically attract some voters in the industry, it’s going to repeal a lot more of voters in general.Report
My expectation is that people worried about the certainty of losing their jobs is more of a political force that the broad forces of people who want to fire them. It’s the whole “narrow special interests who are highly motivated” vs “broad general interests who are not”.Report
“Lost jobs”, which are lost because they are no longer needed?
Imagine for a moment that some new software app eliminated the need for all those billing and coding people.
What would the conversation about that look like?Report
Think about how bitter the auto workers are about losing their jobs and how much political trauma it generates. Think about how many times you have talked about how it’s truly horrible that those jobs aren’t “good” any more.
The UAW at it’s peak in 1979 was about 1.5 million workers. Picture all of them being let go over a decade because of government action rather than 1.2 million of them being squeezed out by the market over a period of 30 years.
That’s about half the level of pain which is required here because there are roughly twice as many people well paid uselessly employeed in the HC system.Report
Like coal miners and truck drivers, maybe these people can learn to code?
The objection here sounds astoundingly Soviet, the sort of thing Republicans used to ridicule. That we must keep people working at tractor factories which aren’t needed, because we don’t want to lose the jobs.
Put another way- if the work these people is economically valuable, it wouldn’t be possible to be eliminated.
Or does that rule only go for low wage workers?Report
Objection? What I’m doing is describing why I seriously doubt the gov is the tool by which we want to fire all those people.
For the record I’m solidly in favor of firing them all. IMHO we have to do this if we’re going to bring down prices.
The market has a solid record of being willing to destroy millions of jobs. I can’t picture our gov having the political will to take responsibility for destroying millions of well paid jobs (to the tune of 2x the UAW at it’s peak).Report
Isn’t the conventional wisdom among economists that the workers always find new jobs?
Or do we have millions of idle steamfitters, punchcard typists and elevator operators?
Even the acknowledgement that our health care industry has millions of idle workers who contribute nothing of value, seems like a powerful argument for its reform.Report
It is. It’s debatable how it plays out in practice (because displaced workers are not necessarily going to be picking up new jobs that are as good or better), but the net effect should be to improve things.
All in all this particular criticism of Warren’s plan reminds me of Milton Friedman asking why workers weren’t moving rocks with spoons.Report
Personally, I am not of the sort to just write off a huge chunk of the country with “economics bitch. life ain’t fair. it’s your fault that you picked an industry that blew up. suck it up buttercup.”
Two million people suddenly with no jobs and limited prospects feeling like they got shafted sounds like an army waiting to happen to me. Part of NAFTA was programs and money to help displaced workers find new careers. It seems prudent to have similar mechanism to help those getting the short end of the stick for “the greater good” or “economic efficiency”.Report
If memory serves one of the things we should have learned from these NAFTA job-placement programs was that the gov sucks at this sort of thing. If we need to have “money to help displaced workers” for political reasons then that’s fine, but we shouldn’t expect much.
Fire them. Let the market sort it out.Report
To be perfectly honest, one of the campaign ads I wrote in my head for (Democratic Nominee) involved bragging about throwing Insurance People out on the street the way that Clinton bragged about putting coal miners out of work.
Like, really leaning into it.Report
Honestly, they could.
In reality, a lot of the lost jobs are going to be, like, that other woman who is sitting behind the counter at the doctor’s office, not the receptionist but the other woman, who is mysteriously working on her computer. Because she’s the dealing-with-insurance person, and she’s going to be out of work.
Which…the Democrats can’t really brag about. They could counter complaints about costing her a job with ‘Every time you get medical care, you’re having to pay the salary of her to deal with insurance companies, and wouldn’t you rather not do that?’ so it wouldn’t look that bad to the average voter, but they can’t really brag about getting rid of an innocent office worker whose job it is to call insurance companies and beg them to pay for things.
But we all know Republicans won’t really explain what’s going on, and instead just SOCIALISM loudly at it. Republican have no actual trusted method to get get policy facts to anyone anymore.
So the Democrats sure as hell could lean into throwing insurance company executives out into the streets. People hate health insurance companies worse than Congress and Wall Street:
https://qz.com/1033336/survey-americans-hate-the-health-care-industry-even-more-than-wall-street/
The only thing they hate worse is…drug companies. For literally the same reason:
https://theharrispoll.com/only-nine-percent-of-u-s-consumers-believe-pharmaceutical-and-biotechnology-companies-put-patients-over-profits-while-only-16-percent-believe-health-insurance-companies-do-according-to-a-harris-pol/Report
That’s not how I’d do it. I’d have the voice-over start with “insurance companies deny the first claim as a matter of course”. Show a white hand with a “DENY” stamp just going through a pile of papers and stamping them with big red ink. Pull back and show it’s an old white guy, out of central casting, who is the guy they call when they need a “fat cat”. Have him laugh as he stamps each paper.
“When I am president, these people will be out of work!”
Show this same guy holding a sign that says “will work for food” at the highway exit (maybe wearing the same suit!).
Have candidate say “He’ll still get health care, though. Everybody gets health care under my plan!”
“I’m Candidate Bagadonuts and I support this message.”
They’d get 40ish states with that ad.Report
Agreed with all of that.
I’m not saying that the level of political pain needed to do this is so great that this isn’t going to happen from Congress.Report
I think this plan is a perfectly “reasonable” plan in theory, that has no chance of passing, but will stop the “will you raise taxes,” because the truth is, if you want a European welfare state, everybody short of fairly poor people will need to pay more taxes.Report
Yes, but Warren won’t admit to your final very plain stated fact. Bernie will, Warren won’t. This plan is her attempt to square that circle by showing, sort of, how she intends to try and finance it without raising taxes on the middle class. She does raise taxes on them, of course, but not exactly directly.Report
That’s because Warren realizes the downside cost of disappointing wonky upper middle class liberals like you and some conservatives who would’ve attacked her for hiking middle class taxes anyway, is worth not having $1 zillion dollars in ads with her saying middle class taxes will go up to pay for Those People’s Healthcare.
I mean, my plan would just pass it, fund it via the deficit, and once everybody likes their new and shiny health care, in about two to three years, say, “OK, we need to raise taxes to fund it.”Report
I support single payer. But I support winning the damn election a hell of a lot more. My fear is Warren will lose the election and this kind of shit is why I fear she’ll lose it. Her pure acceptable to arch liberals plan won’t be worth a damn if she gets the nomination, loses the election to Trump of all people over this and is sitting her ass in the Senate.Report
I’m with Jesse on this one. I think this is the best way to win the direction.
If we had any sort of media infrastructure capable of pointing out just how big the magic asterisks on her plan are, it would backfire, but we really don’t have that. Thanks, Paul Ryan, for destroying the last vestiges of bipartisan institutions that could actually credibly talk about the realities of the budget!
I think Warren’s approach here is pretty cynical, but the alternative is naivete that will work even worse.Report
I suppose that cynical take is plausible. It sure seems higher risk to me than simply adding a public option to the ACA and widening it as the public comes to appreciate it.Report
The Senate isn’t going to do that either, and it’s not really clear that the ACA is more popular than M4A when people think they won’t have to pay for M4A.Report
The ACA is here, now in hand, legislated and created. Adding to or expanding it is naturally a lot easier a lift to both campaign on and to legislate on than M4A. Especially since Warrens M4A also baldly states she’s taking away everyone’s option for private healthcare. Even if her current plan can let her defang the taxes on the middle class argument; she still has to deal with that.
I will reiterate, I have no personal animus against Warren and if she gets the nod I’ll support her to the hilt. I just really would like to win 2020 and my personal estimation as to who would have best odds to win have her at the #4 place behind Klobuchar, Buttigieg and Biden (in that order).Report
Yeah I get that.
Like I said, I think none of this is going to pass.
While I’m pulling for Warren that’s not the reason I’m mostly defending her healthcare approach; her approach on trade, for instance, is very bad not only in terms of policy but politics. And unlike HCR of any stripe, that she could actually make happen just with the powers of the office she’s running for.Report
Ok, I get that, but if you grant that it’s unlikely to pass and you grant it’s an electoral liability in the present then why defend it? Where’s the upside?
Or is this a line of “ask for the whole loaf so you end up with half a loaf” kind of strategy?Report
Was that study awhile back about how americas poorist are richer than most average Europeans been refuted?Report
Huh. That doesn’t even pass the smell test. How mangled must the stats have been to get that.Report
maybe, it’s been awhile since I heard that notion, it very well could be false, here is a link I found on google:
https://acton.org/publications/transatlantic/2019/08/27/americas-poorest-are-richer-most-average-europeans-study
If yall have found errors/bias in it or a full throated refute, I’d be curious to know about it, as I am not currently holding it as whole cloth.
Jesses mention of ‘European’ made me recall it.Report
Interesting reading I just spent about 5 minutes tearing through the related docs.
Quick notes:
I am always a bit sceptical of making apples to apples comparisons between research between two totally different groups. However, that does not make it facially invalid.
When starting to cross check the data: the world bank (WB) shows per capita consumption expenditure in USA in 2010 at $32,632k. Bureau of Econ. Analysis (BEA) seems to say $31,953. So 2% -ish different, good sign.
I can’t immediately see how they get to per capita income by quintile. The quintile consumption numbers all seem to be based on household not individual. Maybe we can assume that household size is pretty much the same across income groups. I have my doubts though.
This is interesting. I may try and kick this around saturday to see if I can figure out more.
OOPS, just found their spreadsheet. They do assume a uniform distribution of persons per household (2.6). I would have to go find some data to confirm, but the impression I get is that the poorest folks in the US tend to live more persons to a household than more affluent folks. If that is case, this would mean that the per capita number would be overstated by some amount. How much? … More research.Report
Yeah, and there are things like debt loads, and unaccounted capital formations can change how things look on the ground.Report
How debt is treated is a good question I did not see addressed. It is probably in there. Debt is a huge deal for the poor.
Over such a large population, I would think unaccounted /realized capital formation to average out. That is to say some stuff is not counted, but stuff is counted that was uncounted in prior periods and it probably averages out. But that is straight up intuition.
I mulled the whole household size during my drive. It seems that it is likely important to the question at hand. Deintegrating data is often dicey. Persons per household is notoriously low in the US compared to just about everywhere else. That would make EU look richer than the US at an intuitive level. For purposes of comparison we really want per capita numbers because that is probably the best single number for who is poor vs who is not. I am suspect that breaking it out to per capita from household once it has already been broken out by quintile.
This is a bit extreme, but illustrates the issue. The mean household income for 1st quintile is 57,049 and the 2nd quintile is 66004. So a single person living alone and making 60,000 would be in the first quintile, but only in a few downtown corridors would be poor. To flip it, say there is a multi-generational family of 12 living in a single household and 8 of them work 58hrs each across two part time jobs. Generating $160k total in household income. That puts them in the 5th(top) quintile but at 15,000 per capita, most would consider them pretty dang poor. Interstingly, while I can see how this study would be attractive to right leaning folks they often complain about essentially the same thing in means testing. Specifically, that many means tested programs use household income and thereby breaking up families by moving the wage earner (father) out of the house to qualify for benefits.
Joe, you don’t happen to know any US focused demographers? One could probably tell if the deintegraion issues here are non-issues, fatal, or where in-between.Report
No, don’t know any US demographers, my focus is typically locally focused.Report
Well i’ve skimmed the article a bit and aside from any accuracy issues it’s a really obvious polemic. The Acton think tank has a strong bias from looking at how they describe themselves. So this is not some neutral or peer reviewed research. Those things doesn’t mean it’s wrong of course, but lets not pretend they aren’t trying to defend their loudly announced beliefs which their mission is to spread. The author has a BS in Mech Engineering which doesn’t impress me at all for this kind of research.
Comparing the US to “Europe” is an odd comparison. Europe is sort of big with a mix of rich countries and very not so rich places. Consumption seems like an odd metric. He doesn’t explain why that is good. The avg American might consume 20k in health care while the avg German only consumes 10k yet they get the same level of services. A dutch person may get regular care for free that a poor person pays a lot for one way or the other. Obviously, or it should be, many of the poorest americans don’t’ have health insurance or only get it from the ER in emergencies which makes comparisons of consumption wonky at best.
All this is from a quick friday night skim with a movie on in the background. And really a Mech Engineer?Report
Some quick notes. What is here is not that deep a thing. It is an integration and comparison across two similar studies. Structurally, it looks workable for someone with a BS in any engineering discipline.
The charts include per country break outs, so Europe is not treated as a monolith in this case.
Both BEA and WB have corrections to deal with relative cost differentials for similar goods.I do trust both orgs to try and do their best to achieve this if they say they did. I have not looked closely at them and if they are comparable to each other.
What is your view on the poor and ER care? Do they end up getting it for free and not included in the calculation? They pay more and it inflates the income of the poor more than it should? Just trying to figure out the point.
As to being wonky at best. I don’t know how you can attempt to assess income including govt. transfers and compare it across the world and NOT be wonky about it.Report
Poor people who get ER care instead of GP care are getting poorer care since they have to wait until it’s a crisis instead before it’s an immediate problem. If poor people can’t pay then the hospital sucks it up, which i’m guessing wouldn’t’ show as consumption or is paid by the gov. That doesnt’ seem like personal consumption.
Our health care costs are inflated compared to other countries. 1000 dollars of health care in the US might only cost 200 weird euro dollars but give the equivalent care. That would look like the lucky US person consumed 5x the amount of HC. I’m really not sure how well that be compensated for and considering poor people often get worse HC since they over use the ER.
I agree this is wonky at best. Since this guy is a an engenier working for a think tank with a very clearly stated bias and mission it’s hard to believe it’s that’s good. If he had expertise in this kind of thing that would help.Report
Certainly more taxes, but possibly (probably) less costs. Which do you care about more? How much of your money have have left to spend? The distribution of tax vs. paid directly to various entities?
It is an assumption, but if per capita costs are brought in line with European welfare state costs then on net we are spending a lot less on healthcare. If you accept the framing that all costs eventually land on the individual, then a large net decrease in costs should eventually show up in individuals pockets.
The framing that M4A is a giant tax increase that must therefore decrease the amount of money that individuals have is incorrect.Report
https://mobile.twitter.com/ryanstruyk/status/1190247398402142208Report
@Oscar Gordon:
Sorta cuts both ways doesn’t it?
In any event my desultory googling turned up a helluva lot more “don’t think” and a helluva lot less “here is some historical data coupled with relevant data” so.
This Tax Policy Center paper {PDF) seems typical.
I didn’t read super-closely but this passage from the conclusion stuck out.
As we see with the Tariffs, a lot of companies are quietly eating as much of the additional cost as they can, but if you listen to interviews, they all say the same thing: We are trying not to raise prices/cut jobs or wages in the hope that this madness will stop before we have no choice. Because there is a hope that the tariffs will go away.
But a new corporate tax? No reason to hold out, you start adjusting ASAP.
Unless you can show that capital is eating the cost of taxes, I will assume the cost is passed to labor and/or customers, because that is what capital does whenever their costs go up for the long term. If the cost of raw materials goes up, that cost is passed on. If the cost of labor goes up, the cost is passed on in some fashion (if prices can not rise, quality/quantity/speed will go down – it’s the three legged stool).
Maybe there is a way to structure a corporate tax that doesn’t simply result in a pass thru cost, but as long as ‘shareholder value’ dominates business incentives, the people who extract the most wealth from the corporation will find ways to not have that tax land on them.
It’s far simpler to just tax those people. But let’s be honest here, taxing those people doesn’t actually result in a lot of revenue, because despite how much wealth they control, there just aren’t that many of them. But the customers and employees – they are legion. And corporate taxes just extracts a little more, barely noticeable, revenue from the legion.
I’m not objecting, per se, to the raising of taxes. It might be necessary and justified. But let’s stop pretending that raising taxes a corporation is not raising taxes on the middle class.Report
I think smart people already understand most of that.
To reach people who don’t, I’d suggest you explain it in terms of weed.
“Warren says she’ll raise all the health revenue by massively taxing all the marijuana growers and retailers. But don’t worry, you won’t have to pay any more at the dispensary because they’re the ones who have to pay the extra tax, not you!”
Three days later when you run into them again, they’ll sound like Milton Friedman when they explain why Warren’s plan can’t possibly work, including secondary and tertiary effects.Report
One key difference, which makes it harder to draw conclusions, is that these kinds of corporate income taxes are not increasing the costs of outputs (like the gas tax) or inputs (like a payroll tax) or both (like tariffs), or else your conclusion would follow pretty immediately, and for tariffs, and to a lesser extent the others, increasing prices of the goods in question is the point.
Doesn’t mean it won’t happen that way. Just that I don’t think we know it will happen that way.Report
Also I’m not saying this because I’m convinced that Warren’s plan outlines a realistic approach to funding M4A, ’cause I don’t.
I’m saying this because I’m genuinely skeptical of the specific argument being made about corporate taxes.Report
Given the incentives at play, and human nature, I can not see corporate taxes as anything but a pass through. A given company may be willing to absorb the costs in some fashion that does not lead directly to increased prices or reduced wages, but I assume that what won’t happen is that the leadership will reduce their take. Perhaps it comes out of dividend payouts, which as George notes, impacts pension plans and 401Ks. Perhaps it comes out (per Brandon) as reduced investment in the US.
But in some way or another, the cost is borne by the public at large.
Corporate taxes (as they are typically structured) are just a way for (mostly) liberal voters and politicians to pretend that they are not taxing the bottom 4 quintiles. I imagine they could be structured such that they don’t necessarily tax the middle class, etc., but we don’t do that because the whole point is that they are revenue generating, and not intended to modify corporate behavior.
IMHO, revenue needs to be generated from people specifically (income and sales tax). Taxes on legal entities, or fines and fees, should only exist to compensate government costs or to modify incentives.
So be honest. We want M4A, we will need to raise taxes. We will change the laws such that employment taxes are not based upon wages, but upon the value of corporate HC plans. Now companies have an incentive to not only dump their plans, but to also raise wages.Report
If your publicly traded corporations all get hit with some massive income tax applied to profits, then they have a couple options.
For some companies, there is the option to structure things so they don’t show any profits, which is common in Hollywood. Everybody is still getting rich but there’s no “profit” to tax. In this case her scheme fails because it doesn’t raise any revenue.
Another thing to note is that companies that don’t pay stockholders, and likely never will because of Warren’s taxes, will likely see their stock price collapse, making it easy for them to get snapped up by foreign firms, and the money ends up overseas.
Other companies would normally retain a good stock price because of their capital assets which can be sold off, but the trouble is that if the company couldn’t make money off that equipment because of Warren’s taxes, why would anybody buy them because nobody is going to be able to make money off the capital assets and equipment. It would be like bursting a real estate bubble, but with US companies, where the total value of everything plummets. That would have a massive ripple effect and everybody would take huge write offs. In that case, her taxes wouldn’t raise any revenue even though they’ve left everyone broke.
The direct pass through to customers is probably the least damaging option for both the companies and the economy.Report
http://www.lawyersgunsmoneyblog.com/2019/11/american-exceptionalism-and-health-careReport
Yes, but astounding profits of the medical and pharmaceutical industries allows us to be more innovative.
Why, America invented the boner pill and leads the way in vaginal reconstructive surgery.
Take that, Europe!Report
In a completely unforeseen development, Beto O’Rourke’s decision to take a massive dump on the First Amendment was not enough to stave off an ignominious end to his Presidential campaign.Report
We hardly knew him.Report
What a colossal waste.Report
I have to say that no Presidential primary campaign has degraded my opinion of the person running it as much as Beto’s did.Report
Ditto, if he had just had the brains to try for the other Senate seat in Texas. *sighs*Report
Probably for the best, his village needs a lot of idiot stuff done.Report
https://fee.org/articles/our-unhealthy-addiction-to-health-insurance/Report
The structure of my healthcare spends is very much in this vein. It has been for about 10 years, since I switched to HDHP+HSA. Occasionally now, they are NOT surprised at the question “What is the cash price vs. negotiated rate with my insurance?” Usually they don’t have an answer, but at least I am no longer the only one asking. Good to see some folks are pushing for more awareness of how it all works and maybe even bifurcating the payment systems. I have my doubts about separating them being a workable solution though.Report
I’ve very briefly skimmed the linked to outline, so I’ve probably missed a lot. But here are three thoughts.
1. “And we make up the difference with targeted spending cuts, new taxes on giant corporations and the richest 1% of Americans, and by cracking down on tax evasion and fraud. Not one penny in middle-class tax increases.”
Any reasonable and workable plan is going to have to tax the “middle class.” I don’t mean only a plan that’s capable of being passed. I mean a plan that would actually pay for what it claims to pay for and have the benefits Warren claims it will have. This fiction that there’s a small number of very elite, bankers and corporate raiders hoarding all the wealth, and all we have to do is take the money away from them, is in my opinion a fairy tale. This is a reprise of Warren’s strategy: identify simple villains and try to rally people against them.
2. I’ve said this before, but “Medicare for all” has a branding problem, whatever the merits of a single payer system. A goodly number of voters probably think that “Medicare” is “Medicaid,” or that thing that pays for (other) people’s health care and that does a poor job of compensating doctors for expenses. Also, for others, “Medicare” is that tax taken from their paychecks. For still others, “Medicare” is that government bureaucracy that make taking grandma to the doctor a paperwork headache (never mind that it also reduces the sticker price she pays). I want to emphasize the branding problem is one of impressions, not necessarily reality. Warren needs a different name for her plan.
3. If Warren is elected and tries to get this plan passed, I’ll probably support it. I have reservations about single payer systems, but her plan would probably be better than ACA, and the type of plan that might actually get passed would have an even better chance of improving on the ACA system. (And I had/have serious reservations about ACA, but I believe that on balance it’d be better than pre-ACA, and I really, really like the idea, if maybe not how it works in practice, of local area pricing, no lifetime limits, and no pre-existing condition restrictions).Report
My days of not taking Warren seriously as a wonk are coming to a middle. I might put up a post at some point. But this boils down to a series of amazing assumption:
1) That we can somehow save $7 trillion over the urban institute’s analysis because reasons.
2) That a $9 trillion tax on employers is not a tax.
3) That we can decriminalize illegal immigration and bring in a trillion in revenue (but no additional expense?)
4) That increasing IRS enforcement will bring in 10-40 times what anyone else estimates.
5) That we can triple her proposed wealth and tax triple the revenue (which most people think is massively overestimated)
6) That we can save money with a publicly run drug company (because drug companies that are immune to lawsuits are great)
7) That we can tax unrealized capital gains.
In a way, I’m grateful to Warren. We said for a long time that there was no way to finance M4A without massive taxes on the middle class. And now she just went and proved it.Report
It isn’t the way to get this train to the station. And that sucks because it needs to get there. I don’t understand whats wrong with pushing to universal coverage through the ACA exchange.
Three reforms come to mind to push this forward that I think would be way cheaper and politically feasible.
Use the commerce clause power to pre-empt state admission requirements. From now on we only have one national market at healthcare.gov instead of a bunch of arbitrarily constructed state markets.
Require part C and Part D plans to take people under 65 and be on the federal exchange (i.e. soft public option).
Give tax incentives to private business to phase out basic plans (keep the supplementals, disability, etc.) and to individuals to move to the exchanges (maybe even subsidize the move).
I think this would stop state death spirals, advance coverage, and start slowly disconnecting health insurance from employment, which is the most painful part but the thing that has to happen. Maybe in 40 years we can look like Germany or Austria. Private delivery and lots of consumer choice. Anglophone approaches like this are DOA here and shouldn’t be bothered with.Report
I’m too ignorant of the specifics to comment knowledgeably, but yours seems like the type of thing I’d support much more enthusiastically than Warren’s proposal.Report
I’ll start getting my paperwork ready for 2024.
In all seriousness though I’ve been doing corporate law in the healthcare industry for 10 years. The public and private sectors are so intertwined it isn’t really possible to do something this crude. What needs to happen is slow, careful evolution into health insurance as a public utility, which is really how we should start thinking of it. No ideology, no big shareholder profits, but a necessary part of the infrastructure required to run a modern economy. And hey if they (or their subsidiaries) still want to produce excess coverage products and sell them that’s cool too.
And it’s going to look different than other parts of the Western world which is fine, because we’re different. We should be thinking less like Labor and more like Bismarck.Report
Agreed.Report
Republican Presidents (and to a lesser extent Congresses) who have already demonstrated a lot of interest in sabotaging the exchanges, and a federal government that is structured in such a way that makes it incredibly easy for the President to do that unilaterally. Also, while the state entry requirements are pretty dumb, in practice the same thing will happen where regulatory nonfeasance on the part of Republican Presidents will mean that all plans rush to the bottom and everything turns into worthless but expensive insurance.
Using Medicare as a soft public option would somewhat mitigate that, but only somewhat.
The more kinds of payers there are, the more ways there are to sabotage the project by sinking some of them in ways that only screw over subsets of voters and thus not reap the electoral whirlwind. And that becomes much easier with the ways that a malicious executive could meddle with a multipayer system with the necessary degree of regulation to make it work.[1]
If we had a somewhat sane center-right party that had vaguely normal goals then yeah your plan would make a lot of sense, and probably deliver better outcomes than the approach taken by Warren or Sanders. It’s very close to the plan I would design if I trusted the enforcement bureaucracy to be merely as bad as an ordinary bureaucracy. But the GOP has made it clear that blocking any sort of UHC is one of its signature policies, and it will use any available tool at its disposal to do it.
M4A puts everybody in the same boat. This has a lot of disadvantages but one signature and necessary advantage: the political consequences of sinking it will be too much even for the US Right to contemplate.
[1] An NHS-style system would be even worse of course.Report
I actually don’t see how what Warren is proposing would be any harder to sabotage. Arguably it’d be easier. Just name the worst possible actor as Secretary of HHS. And that’s based on the assumption that this kind of surgery wouldn’t kill the patient in the process.Report
It wouldn’t be harder to sabotage practically.
It would be much, much harder to sabotage politically because it would be much harder to ensure that the effects of the sabotage don’t land on people who vote for you, not just people who vote for the other guy.Report
If you happened to idly wonder “what will happen to all of those people who work in insurance?”, Warren has a plan for that:
Report
Don’t worry about them. Anthem, United, Aetna, the professor and Mary Ann are all going to be along for the ride.Report
Interestingly, someone very close to me is upper-middle-management at a big insurance company, and they support Warren. Or, they have in the past and I strongly suspect they still do. They have no love for their industry or their field and think it can do well enough and think a more equitable system that destroys their industry might be better for all.
However…..that person is nearing retirement age and probably can benefit from their long years of service regardless of what happens to their current employer.
And…..Warren’s “no one gets left behind” is probably a combination of sincere and disingenuous. It’s sincere because she probably on some level really wants to believe (or wants her prospective constituents to believe) that she cares about lower-level and middle-management health care professionals. And she probably really believes a new single payer system can benefit from the services of a lot of them, maybe even most of them.
It’s disingenuous because of her simplistic, quasi-conspiracy style of talking about these things. The insurance companies are to blame because greed. It’s people very high up who are raking in the profits. It’s not about the people who are working hard and making a “middle-class wage” (read sometimes as “too low a wage to make ends meet” and sometimes as “good, living wage jobs”). It’s disingenuous because many eggs will need to be broken to make this omelet, or even InMD’s omelet, which to me seems much more doable.
Of course, politicians have to say disingenuous things to get elected. And I’ll vote for her if she gets the nomination.
ETA: I’ve anonymized some of the pronouns.Report
This is a major part of the problem.
I support M4A but am very skeptical of the funding proposal that Warren has put forward.
But it is looks much less painful for most voters than a more realistic approach would. And no one really has broad credibility that would allow them to effectively push back in ways that are going to connect with Democratic voters, in part because so many of the people who have the expertise and platforms to push back also have a long record of letting fiscal considerations slide when it’s a matter of tax cuts or defense spending.
And the kind of folks we have here on Ordinary Times, who might be swing voters, but are highly informed and policy focused?
There just aren’t enough of them to matter in an election. The modal swing voter is not highly informed and policy focused, and while they may well be susceptible to scare mongering, it’s far from obvious that the advertisement and media environment wouldn’t make InMD’s much more moderate plan look any less intimidating than Warren’s.
Anyway, Warren’s plan won’t pass. But InMD’s wouldn’t either.
But for all that it’s way, way too expensive I stick to my contention that something along the lines of Warren’s plan is a much better bet to solve the actual problems we have with US healthcare. (And there are ways to water it down that would make it less of a budget buster and reduce some of the other problems that would not, I think, compromise outcomes noticeably, and might even improve them.)Report
If the ultimate plan is shoot for the stars and land on the moon as a compromise then so be it. But I don’t think tweaking ACA is as unpassable as this proposal. It would mean winning the Senate, no easy feat, but then youd need to of course have a plan those Senators in precarious seats could support.
Your last paragraph is what really scares me though. Providers are themselves in extremely precarious places outside of big metro areas, which tend to he dominated by a few big health systems. It’s not crazy to think that this could run huge numbers of hospitals and practices out of business in a matter of months. Think about the political consequences of that.Report
The ACA needed an actual filibuster-breaking majority to get through at all, and in order to do that they had to strip out a public option considerably softer than the one you suggested.
Winning the Senate isn’t enough; you would need to win the Senate so that you either have 60 votes who are left of the ones that we had briefly in 2009-2010, or you need a smaller number who are willing to drop the filibuster.
Than means probably 53 or 54, given where Manchin, Sinema, et al. are going to land, and not only is this a long shot, how likely is it all the new seats (which are definitionally swingy) are going to be held by folks who are any more eager to use the nuclear option than Sinema?
As for running all the rural providers out of business in the short term? It’s not crazy to think a single payer plan could do that if it weren’t designed not to do that, but it is crazy to think a plan that actually got through Congress at all would do that. Avoiding it is a pretty hard political design constraint.
But yeah, since I think neither is going to pass, the question boils down to which plan is better politics. The actual plan will be designed in a very different political environment, if we ever get there, no matter who is elected.Report
In the conversation between you and InMD there are a lot of shared assumptions and goals that are sharply at variance with our current political moment.
You both agree that some form of universal health care is an important goal, one that is worth working and sacrificing for.
About a quarter of American voters, about 80% of elected Republican officials, strongly disagree with that assumption.
They have the opinion that health care should be a consumer good, available only to those who can pay.
In their minds, this is not an idle issue; It is a critical part of their hierarchical view of the world, a world where poverty is a just punishment for sloth and sinful living.
And anything that threatens that worldview, such as any proposal for universal coverage is an existential threat which they will fight to the last breath and use any tools at their disposal.
This is the political terrain we inhabit.Report
I don’t really think that’s the GOP politicians’ and GOP voters’ view–that ” health care should be a consumer good, available only to those who can pay” and that they hold a “hierarchical view of the world, a world where poverty is a just punishment for sloth and sinful living.” Maybe some view it that way, but I believe most don’t. I think it’s a mistake to mischaracterize others’ views. And I believe that’s what you’re doing.
I do agree, however, that their actions (especially the politicians’ actions) are very consistent with that view.
Now, you might point out that action represent what the actors truly believe, regardless of what they say to others they believe and regardless, even, what they deep inside tell themselves they believe. Or, you might say that what they “believe” is besides the point, given their actions.
I would agree with that last sentence, if that’s your view.Report
Somewhere around 20-25% of people, when polled, identify as “strong supporters” of President Trump; that’s roughly consistent with the fraction of Republicans who supported him in the primary.[1]
I think that’s a decent proxy for the fraction of Americans who hold the kind of authoritarian views Chip describes, though I think they also tend to view things as punishing the out-group [1] more than they have Socially Darwinist views about poverty equating to sloth.
I don’t think it’s all that remarkable that so many people have this kind of view. Historically it’s been pretty common in the US, and it’s not exactly unknown in the rest of the world.
What differs now is that so many of those people have wound up in control of a major party in a political system that accords major parties astonishing power and durability.
[1] Rough proxy; there’s likely some fraction of Trump faithful who genuinely reject that view, revealed preference aside, and some fraction of Trump non-faithful who support it but have other commitments that drive them elsewhere politically.
[2] Be it libs, members of other races or religions, foreigners, or some mix of the bunch.Report
Pillsy, Sorry it’s taken so long for me to respond. I’ve been away since you wrote your comment.
I didn’t take Chip, in that comment, to be talking about the presumed authoritarian leanings of Trump’s hard core supporters. I took him to be explaining their views, and the views of Republicans more widely, on universal health care and on approaches to fixing health care provision–and further, on the way they look at poverty.
I’m not convinced that even the hard core Trump supporters really believe that health care should be available only to those who can pay. They might believe that ACA and M4A are the wrong ways to go about it, and some might even believe that a freer market would help. I disagree, but I think, or at least hope, that they have some vision of the good and it’s not just social darwinianism….when it comes to health care.
For the other point, about poverty, I’m on less firm ground. Maybe that presumed 25-30% really do have those views about poverty.
Of course, for me, this is mostly speculation on my part. Even my small number of anecdata doesn’t necessarily back up what I’m saying.Report
The problem is that health care *IS* a consumer good.
And saying that it isn’t one is a good way to make sure it’s less available in the future rather than that it is one.Report
The problem is that health care *IS* a consumer good.
I suspect that Chip means it’s not a consumer good in the usual “competitive market” way people think about purchasing consumer goods. We all know the standard factors that economists include when they say competitive: everyone is a price taker, everyone has perfect information, markets clear, etc. Most health care markets violate at least some of those.
A couple of years ago I overheard a doctor telling a patient, “The practice only uses this particular lab for this blood test. I don’t know how much it will cost you, since I don’t know if it’s in-network or not for your insurance, or where you stand on deductibles and out-of-pocket.” One of the things I like about Kaiser, where we are getting our care these days, is that when the doctor checks off the test on the computer screen, the software tells him how much it will cost me.Report
Oh, the market is messed up, that’s for sure. But I’m pretty sure that he thinks it’s not a consumer good (but it can be delivered as one).Report
Everything can be delivered as a consumer good, if we wished it to be so.
But consumers don’t consume all goods in the same way, and the markets reflect that.
For example, health care is a very different good than say, toasters. Unlike a toaster, no one wants health care. People only consume it when they have no other choice, they don’t do brand differentiation or comparison shop or any of the other behaviors that economists point to.
So while we can call health care a consumer good and try to deliver it like toasters, it will never actually be the same as a toaster.Report
I’ll repeat what I said here:
These things are consumer goods. Pretending that they’re not is a good way to run out of them and not understand why.
We’ve already got examples of doctors saying “yeah, if they do M4A, I’m shuttering my clinic”. And why are they saying that? Because health care does not cease to be a consumer good when we say “we’re not going to deliver it as a consumer good anymore!”Report
We have no problem delivering water or electricity or fire services in a non-market fashion, yet we don’t seem to run out of those things.
We have no problem delivering health care to servicemen or veterans or senior citizens or indigent patients on a non-market fashion, yet are we running out of doctors?
Just because a resource is limited doesn’t mean the marketplace is the only method of delivering it.
And to touch on my original statement, our moral stance health care is or should be very different than toasters.
Most of the great moral and ethical traditions hold that consumer goods should rightly be rationed according to price. But they almost all agree that rationing medical care by price is unconscionable.Report
We have no problem delivering health care to servicemen or veterans or senior citizens or indigent patients on a non-market fashion, yet are we running out of doctors?
Ah, I think I see the disconnect.
You think that we have no problem delivering health care to servicemen or veterans or senior citizens or indigent patients.
You also seem to think that sufficient moral stances can change things.
Pray in one hand, poop in the other. Lemme know which hand fills up first.Report
That’s a non sequitur.
We “have problems” delivering toasters to everyone who has the cash, but to assert this is a reason to change our delivery system is absurd.
And moral stances don’t change economics, they just make them irrelevant.
No one, for example, thinks that providing police or fire protection to remote houses is covered adequately by the tax revenue they generate, but if I were to suggest we eliminate that, everyone would think I was crazy.
Our moral stance that everyone is entitled to protection under the law causes us to disregard the economics, and if we have to pay extra so some remote house is covered, we gladly accept that.
Why should health care coverage be any different?Report
I could’ve sworn you live in California, which is running out of those things.Report
That’s a non sequitur.
If your argument rests upon “we don’t have problems doing X” and there are stories that come out, every day, that talk about the problems doing X, it’s not a son sequitur.
It’s a refutation.
And moral stances don’t change economics, they just make them irrelevant.
No. They don’t.
No one, for example, thinks that providing police or fire protection to remote houses is covered adequately by the tax revenue they generate, but if I were to suggest we eliminate that, everyone would think I was crazy.
No. They wouldn’t.
Our moral stance that everyone is entitled to protection under the law causes us to disregard the economics, and if we have to pay extra so some remote house is covered, we gladly accept that.
No. It isn’t.
Why should health care coverage be any different?
I’m arguing that it isn’t.Report
Hey if you want to make an argument proposing that emergency services be delivered via a market, please proceed, governor.
But when Gabriel says that conservatives don’t really believe those things, I’ll point him back here.
Because, yeah, they really do.Report
It’s more that if we can’t afford to provide police protection to remote houses, we don’t. There’s after-the-fact law enforcement… but that ain’t the same thing.
I mean, this is the way it actually is.Report
Why isn’t it the same thing?
After the fact police protection isn’t covered by the recipient’s taxes anymore than chemotherapy for an indigent patient.
So why do we gladly provide one and not the other?Report
I’m not sure that “gladly” is the best term. It’s more like “no, you can’t kill people”. And law enforcement in remote rural areas really does work differently than in cities. Like, significantly.
And now that rural hospitals are closing, so does rural health care.
I am honestly surprised that I am coming across as controversial with this. I am merely describing the world as it actually works.Report
It is “controversial” because if police protection is different for different people depending on budget and personal resources, then HC is too.
Which instantly takes us to death pannels and other resource limiting methods run by the government, which NEED to be in place if we want UHC.
Because at the end of the day, the demented 90 year old bed ridden guy with cancer shouldn’t be spending millions of dollars of public to stay alive. And the moment we accept that, we’re DEEP into “how do we do limit his care” and not “everyone gets everything”.Report
At the end of the day it is more comforting to the good people, to think the good people are making the good decisions.
If those decisions take longer or are more costly, it’s just the omelet process that people die waiting for a quality death, instead of getting more marginal care sooner.
I mean we have seen decades worth of socialized HC and there is no mystery of how the good folks blind themselves to the failings of these systems in order to keep the veneer that maximizes their mental comfort.
What the hell happens when the bad people come up with a better mousetrap?
I mean it has to be a bad mousetrap eh?
To think otherwise might be uncomfortable.
If your faction is entrenched will to power good people, all moustraps that aren’t yours have to be bad.Report
Why do we provide services without charge for things like police and fire and EMT but not health care?
Whether it is rural homes or urban homes, service is provided on demand regardless of ability to pay.
Why should health care be different?Report
Because the demands for law enforcement and HC are at opposite extreme ends of the spectrum.
I’ve summoned the police to my place twice over my entire lifetime. I’ve had serious interactions with them outside my house 2 or 3 additional times (or zero depending on your definition of “serious”).
Money is BY FAR the best way we’ve found to distribute scare resources in a multi-variable, multi-person problem of this nature.Report
So should police, fire, and EMT services be provided on an “ability to pay” basis?Report
In a community sense they are.
In many communities, presumably including yours and mine, it’s possible to have so many police that all needs are met. This is paid for by my/your taxes and we’re willing to pay for the police even in years when our need for them is zero.
In places like Baltimore, it’s not possible to have enough police to meet every need so they don’t. In that context my expectation is that the needs of tax payers and/or the rich come first or the city loses it’s tax base.
Moving this back to HC, if we’re not going to ration on the basis of money, how will we ration?Report
Yes, in times of extreme strain, all emergency services are rationed in a triage method.
So if health care were rationed the way emergency services are, would that be a problem?
In other words, we do the best we can, but triage during times of extreme strain?Report
There is a charge for those services, Chip. The fact that the charge is invisible to you does not mean that it does not exist. Police, Firepersons, and EMTs all get paid.
And you know what happens when they don’t get paid *ENOUGH*?
Well, Doc Saunders tweeted about what would happen to his clinic under M4A.Report
There will be a charge for M4A as well.
So I’ll ask a third time, why should police fire and EMT services be rationed by government fiat, while health services be rationed by price?Report
My answer involves stuff like “doctors have said that they’d have to close if M4A went into effect”. I even linked to someone who said that. A doctor, even.
That’s why.Report
Because Price allows for efficient decisions. When applied to HC that means…
1) If there aren’t enough lasic surgeons around then more are created.
2) Cures for things like Cystic fibrosis are created.
Current cost for CF’s cure is something like $100k a year. In 50 years it will be a few pennies a day. Eliminate profit and things like that are simply not created.
And I’ll point out that you STILL have no answer for how the gov will ration things with UHC. You seem to be trying to imply that there will be no rationing.Report
As I mention above, suppose we ration health care the same way we do with other emergency services?
Basic service is paid for by general taxes;
If you want more, you buy additional service on the marketplace.
Kinda the way Medicare works right now. I guess that’s why they are calling it, “Medicare For All”.
We do this with police, we do it with fire we do it with EMT service. And for the most part, the public accepts it without too much complaint.
Why would this be a problem?Report
Why would this be a problem?
Because we have reason to believe that doctors would shutter their clinics if we did it with M4A.Report
I’ve heard you say this several times, and my follow up question (to you and Dr. Saunders) is
“Shutter the clinics and do what? Learn to code?”
I am asking this in all earnest. Are doctors so rich that they will just retire and live from their wealth (better use it before Elizabeth Warren takes it away).
In real life, doctors, and the doctors market, will accommodate the change.
Others have already pointed out that clinic’s costs will go down because the insurance billing and insurance compliance functions will be reduced to a small fraction of what they are, so both revenues and costs will fall (who will fall the most is unclear right now).
Doctors might make less money than now, but most professionals, and almost all non college educated people make less than doctors do, and still can raise their families. To the extent that the new structure makes it impossible for doctors to service their own student loans, which are massive, and out of proportion with most other professions, I would expect President Warren will have a plan for that.
To the extent doctors really retire and move to the Bahamas rather than work under M4A, there are thousands of very well qualified doctors and nurses across the world, unsaddled by the American doctors student debt, which will be happy to move to the USA and work in rural Kansas or Baltimore inner city for M4A in exchange for a green card.
The only thing I really don’t believe in, is doctors picking up their toys and moving en masse to Galt’s Gulch.Report
You might get to that omelet eventually but its a hell of a way to break the eggs. It’s kind of naive to pretend pay isn’t a real part of this discussion. Relying on an ability to restructure another large part of the economy as an answer is magical thinking.
No, every doctor is not going to go off to Galt’s Gulch but you could have a sudden drop in supply with real impact on real people. Hand waving about immigrants is also at best a short term answer. The thing about immigrants is soon enough they become Americans with lifestyle expectations and kids to send to college just like everyone else. The experience NHS in the UK has had with this (not to mention strikes) is instructive. Providers are mostly good people with good motives but most aren’t clergy under a vow of poverty and theyhave bills to pay too.Report
I could be wrong, but TTBOMK, a doctor from a foreign country can’t just pop over and start practicing. So unless Warren is also going to take on the AMA and force every state to relax their licensing requirements…Report
They aren’t, and more challenging is that licensing and scope of practice is done at the state level, not federal.Report
Getting licensed in the US isn’t horribly difficult for foreign doctors, since so many of the ones I’ve seen have been foreign. Appalachia is full of doctors from India, the Middle East, and elsewhere, as it’s a bit harder to lure native US doctors to the region. This perhaps contributed to the area’s early problem with pill mills.
I haven’t looked into it, but a foreign doctor isn’t going to have a staggering amount of student loans to pay off, and thus be in a much better financial position than a US doctor in regards to profitably working in a rural hospital. There’s probably also some program that sticks them in a rural hospital in return for helping them get trained or certified, similar to the plot of “Northern Exposure” where Dr. Joel Fleischman ended up in Cicely Alaska.Report
Like one thing we should all be able to agree on, left, right, and center, is that the way we do professional licensing in this country sucks skunk farts.Report
That’s a fact.Report
QFTReport
You are right, the AMA’s supply restrictions are a non trivial part of the health care cost problem, by rationing the licensing of practitioners. But, like with engineers (example: me), there’s nothing inherently wrong on how doctors are trained in many parts of the world, from Canada, to Mexico, to Japan, to China, to Israel, to Western Europe.
So I don’t find anything inherently wrong with allowing foreign doctors to go through a licensing process even if they trained in a foreign university.Report
I’ve said it several times because it strikes me as a showstopper.
So the response to the good Doc saying this is “you’re bluffing”?
I guess we’re gonna find out, ain’t we?
Maybe we can use social shaming to keep them at work!Report
I’m not saying the good doctor (whose posts I miss terribly) is bluffing.
I’m saying he’s probably venting in frustration because he can’t have done the math, because no practitioner can do the math yet.
The good doctor can calculate how much the practice’s revenue will go down, because he knows how many patients he treats, and how much M4A will pay.
But he doesn’t know how much his operating costs will go down by reducing the costs of managing billing to insurance companies. These costs are far from trivial. He doesn’t know what will be the billing costs for his practice under M4A
So the good doctor can’t know yet if his practice will, at the end of the day, be less or more profitable, and by how much.
Medical billing specialists are doomed under M4A. But they are doomed under any change of the current system, be it the UK system, the German system, the French system.
But doctors might even come ahead. Right know, neither we nor them know.Report
Concierge Medicine.
Go work for a hospital.
Shutting down his clinic is not the same as leaving the field entirely. What he’s pointing out is “less pay” = “less work”.Report
I had a chance to speak with a Kaiser Colorado doc who wasn’t mine. She said that she could make more money in a different sort of practice. OTOH, she said, there’s much to be said for working a sane schedule and not having the “small business headaches”.
I have always wondered why Kaiser is wildly popular in California, Colorado, and Hawaii, at least reasonably successful in some other states, and struggles in still others.Report
Is that your real objection?
If that problem were fixed somehow, by adjusting compensation rates to where Dr. Saunders would continue practicing, would you support Medicare For All?Report
My real objection to what?
If it’s to “overhauling the health care system”, no. My objections is not limited to that.
If it’s merely to the question of “why do people think that this won’t work?”, then, yeah. I think that that answer is, by itself, sufficient to answer “why do people think that this won’t work?” (But, get this, while it is sufficient, it ain’t necessary. There are others that are also sufficient.)Report
Serious question-
What other objections do you have to Medicare For All?Report
There are plenty. Under a government run single-payer plan, the most obvious way to reduce costs is to pay health care workers a lot less. That’s easy because the change turns health care into a monopsony, a field with one customer who pays for everything,, the government. Canadian and British health care workers don’t make nearly as much as their US counterparts, which is why we get a lot of their doctors and nurses to move here.
One side effect of that is that their health care workers put in far less hours than ours because people won’t work long hours for little compensation. Another effect is that many of their brightest people don’t go into health care because other career fields pay more.
So the idea that single payer will reduce costs without affecting quality and the amount of care delivered is “magical thinking”. Quality and quantity will fall.Report
Off the top of my head, we don’t have enough doctors, nurses, etc. We have too onerous of a regulatory regime (the FDA is actively harming delivery of health care). We have no expectation that there be such a thing as “Demand Management”.
If you want a longer essay, I have written them in the past and they didn’t get us anywhere. I can link to them again because I still pretty much stand by them and I don’t see how circumstances have proven them false yet.Report
The reason I ask is that those all sound like technical, solvable problems.
When I talk to conservatives (and yes I’m using you as a proxy for conservatives) it becomes apparent that the real objection is far deeper, at the level of morality where universal healthcare is an affront to the Right Ordering of the universe.
For example, if you say that universal healthcare can’t work because of a shortage of doctors, would you embrace some scheme to radically increase their number? Like some combination of regulatory reform, guestworker program, subsidy for new doctors thing?
Most of the time, conservatives don’t embrace those things.
The Objection, whatever it is, is kept there as some fixed part of the natural order and they are resistant to changing that.
Which brings me all the way back to my original comment, that for liberals, universal healthcare is a technical problem to be solved, while for conservatives it is a moral offense.
Is it really, for you, a moral offense?
Or does there exist some world which has Universal Healthcare that you would find acceptable, and what would make it different than this one we live in?Report
I agree. They are. I even talked about how I’d solve them in the essays I’ve written before.
But it involves assuming that medical care is a consumer good and treating it accordingly.
“Like some combination of regulatory reform, guestworker program, subsidy for new doctors thing?”
Um, sure?
“Is it really, for you, a moral offense?”
I’m not the one using the word “should”.
I’m the one saying “Hey, this doctor over here said he’d close if they instituted M4A. That’s the way it is.”
Or does there exist some world which has Universal Healthcare that you would find acceptable, and what would make it different than this one we live in?
What I find acceptable might be different from what you find acceptable.
For example, I find a two-tier healthcare system acceptable.
what would make it different than this one we live in?
For the systems that I think would work, I try to imagine what would make them sustainable. As such, they’re likely to offend the people who find healthcare to be a moral issue. Do you want me to link to the essays I’ve written on this in the past?
They didn’t help then but they might now.Report
That’s the ticket. Let’s take all the doctors and nurses away from struggling countries where basic health care is desperately needed and make them do calf implants in Pasadena. But liberal privilege doesn’t exist. No siree Bob!
Among the serious objections conservatives and, well, sane people have to single payer and government run health care is that government bureaucracies have a horrible track record when it comes to efficiency, innovation, easy-of-use, cost, and accountability. They sell you on utopia and then deliver more DMV.
This is a long-understood problem with centralized bureaucracy and top-down solutions. The only reason to think US government healthcare would be even a tiny bit better than Soviet government health care is that we have more money because we have less government intervention in the rest of the economy.
Heck, just look at where we apply our best and brightest bureaucrats employing the best and brightest employees, the nuclear power industry and NASA. The one can’t build a working power plant and the other has to pay Russians to launch Americans into low Earth orbit.Report
What if we tried to let the free market sort it out, and allowed doctors to go anywhere in the world in search of higher pay?Report
We do. That’s why we have so many highly qualified foreign doctors. The British NHS does what they can to fight their brain drain, but given their greatly limited funding, there’s not a lot they can do to compete.
Our US patients seem to like all the British nurses and their English accents, while British patients get nurses with Filipino and Pakistani accents.Report
You really are using the word “should”, though, at least implicitly.
I mean, you wouldn’t accept a system of universal healthcare that involves draconian government action that infringed rights, right?
Like if the government held a gun to Dr. Saunders’ head and said “You vill treat patients for free, or else its the FEMA camp!”
So your implied precondition to all of this is that some moral criteria are respected. Which is kinda how everyone thinks.
Whenever anyone says that something “works” they mean that it delivers the goods while conforming to our moral norms of how the world should work.
But I think its important to get those preconditions out in the open, since they are at least as important as any technical criteria.Report
I mean, you wouldn’t accept a system of universal healthcare that involves draconian government action that infringed rights, right?
Is that what is being suggested?
At this point, I thought that only things that wouldn’t work were on the table.
If we want to put things on the table that not only wouldn’t work but wouldn’t be considered acceptable by people far more centrist than I, feel free to put them there and if those more centrist than I need help in their arguments against what you’re proposing, I’ll jump in.
At this point, however, I’ll assume that we’re in “Nobody Is Arguing” territory.
Whenever anyone says that something “works” they mean that it delivers the goods while conforming to our moral norms of how the world should work.
I’m more interested in what works and then trimming and pruning away the immoral from that.
If you want to start with the moral and then start pruning away all of the stuff that doesn’t work, you’re going to find yourself in an argument like this one.Report
Right, because when people hide their moral priors, the conversations go in circles.Report
You want my assumptions, here. If those assumptions are wrong, I want to know it. But I don’t think they are… mostly because the arguments against them take the form “you’re bad” rather than “you’re wrong”.Report
I notice that none of those items are moral/ ethical concerns or for that matter, were even remotely political.
Meaning that we could in fact hold a gun to Dr. Saunders’s head, force him to deliver health care for free, and easily overcome your Iron Triangle problem.
But that is obviously not what you meant, since you assumed Dr. Saunders’s rights and liberty would be respected.
But even if we all agreed that they should be respected (and I do!) I think your Universal Healthcare with two or three tiers possible and desirable, even from a liberal perspective.
Heck, we have that right now for Medicare, and Obamacare literally has three tiers of Bronze, Silver and Gold coverage.
So taken at face value, your proposal would put you in the middle between Gabriel and InMD.
But honestly, I’m not thinking your’re really there.
Am I wrong?Report
Meaning that we could in fact hold a gun to Dr. Saunders’s head, force him to deliver health care for free, and easily overcome your Iron Triangle problem.
No.
You’re wrong.
This is why it’s frustrating for me: your moral certainty is rooted in assumptions that are wrong.
The plan of forcing him to work at gunpoint would not, in fact, work. There is a point at which he would say “no” and either sneak away in the middle of the night or you would be forced to pull the trigger and shoot him and, in either case, no more Free Health Care.
But what I do think is that Universal Health Care is inevitable and it will come with multiple tiers as a matter of course. The lowest tier will be called “the shitty tier” and I will be called “bad” for wanting the highest tier to become better and better and better and have the lowest tiers give the shitty health care (that was considered top of the line a decade or two ago) instead of suggesting that everybody be treated equally because, if we killed the goose, we wouldn’t have to be limited to the eggs it gives us. We could eat a feast that *EVERYBODY* could enjoy!Report
For example, Warren depends on reducing drug companies incomes by 80%.
That’s more than their entire R&D budget plus lots of other things. Presumably they can still make the existing drugs, but won’t have the resources to make new drugs.
Burning an industry like that down is easy, building it a new after everyone involved has gotten other jobs will be much harder.Report
Chip even has potential inaccuracy in his own framework.
Without competition there is no motivation to do better work, so your thresholds on time and quality have been shown in forced socialist systems to sink to the minimum not to be shot.
I also suggest that it is because the public schools are the way they are, that we are still having these conversations in 2019.Report
You miss the point.
By fixating on the gun to the head example you ignored the other point, which is that your proposal is actually very middle of the road liberal thinking, yet somehow you write about it as if everyone would scream in horror.
Why do you do that?
Medicare itself is a multi-tiered program. Is Medicare “shitty”? A lot of people think so, but most people love Medicare and don’t want it messed with.
Again, Obamacare itself embraces a multi-tiered approach, much like your proposal.
So even your own proposal makes you sound like a 2009 version Democrat.
But you seem to write about it as some horrific dystopia, which I find puzzling.Report
your proposal is actually very middle of the road liberal thinking, yet somehow you write about it as if everyone would scream in horror.
Why do you do that?
Because I noticed what happened when I wrote about it.
For example, I got accused of wanting people to die.
This is something that happened.Report
At least nobody accused you of proposing FEMA camps with death panels.Report
If we can get to the point where you see, yeah, Jay gave a fairly middle of the road (if not milquetoast!) suggestion for a solution and was accused of wanting people to die, you might be able to get yourself into a mindspace of why I see the problems that I see.Report
” I think your Universal Healthcare with two or three tiers possible and desirable, even from a liberal perspective.”
that’s because you’re a bastard who wants sick children and poor people to die because they can’t pay, that’s the only reason, you want them to die because they can’t pay. You want that.Report
And, yeah, that’s snarky viciousness, but it is the attitude that you’re going to have to overcome when you propose a two-tier healthcare system. It is the attitude that you yourself have thrown at people who thought maybe we shouldn’t rush headlong into Fixing All The things.Report
What about a moral norm that includes an acknowledgment that the existing system:
A. is very fragile and built on decades and decades of decisions and infrastructure. An ill-conceived shock to it, no matter how well intended, could have severe consequences for huge numbers of people; and
B. has some things that are worth saving. We don’t want the Johns Hopkins of the world to disappear and be replaced with nothing but VA hospitals.
My opinion is that expanded coverage is only a net win if these things are adequately accounted for.Report
If we assume that it’s politically impossible to fire millions of people but it’s not politically impossible to spend 20-50 Trillion more then we’re in “break the budget” territory.
That’s the whole “socialists run out of other people’s money and leave a mess” thing which was Thacher’s observation.
And there are other ways to break the system short of 20+ Trillion. There are enough Warren-is-economically-insane proposals on the table that I seriously doubt she’d make the system better.Report
It could be worse!
We could be letting millions into the country who are less smart on average than Chip, but more than willing to vote 70% into the same delusions.
Wouldn’t that just be a clusterfish.Report
I think I would be fine with it, but imho you would not be nor would Warren (which is why she is suggesting ways to transfer expensive insurance plans into MFA).
You suggestion is two tiers. MFA which is going to suck. Year long delays for service. Doctors who refuse to take it. That doctor who said he’d close his clinic was serious and he’ll migrate to the upper tier. My wife grew up under a system like this and she’d have to bribe the doctor so he’d “have time” to see her.
So rather than allocate service based on money, we’ll be allocating availability of service based on money.
My expectation is that the creators of the lesser system will try to force everyone to use it and only it.Report
Back in the day, Soviet propaganda films would show stuff like race riots, and say “In capitalist America, when Negro peasants drive across country, they need a special green guide to avoid racist oppression!”
And the takeaway for the Soviet people was “Holy crap! American peasants have cars?!”
Today Republican propaganda is like, “In socialist dystopia people have to dun dun dun…wait for their healthcare!”
And a lot of Americans are like, “Holy crap! I will get healthcare?!”Report
In completely totally unrelated news:
How One Employer Stuck a New Mom With a $898,984 Bill for Her Premature Baby
https://www.propublica.org/article/how-one-employer-stuck-a-new-mom-with-a-bill-for-her-premature-baby
Ya think this woman is receptive to propaganda about “delays of service”?Report
cool story bro, but what do you do when the government-run health plan does the same thing?Report
I mean, this is the closest I can find to a “law” saying that health plans can do things differently for “adverse health events” or whatever, and it’s discussion rather than lawmaking, and explicitly states that health plans aren’t required to do that, and in fact there’s discussion to the effect that having a long window for mid-year plan changes encourages people to wait until they’re sick, thus raising prices. So the government had the opportunity to let you change your health plan any time you needed, and they did not take that opportunity, and on purpose, and they did it to save money.Report
See, you guys complain bitterly about being portrayed as heartless monsters, but your first response to a story like this is to attack any proposed fix.
In the ideal conservative world, what happens to a person with no money who has one of these medical catastrophes?
We’ve been asking this question since 1932, and all you guys come up with is shruggy face emoji.Report
For what it’s worth: I don’t mind being called a monster as much as I see it as an indicator that not even middle-of-the-road solutions will be considered acceptable.Report
I am honestly having a hard time seeing your proposed plan as anything other than some variant of Obamacare, or the various coverage plans around the developed world..
But maybe you are saying something other than that.Report
And yet I was accused of wanting people to die.
Weird, huh?Report
And so…what?
Like, you reject Warren’s proposal because…people on the internet said you were worse than Hitler when you proposed Obamacare Lite?
I’m not grasping your logic here.Report
I reject Warren’s proposal because I think it won’t work.
I suggest mine because I think it will.Report
This is trying to compare “everyone gets everything” to “what we have now”. Not using money to deal with resource allocation doesn’t mean we’ve created more resources, nor does it change that keeping that kids like that alive is amazingly resource intensive.
It is possible UHC is willing to shell out millions and millions of dollars so a handful of extremely premature babies can live (often with life long problems).
It’s also possible UHC simply gets rid of level 4 neonatal intensive care units so the issue doesn’t come up. Make that baby wait in line for care and it dies, so it probably dies.
UHC implies cheap care to large numbers of people, it does NOT imply whipping out the money hose for extremely expensive individuals. Winners in the new system would be people with untreated diabetes, and I’m sure there’s a long list of others. Losers in the new system would probably be that baby, and everyone who currently doesn’t wait in line because they have great coverage and/or money.
They die. Just as they would if the cure-for-whatever hadn’t been invented yet because Drug companies aren’t allowed to make profits on new cures, or if the State decides these units are too expensive to have around.
However trying to pretend people don’t die and/or you’re going to give everything to everyone is deep into magic thinking.Report
The Republican/ conservative plan is, just as you say, to let people without money die.
So yeah, as you say, lets stop pretending that won’t die under the status quo, and lets stop pretending that people won’t die under Republican rule.
The question is, will more people die under President Warren, or President Trump?Report
I can’t wait for those bewildered words to come out of AOCs mouth “We have to wait in line?” “Are you kidding me!!!” and then some one whispers in her ear for two minutes, and in a clear voice similar to Trumps she says, “well of course…. we have the best lines anywhere!”, “Just look at our great lines!”, “They really are the best lines!”Report
Holy crap, in socialist dystopia, peasants have health care?!Report
so um
you’re honestly going with “the Soviet-era healthcare system was preferable to what the US has now”
you’re unironically going with thatReport
I’m saying that your nightmare scenarios, the ones with scary music and black and white pictures, are better than what a lot of Americans have right now.Report
“I’m saying that your nightmare scenarios, the ones with scary music and black and white pictures, are better than what a lot of Americans have right now.”
I think maybe you need to read “Ship Of Fools” and tell me how you aren’t one of the people saying that the Soviet Union is really great because everyone is guaranteed a job.Report
Yes. Agreed.
Any massive change to a system this big is going to create lots of winners and losers.
Having said that, there are aspects of this plan that come close to “everyone loses”. She’s apparently getting rid of new drugs. That’s going to kill lots of people, but it will do so invisibly without anyone taking responsibility because we can’t know what cures won’t be invented. She’s also increasing demand, decreasing price, so the expectation should be serious supply issues.
It would be very easy to end up with the bulk of America losing and only winners those who unwillingly have no access to the HC system win (i.e. the people Obamacare was supposed to eliminate).
And that’s making the breathtaking assumption that our political process will take responsibility for firing 2+ percentage points of the GDP worth of jobs. If that assumption isn’t right then we get all this AND scary high tax increases.
IMHO we should focus on fixing HC markets and making the entire system cheaper.Report
Creating equal numbers of winners and losers can be a disaster for the party that does it. Say your policy greatly benefits those whose last names are ‘A’ through ‘M’, but devastates those whose names are ‘N’ through ‘Z’. You’re not really going to pick up many from the opposing side who fell in the ‘A’ through ‘M’ category, but you will be hated and despised by many those in ‘N’ through ‘Z’ who used to support you. So your support might fall from 50% to 25%, getting you tossed out of office and turning your political opponents into heroes for undoing what you just sacrificed yourself to implement.
That kind of thing makes attempts to seriously re-slice the pie fraught with danger, with some programs becoming a “third rail of politics”, where the politicians say “touch it and die.”Report
If only there were actual political parties with credible ideas to do just that.
But alas, the only non-Democratic political party in America has, as its foundational creed, the idea that health care should be denied those without money.Report
This is the problem of adding weasel words.
“If only there were actual political parties with credible ideas to do just that.”
Yeah. I wish there was one too.Report
“Denied” implies something like the abortion debate. No one attempts to prevent access, but there are lots of needs for scare gov dollars.
If you’re going to be reaching into my wallet to help someone else’s bottom line, then it’d be nice if their problems weren’t self inflicted, if they weren’t gaming the system, and if this funding is going to good things rather than bad things.
There is an easily crossed line between “helping” and “enabling”. There is an other easily crossed line between “helping” and “being taken advantage of”.Report
First, some of those things like drug testing actually cost more money than they saved.
And conservatives know this. Yet insist on them.
Second, yes people actually do deny access forcibly. When insurance money runs out, hospital personnel physically pick people up and dump them into the street.Report
So? This is an ethical argument, not a fiscal one. If you’re reaching into my wallet, then it shouldn’t be to help my cousin stay high.
Similarly cars get repossessed and houses are subject to eviction. Also similarly society decides we won’t pay for some medical treatments and people die. And then we have people like Terri Schiavo who need to stay on life support forever until they die of something else.
Big picture, there would be a HUGE amount of human welfare gained if we could make HC cheaper. That way everyone could run their own lives and decide for themselves what the most beneficial course of action is. Throwing money at the problem isn’t “making this cheaper”. Pointing to someone’s crying eyes and insisting “we help them” isn’t a plan, as showcased by the liberal plantations in your example still having crying eyes. It’s not conservatives who are preventing all crying eyes from being removed, it’s reality. No matter where we set the bar on how much HC to supply, it STILL won’t be enough.
And yes, even if we made everything cheaper the latest and greatest stuff would still be expensive. Yes, people would still die. The question shouldn’t be how to eliminate death from reality. Pretending that we can give everyone everything simply doesn’t go anywhere useful, we end up paying for everything until the budget breaks.Report
Until some Republican actually makes a coherent argument for making health care cheaper, the Democratic plans are the only alternative to the status quo.Report
Pass laws which create the normal conditions for markets to work. Published prices. Create competition. Prevent shady deals… which a lot of these private-deals-with-one-insurance company only fly in the face of. “One price for all for the same service” would probably be useful although that is in direct conflict with “medicare will pay less for the same service”. That would get rid of the whole “large groups negotiate rates” and take us to “medical providers compete on the basis of efficiency.” Tort reform would be useful, something akin to what we did for vaccine manufacturers.
Increasing supply would be amazingly useful. Import foreign doctors. I went to a lecture by a high priced specialist surgeon who complained he’d been thoroughly educated on how to deliver a baby, but he’d never done so and he almost certainly never would. Eliminate the useless crap he’s forced to learn and his education would be much quicker and we’d have the bandwidth to create more doctors.
We are deep into “special interests have captured the process and there effectively is no market”. We have a ton of structure which was put in place by special interests to prevent competition, reduce supply, and increase prices. If MC prices were a lot cheaper then most of the issues you care about would be much simpler.
There are medical fields where insurance doesn’t apply, lasic surgery, plastic surgery, pet care, and there we have high quality, low price, and high availability.
If their plans are taking ideas from that list then more power to them. If their plans are to burn money until there are no crying eyes then all they’re going to do is burn money.Report
OK, so the problem with this policy agenda for health care isn’t that it’s necessarily all bad or even mostly bad. I’m really skeptical that simply publishing prices and preventing shady deals alone would do the necessary work for a variety of reasons, not least of which is the way that emergency care works.[1]
The problem is that while individual Republicans have reasonable ideas about how to handle this, the party as a whole has completely and repeatedly failed to coalesce around any of them, while also doing anything it can to undercut attempts to reform healthcare in a more market-oriented way.
[1] If you’re lying on a gurney in an ambulance with a dislocated knee you aren’t really in very good shape to bargain hunt, and the number of choices you have may be strictly limited well, to cite one example with which I am personally familiar.Report
My take is similar to Pillsy.
Dark, you are being very earnest, very serious and thoughtful in laying out a vision of compassionate conservatism.
But you are unique and entirely out of step with Republicans. There isn’t any elected Republican anywhere who shares your ideas, and if one did he would be buried in a primary landslide.
So yeah, props for the effort and sincerity. Maybe Michael Bloomberg has a campaign staffer position open.Report
Thank you.
Sure. Special interests own the process, anyone who even presents markets as the solution gets attack ads showing him throwing sick old women off of cliffs. I’m even skipping the political hot potatoes of outlawing 3rd party pays and making employee health benefits taxable.
None of which changes that this is roughly what should be done if we’re trying to max human benefits and outcomes.
Nor does that change that if the political winds align and we go with single payer, we’ll find out the cynics are correct about it’s flaws, including that it’s expensive.Report
Lots of people don’t “get” markets and intuitively trust command and control more because you can see what’s going on. The problem is that experience shows markets work MUCH better at this sort of issue.
RE: Emergency Care
Uniform prices means “no jacking up the price because you can”, or because they have/don’t-have insurance, or because your set of admins has made “special” deals with other sets of admins (networks), and so forth. If you offer this service at a price to someone, anyone, then you need to offer it to everyone at the same price. If I’m totally out of diapers in an unfamiliar town, WalMart doesn’t raise the prices on me.
Pot. Meet Kettle. Obamacare was a plan as far to the left as Obama could manage. There simply weren’t the votes for single payer. In order to get Obamacare passed, he needed to buy off the hospitals, insurance companies, and so forth.
But let’s go over some of the advantages. It could be passed piecemeal. Force prices to be published one year, then force uniform prices another. You’re not taking a wrecking ball to one seventh of the economy with the blitheful assurance that socialism will simply work this time.
This would require a budget of roughly zero, it’s not a 20-50 Trillion dollar experiment.
It doesn’t involve magic thinking, so it would work. We’re not increasing demand, decreasing supply, and expecting prices to remain constant. We’re not pointing to one pair of crying eyes and picking them as a winner when there are untold hundreds of millions of similar sob stories waiting in the wings. We’re not expecting our brilliant selfless politicians to eliminate 3% of the GDP worth of jobs, decide who gets to die (and stand up to their relatives), and get command/control to work.Report
that was to pillsyReport
The reports I got from a Venezuelan nurse before my contact went silent said the hospitals didn’t have windows so they had to worry about birds defecating on patients. Also there was some weird mix of sludge growing on the floor.
They decided to deliver a baby at the house, but Yeah, by Gawd there was (after the bribe) health care for peasants, that could make it past the Cuban snipers who were openly killing people in the streets.
Say Chip, Cuba is only 90 miles off the Florida coast and they are in dire, dire need of good architects because their buildings are literally falling down around them. Any reason your hanging around in this backwards capitalist, white supremacist nation?
The comrades need ya brother!Report
This is an interesting approach to arguing against socialized medicine.
The USA’s GDP per capita is about $60,000.
Iceland’s is $55,000, Norway’s $62,000, Canada’s around $45,000, Germany’s $47,000.
Venezuala by contrast had a GDP per capita of about $15,000 in 2014 before it went basket-case. Now it’s down to like $3,000 or less. Cuba’s GDP per capita is about $8,500.
So I can see why you ignore economically dissimilar countries like Norway and Canada, and focus on economically similar ones like Venezuala and Cuba, for analyzing how socialized medicine would probably work in the USA.
For next time, I’ll just point out that Niger has socialized medicine and its GDP per capita is only about $1,000 – surely an even more useful predictive model for how socialized medicine would work out in the US.Report
Economic determinism cannot fail it can only be failed.Report
Ah, our Marxist quote of the day.Report
My comment was in response to the context of Chips comment about socialist dystopia.
If I were to pick a non-dystopia, I probably would have picked Canada like I did way up above in that link I provided in context of wait times.
I appreciate that you were willing to call me on it though, a apples to oranges case should be called out.Report
I gotcha, thanks!Report
“For next time, I’ll just point out that Niger has socialized medicine and its GDP per capita is only about $1,000 – surely an even more useful predictive model for how socialized medicine would work out in the US.”
see, you’re imagining this like some kind of Ultra Combo Finisher, but what you’re telling me here is that you consider whatever healthcare people get in Niger to be an acceptable level of healthcare.Report
Here in America, when people’s health insurance runs out, they are dumped on the street sometimes wearing only their hospital gown.
https://www.latimes.com/business/la-me-patient-dumping-20180702-story.html
Is that how it is in Nigeria?Report
Of course not. Nigerians would never put up with the Third World conditions in California.Report
NHS waiting list hits another record high: 4.4million people are now waiting for routine operations as the figure is the worst ever for a third month in a row
https://www.dailymail.co.uk/health/article-7236985/NHS-waiting-list-hits-record-high-4-4m-people-waiting-treatment.html
Eight cases in five years that have been settled vs. over four million people who have no recourse.Report
That is… a very odd conclusion to draw from what I wrote.Report
Joe, that bad stuff only happened because of the hoarders and wreckers. If only we can find all the bad people and put them where they can’t hurt anyone then everything will be just fine.Report
Did I mention we will probably have some problems with social truth?Report
“The government provides free health care to all the citizens! And if you greedily want more than the government has determined that you need, well, you can pay for it yourself. Besides, there’s no guarantee that cancer treatment would work, and diabetics can manage their condition quite nicely with diet and exercise, and heart patients really ought to have taken better care of themselves instead of expecting the rest of us to pay for their sedentary meat-eating lifestyle, don’t you think?”Report
I haven’t followed this subthread very closely, but I’m not saying conservatives don’t believe health care is a consumer good. I’m saying they (or most of them) don’t really believe there should be no provision for those who can’t afford it.Report
It is how they behave. Look at any place where conservatives have the ability to control it, and provisions for those who can’t afford it are in fact nonexistent.
Like the patient dumping scandals I linked to. Even though the stories were from California, they happen nationwide.
You can find people all across America going bankrupt , or just dying for lack of ability to pay.
That’s how injustice works. Unjust societies always find a way to turn their gaze away, to rationalize, to ignore it through sheer force of will.
But it happens. And it happens through deliberate willful choice by the electorate.Report
That’s interesting behavior, reference something that happened in LA and paint a nation of conservatives with that brush.Report
Wherever conservatives hold power, they aggressively take steps to reduce access to health care for poor people.
Work requirements, drug testing requirements, eligibility requirements, wait times, cutoff limits.
This isn’t theory or hypothetical, its historical facts on the ground.
The conservative pattern of behavior is that if you don’t have money, you don’t get health care.Report
The liberal pattern of behavior is that if you do have money, you won’t for much longer.Report
Or, looking at both your link and my link, HC is expensive and no matter which way you slice it, there will be some form of rationing.
Blaming this on “conservatives” when the example you give is from a very liberal city in a very liberal state is quite disingenuous, not to mention mendacious.Report
1. Everyone agrees there will be rationing; Republicans want to ration by price- Democrats want to ration by availability and medical need;
2. Everything I mentioned – the work requirements etc-are happening in Florida, Georgia, Kentucky, Texas, and everywhere conservatives hold power.Report
“ration by availability and medical need”
congratulations you invented price
“but wait no I didn’t say anything about MONEY”
neither did I, broskiReport
I’m perfectly happy to compare the rationing performed by peer systems around the world, with the rationing by price performed here.
All I really insist on, is to make it clear that with conservative control, if you don’t have money you don’t get health care.
Because there is a lot of effort put into hiding that fact.Report
But you showed that with liberal control if you don’t have the money you don’t get health care.
All I insist on is a little honesty. But there is a lot of effort in hiding that.Report
Insurance companies and hospitals dumping poor patients was result of which liberal policies?
What proposed conservative policy would prevent them from doing that?Report
Maybe California should quit letting the state’s conservatives (who all meet at the IHOP near Vetura and Vanalden on the second Tuesday of every month) write all their health care regulations.Report
And who passes laws in CA? Zombie conservatives (are there any after 2018?) or the Democrat Super Majority? With Gavin Newsome getting final veto power? LA has had a Democrat mayor since 2001, and the CA governor has been a Democrat since 2010. The insurance commissioner of CA is Ricardo Lara, a Democrat. The commissioner eight years before that was Dave Jones, also a Democrat. So, at any time in the last decade and probably longer, the D’s could have stepped in if they thought this was a real problem.
That article talks about homeless people, no insurance involved probably in any case. So, a hospital in an LA suburb has a man removed, early or not we don’t really know. And as I have shown above, every person involved who could have changed a law to prevent this is in no way a conservative, and yet you blame them. Indeed, the law that insists that a hospital treat those not able to pay was passed by a Dem. House and Rep. Senate, and signed by Regan, a conservative(!) The article you linked mentioned eight whole incidences over five years, and again it is fully under the control of the Democrats that these happened. Not a single thing about what you are mentioning has anything to do with conservatives.
This is all on the left.Report
You’re not really making a serious argument here.
Are you saying dumping doesn’t happen under conservative control? That if someone runs our of insurance money, conservative states just give them free treatment?
Of course you’re not saying that, because that is risible.
So what is your argument here? That liberal states fail to meet their stated goals of universal coverage?
So stipulated! Agreed, this should not happen!
In fact, we are so chagrined at this happening, we now support universal health care coverage like the Warren plan.
See, your own argument leads inevitably back to supporting Warren over Trump.Report
Wow, I haven’t seen goalposts move that fast in a long time! You go from blaming conservatives for what are demonstrated to be liberal failures and conclude that we have to vote for an innumerate liberal. Well, OK then.
And I have the unserious argument?Report
So we agree dumping is a failure of liberals.
What is the conservative plan to prevent dumping?Report
I don’t know, but you might try to find one and ask her?
Just a thought.Report
We have, and the answer is Die Quickly.Report
Somehow, I don’t think you actually asked a conservative.
Somehow.Report
A conservative is a liberal who has been mugged by reality. For all the talk about wanting to ignore price, reality is all about price.Report
“All I really insist on, is to make it clear that with conservative control, if you don’t have money you don’t get health care.”
Time is money, sir. If I can’t wait at the hospital all day for the pharmacist to make my medications, I die. If I can’t afford to wait six months for the surgeon to be available, I die.Report
Money is money, too. If you can’t pay for a surgeon out of your own pocket, now or 6 months from now, and nobody else picks up the tab, you die.Report
I’m not the one saying “there are no doctors who can do what you need at the price you’re able to pay” is an outcome we shouldn’t accept.
I mean, you’re saying you accept that people might die because they can’t see a doctor, and you’re also saying that it’s a terrible awful thing that someone might die because they can’t see a doctor, and I’m asking you to explain how you reconcile those attitudes in your mind.
If you’re taking the attitude that doctors form a monopoly-like market due to a limited number of providers then, shit, it’s not health insurance you need to go after, it’s the RUC, which is a group of doctors that sits down and decides how much it costs to go to the doctor.Report
I’m asking you to explain how you reconcile those attitudes in your mind.
What’s to reconcile? There is no conceivable system where everybody gets everything they need (for some values of need) or want (for some values of want), so if you think it advances the discussion then, yes, under any conceivable system, some will die, either because they can’t pay on their own or they can’t wait while someone else pays. I think my “pay, wait, or die” is inevitable position has been perfectly clear to just about everyone else.
Any system will have some combination of these features, as will any non-system. Lots of countries throughout the world have managed to create systems of different kinds, with different pay-wait-die balances, that seem to suit their people. We can, too.Report
If pay, wait, or die is a necessary feature, then what is it about the US system that you find unjust and that would be more adequately addressed by a different system?Report
Ooo, oo, I have some:
1. The massive inefficiencies caused by people without insurance, or with bad insurance, only visiting medical facilities in an emergency, costing the system way more money (Money that could be used to ‘pay’ for more health care, thus causing less ‘waiting’ and ‘death’.) than if they were able to access them earlier.
2. The closing of rural hospitals due to people in #1 who cannot pay their bill, causing even _more_ inefficiencies.
3. The price gouging by pharmaceutical companies that appear to have the entirely correct idea that they can raise the price of any random drug they happen to currently be the sole supplier of to whatever they want.
Those three are just off the top of my head how we could adjust the current system _without_ fixing the shortage of doctors that results in ‘pay, wait, or die’.
Of course, we should also fix _that_, which is caused by doctors basically attempting to keep their own numbers small so as to have a monopoly, and honestly at some point it becomes required for the government to just throw the accreditation people out on their asses and say ‘We _will_ operate more schools for doctors, regardless of whether you want it or not.’. (Or, at least, look at some of the insane things they do to keep doctors from graduating. For the obvious example, try to make them operate 24 hours without sleep.)Report
I keep coming back to the fact that we have socialized police, fire and EMT services, without this sort of insistence that such a thing is un-possible because of “pay wait or die”.
Do we provide universal fire coverage to every house?
Yes.
Does the system overload at times causing wait times?
Yes.
In times of overload, do government bureaucrats ration by triage?
Yes
If demand outstrips supply, do we raise taxes to increase the supply?
Yes.
Does this lead to tyranny and gulags?
No.Report
Socialized police and fire have become among the highest cost, if not the number one highest costing social constructs in many population centers. So much so the cost are negatively impacting improving water and sewer infrastructure.
That in itself wouldn’t be so bad, as municipal loans and debt can be an answer to improving infrastructure, but those debts translate eventually to taxes and fees make it to the base, which the base in most developed nations are carrying personal debt of some degree that interest rates are well above zero. So your higher degrees of socialization are leading to longer durations of personal debt, were interest rates are pulling out the marginal surplus of money to poor people that hold high debt per marginal income.
And somewhere in this you are wanting to advance socializing health care that will lead to more of this?
Do you hate the poor or something?Report
“I keep coming back to the fact that we have socialized police, fire and EMT services”
okay so you started out telling us that the healthcare systems in Soviet Russia and Nigeria were preferable to what the USA has now because in those two places everyone was “guaranteed” to see a doctor…eventually
now you’re stanning for cops
what
Oh and as for the firefighters, they work for pay too. An old story, to be sure, but worth mentioning; as is the fact that many places have “volunteer” fire departments paid for by user fees or private donations, with little provided by the state other than tax breaks. Hardly the kind of Socialized System that you’re telling us about.Report
And the socialized fire systems are working splendidly.
How is that possible, what with the Iron Triangle and whatnot which supposedly proves it isn’t possible?
Didn’t Milton Friedman predict that if we socialized firefighting, we would run out of firemen, or somesuch?Report
“Didn’t Milton Friedman predict that if we socialized firefighting, we would run out of firemen, or somesuch?”
literally the first Google resultReport
Here is the problem with constantly comparing health care to fire/police/EMT. The vast majority of the population will be able to go through the entirety of their lives never (or being able to count on one hand the number of times) needing the attentions of first responder services.
Almost everybody will need to seek medical services regularly.
The cost schemes are just radically different. You are comparing services that act as insurance against low frequency but high cost events with services that deal with higher frequency, and high cost events.Report
DavidTC gets extra kudos for acknowledging the barriers that are in place that reduce the supply of doctors to the system.
That applies to both the cost and time parameter.
Probably should get points for pointing out that the ‘immediate free care’ and ‘failure to pay’ is producing issues in creating avoidable costs.
The gouging, that is a good topic to at least delve into, probably need to discuss captured conditions that are creating that condition.
I would start by asking: is the floor threshold of our quality set correctly to benefit the most people?
Should the ones setting the thresholds be the ones doing it?
Is there too much legal activity distorting quality and costs?Report
I’m not pushing any particular plan. Your question is better directed to someone who is. Many different plans seem to have worked reasonably well elsewhere, and I am happy to have some sort of negotiated deal that borrows or steals, and possibly creates something new. I just get tired of hearing that X is bad because people who would otherwise get nothing because they can’t pay on their own must wait while someone else pays, or other similar arguments. Every system involves trade-offs among the pay, wait, or die variables. It doesn’t advance the argument to whine about whatever feature you think is a gotcha, especially when your alternative is nothing.Report
There are a bunch of parameters that just appear to be shrugged off in your priors.
Canada from what I have read has a scheme were those who can’t pay appear to receive health products and services, and most sources admit that it is economically unsustainable at it’s current rate.
I think we could make the same case for the US.
So in these very developed countries what has happened to make these systems parametrically unsustainable and unaffordable (show your work in the three parameters quality-cost-time of your pay-wait-or die framework). Parse what is sustainable from unsustainable.
How well off are the people you wish to give the free services to if the economy implodes in doing so?Report
There is no conceivable system where everybody gets everything they need (for some values of need) or want (for some values of want), so if you think it advances the discussion then, yes, under any conceivable system, some will die, either because they can’t pay on their own or they can’t wait while someone else pays.
Welcome to the Republican Party, sir, your complimentary racism is on the table to the left.Report
I’m sorry, since when did the Republican Party have any connection with reality?Report
I think that this is one of those things where those in power argue about how complicated the world is and how difficult logistics are and those out of power talk about Morality and Tactics.Report
As far as I can tell, Warren isn’t admitting her plan would result in rationing and a LOT more than current.Report
@J_A
We decentralized Galt’s Gulch and renamed it underemployment.
Maybe read that book again with that in mind.Report
Boston Herald: Stick a fork in Liz Warren, Medicare-for-All has cooked her
[snip Canadian wait times…]
The author thinks Warren’s plan will leave only Biden and Buttigieg standing as viable options. I don’t see either of them beating Trump, but at least they don’t scare people, and thus wouldn’t hurt down-ticket races. Warren’s early advantage in the race was that people assumed she was a very smart policy wonk. She should’ve just let that assumption ride instead of disproving the assumption by providing a thick stack of contrary evidence.Report
Wow, that’s an eye popping price tag, alright.
Almost as much as the Republican deficits.
Where in the world will we ever get that much money?Report
The money is coming from Chips retirement stash.Report
I had a little peak at that article.
I will note that your [snip Canadian wait times… begins
The Fraser Institute is basically a Koch brothers mouthpiece in Canada. They are notorious for cherry-picking, misrepresenting, and just-shy-of-outright-fabricating statistics to make their libertarian point. Every year they publish the same nonsense about Canada’s tax rates, representing Canada’s effective tax rate as absurdly higher than it actually is. Every year our news outlets (90% Postmedia owned) display the same wide-eyed naivete toward this report. Shocking, I know.
For example, right off the hop, their claim that:
is totally disconnected from my experience. Last time I saw a GP (over a minor hearing complaint – something that would get shoved waaay to the back of any queue based on urgency, level of patient suffering, risk if left untreated, etc.), I just showed up unannounced at the nearest drop in clinic, was in an exam room within 20 minutes, about 20 minutes later someone popped in to apologize for the lengthy wait, and inside an hour I was talking to a doctor. Back at the front desk I made a follow up appointment for one week later, and was on my way.
This is much more typical of every experience I and people I know have with the medical system. It has its imperfections of course, but really the only insights to be gained from a Fraser Institute study are by examining the “method” section to discover what kinds of deliberate methodological flaws are commonly used by shady organizations, so one can look out for them in future.
(If you are interested in doing such a review, the paper is here https://www.fraserinstitute.org/sites/default/files/waiting-your-turn-2018.pdf)Report
I snipped it because it was an aside that detracted from the main thrust of the article, basically filler where someone inserts their favorite study of health care from Canada, Cuba, Britain, Scandinavia, etc, which generally are either inapplicable, apples to oranges, or reflective of some other issues that would require a book-length treatment. ^_^
Warren, like so many others, has taken a talking-point version of the Canadian or British NHS as a goal (government sing-payer for everybody) without looking at those systems as a model to slavishly copy for the first attempt. It’s loony to go with a random stab by an aging American politician to recreate what they think Canada has, while ignoring all the things Canadians had to do and not do to make it work. It reminds me of the Pacific island cargo cults that made jeeps out of bamboo and coconuts. If you want to make a jeep, look at how a real one is made.
For example, most Canadians carry some private supplemental insurance, and a large fraction of their health care spending is still private sector, whereas Warren wants to ban all private health insurance. Canada can’t be paying for the entire health care system by taxing billionaires and large Canadian corporations because then all their billionaires and large corporations would move to Dallas or Miami.
A politician could make a viable pitch by saying “We’re gonna have Canada send us all their paperwork on how they do their health care, and we’ll just do the same thing.” Then we could debate the pros and cons of that, on the theory that the Canadians have weeded out the ideas that can’t possibly work or didn’t work.
Trying to whip up such a system from scratch, as almost an afterthought to a political campaign, is going to include a whole lot of ideas that are profoundly and obviously unworkable, and now all her opponents will point those out. The likely result is that she’ll lose the primary or lose badly in the general, and then serious Democrats will become extremely gun shy about revamping health care, which is normally their signature issue.Report
Sure, I have access to private health insurance through work, which covers some gaps in medicare. Leftish political parties frequently campaign with promises to increase coverage, closing those gaps and making my employer-funded health coverage more unnecessary.
At other times, I have not had health coverage, and it never caused me worry or stress – if I were unhappy at my job, “But I can’t afford to lose health insurance” isn’t a locked cage keeping me at my job – it’s barely a slightly stiff doorknob. “But I wouldn’t be down the street from the Italian bakery anymore” would literally be a higher priority.
This is not to say that gaps in Canada’s medicare coverage aren’t real, and aren’t hard on people with limited incomes and chronic health problems – particularly with their teeth and vision, or needing expensive prescription medications (those being the main gaps in our medicare system).Report
Convenient access to Italian bakeries is probably somewhere in Warren’s plan. If all Italians can have access to them, why shouldn’t Americans?!
Anyway, I think Bernie’s folks will really give Warren’s folks some grief over this. Her “plan” should have remained in the realm of nebulous ideas, or should have stuck to tried-and-true implementations, instead of putting unworkable fantasies down on paper.
As I said somewhere else in this thread, Warren made her career on using odd metrics to write papers that reached unsupportable conclusions, which made for easy headlines and soundbites. It’s her shtick, and it works so long as the only goal is to garner some press, but she has to ignore the academic critiques of her “research”. A story about your 200 mile per gallon carburetor can get you to the podium, but you won’t stay there long unless the thing actually works.Report
Wait-wait wait- Hold on a moment-
You’re telling us Canada has a multi-tiered health care system with a basic level which is no cost, and supplemental insurance for those who choose it?
Monsters. They’re worse than Hitler!
[scary music, grainy photos of the Schitt’s Creek cast]Report
Your example of what is supposed to change is a 1+ pound baby who got almost a million dollars of HC with her mom getting the bill.
Do you consider that to be “a basic level” of Health Care?Report
In Canada, the baby’s NICU care until death or discharge would be within the “basic level” of healthcare, yes.
Our daughter was briefly in the NICU, the cost to us was nil (my wife also was provided a room in a building adjoining the hospital, because we didn’t have a car so she couldn’t drive over from home to nurse the baby). Our daughter’s health concerns were relatively minor, but there were certainly little tiny preemies, as she was in the level 2 NICU at the hospital with the regional level 3 NICU. Their parents were charged the same nothing that we were.
If that baby grows up to be an adult with cavities, that’s different – teeth are optional luxury bones you see.Report
I have a coworker who is in the Air Force Reserves. Instead of taking the health insurance offered by work, he takes Tricare. It’s, apparently, exceptionally cheap and he is exceptionally happy with it. “How is it?”, I asked. “I’ve never used it.”
To the extent that peace of mind is important, Universal Health Care might provide that. It’s not a problem until you need it and, let’s face it, much of the country doesn’t need it.Report
There’s a big difference between being happy with what you have and not needing what you don’t have. One is a matter of opinion; the other is a matter of fact. Someone who has never used his health insurance and is happy with whatever he thinks he has is like someone who is happy not paying for fire insurance. Works out fine until there’s a fire.Report
Hey, one of the things that I see as a legit problem is malaise.
If UHC would eliminate malaise EVEN WITHOUT DOING A SINGLE THING DIFFERENTLY, that alone is a good thing.Report
Healthy people who don’t use their insurance tend to think it’s OK until they need it. Maybe they don’t have malaise until reality knocks on their door, but reality doesn’t care how you feel about it.Report
reality doesn’t care how you feel about it
One of the problems I’m trying to solve is anxiety. Feelings and reality are inextricably linked sometimes.Report
I have Tricare. Being a disabled vet, I get top tier Tricare (aka Prime). It’s nice to have. It’s nice having that safety net.
But I still carry private insurance. Anyone who relies on Tricare is an idiot.Report
I honestly wonder (and I never see any quotes to this, nor can I find any googling a little) if healthcare costs are just reflecting the population of the US age wise? And if so how much?
For example, if you have a set group (US population) and run a bunch of booms and busts like a wave through a set cost provider system, assuming cost per patient stays constant at some level, what happens?
Well, given the population demos for the last and future 5 years, a huge spike in costs to the variable cost group (non-medicare, non millenial group) or as we would all call them, 28 – 50 year olds.
Massive numbers of boomers entering Medicare rates, limited supply (lots of reasons), limited strong earning popilation base (gen x and y, caused by numbers).
Add that up and you get skyrocketing costs to insurance as middle aged people, with the lowest number, highest risk, best taxable income, are the least from a numbers standpoint.
Maybe thats all crazy and its the drug companies and rich docs, but the above is disprovable. I can’t find anything disproving it.Report
Huh, so maybe there are some pretty major swings in demand. I wonder what kind of system could be applied to that.
Something adaptable to differing preferences and ever changing conditions. Something were the parameters can adjust without going to nation consensus of where each parameter should be.
It’s a complete mystery.Report
I wonder what kind of system could be applied to that.
Pain/Expectation management.
Look for marijuana and (and other stuporifics) to become closer to fully legal in the days to come.Report
“I honestly wonder (and I never see any quotes to this, nor can I find any googling a little) if healthcare costs are just reflecting the population of the US age wise? And if so how much?”
The last time I saw per-capita stats broken out by age group, older persons (65+) in the USA were responsible for nearly two-thirds of medical spending. If you eliminate them from statistics, the USA doesn’t spend any more, per-capita, than European nations.Report
Well, the Boomers are going through the middle of the second half of the snake and that will carry a lot of associated stuff with it… but I’d think that them shifting from an insurance model to a Medicare model would offer relief to the insurance model.
Am I thinking about that wrong?Report
The provider system is fixed cost in the short and medium run. As boomers leave insurance pool and go to Medicare, a lot of higher paying procedures go to lower paying procedures under Medicare reimbursement.
With the system cost fixed in the near term, cost shifting occurs by hospitals and providers, and that falls on a shrinking insurance pool group (genxers) to some degree, and since that is such a small number of people vs boomers, you have to increase the insurance costs a lot more per person.
It’s definitely not the only reason, but must be playing some part.Report
I think you are missing a piece of delineation – when people talk about skyrocketing medical rates, they refer to private (and HC exchange programs) often on a colloquial basis.
Yes less money will be provided to the health care provider system as boomers complete their move to Medicare reimbursement rates.
Hospital costs don’t change though, so private insurance makes up the difference, and when we are at a very low population of high earning not yet 65 year olds, insurance per person goes way up.Report
I know that when *I* talk about the skyrocketing price of medical care, I’m mostly talking about how much my insurance costs. It still only costs me a small amount ($25, I think it is) to see my doctor and I’m lucky enough to not need more than an annual physical and a generic prescription at this point in my life.
But, man, insurance that covers a small co-pay and generic prescriptions costs an arm and a leg!Report
If you are between 28 and 55 then yes, that would be a result of the effect I am trying to describe.
If you have any thoughts on the veracity or holes in this thought exercise, I’m interested in hearing them!Report
An option – fund Medicare reimbursement at 75% instead of 50% private insurance rates.
Require insurance cos and hospitals to drop private insurance costs by 15%.Report
See, I figure that this is the greater benefit of M4A and suchlike national-healthcare-plan ideas. It’s not so much that it provides better coverage, or more coverage, or good coverage; or even, down in the basements of the discourse that Chip doesn’t like to talk about, coverage that will result in better statistical outcomes than we’ve got right now.
The benefit is that nobody ever has to think they might lose their health insurance. That concern alone has driven decisions by my family to not take advantage of opportunities, and I’m sure we aren’t the only ones.
The reason I keep pushing against people who tell me it’s so great is that they tell me a story about a sad grandma who can’t pay for cancer pills and then say “THIS is why we need HEALTH CARE REFORM” and it’s like, dude, Medicare won’t pay for those pills either, it’ll just be The Government And People Of The United States Of America telling her to get fucked instead of Aetna Inc.Report
We’ve spent the last however many decades managing supply/demand by creating more and more new stuff. Techniques, drugs, and sub-categories of professionals. The only thing that this has resulted in is people demanding that those techniques, drugs, and sub-categories of professionals (that didn’t even exist in decades prior) cost the same as the weak stuff we had in the 1950’s.
Maybe it’s time to manage supply/demand by looking at “how can demand be managed?”Report
Maybe it’s time to manage supply/demand by looking at “how can demand be managed?”
Demand management is another not-talked-about aspect of M4A. It’s a lot easier to tell people that this-or-that service is Not Covered By Insurance if you can claim that the list of Covered Services was made by The Government, objective and neutral and considering all its citizens’ best interests, and obviously not motivated by profit or executive compensation. (You’ll still be telling grandma to pay for her own cancer pills, but, y’know, at least there won’t be profit going into that.)Report
Watch what your brain/spleen does when you read this headline:
“Aetna paid CEO $18.8M in 2017 following 45% annual increase in share price”
There are a ton of responses that run the gamut between “Only 20 mil for a 45% share price increase?” and “but that money could have paid for 18, almost 19, premature infants!”
The main thing I think is “this ain’t sustainable”.Report
I suspect that some grannys will get the cancer pills because they have a higher Social Medical Credit Score than the bad grannys.Report
Demand management is another not-talked-about aspect of M4A. It’s a lot easier to tell people that this-or-that service is Not Covered By Insurance if you can claim that the list of Covered Services was made by The Government, objective and neutral and considering all its citizens’ best interests, and obviously not motivated by profit or executive compensation. (You’ll still be telling grandma to pay for her own cancer pills, but, y’know, at least there won’t be profit going into that.)
It also stops the absurd hassle of trying to track down insurance that _does_ cover what you need it to cover, and the doctors you need it to cover, and the hospital you’re most likely to end up at, etc, etc.Report
If you’re willing to have a world where some healthcare things are As A Matter Of Policy Not Provided By Anyone that’s fine, but it’s not me to whom you need to explain that attitude about healthcare coverage.Report
I’ll just drop this here, because Warren’s top-down managed “meme effort” is indicative of why she’ll fail.
https://www.youtube.com/watch?v=1x3jZhqlb8gReport
If you just use the database you’ll look pretty silly claiming a ten year old is guilty of 20 year old crimes. Most people are wildly inappropiate matches for a specific crime and any closer examination will trivially exclude them.
Yes, you need more data/evidence, but this is one of those situations where knowing the answer is the bulk of the solution and what comes after that is easy and obvious.Report
testReport
I found this interesting: A tale of two covariates
It analyzes data on health care spending across countries, and it has nice charts.Report
Marketwatch has an interesting article regarding this.Report
Interesting read, thank you for point it out OscarReport
The problem here is that when people say “put real prices on everything”, what they mean is “have people pay for healthcare directly instead of an Insurance Plan covering it”, and that won’t work with the commentors here who think it’s bloodthirsty murder to suggest that people to pay for their own healthcare.
And, y’know, they aren’t far wrong here. “Put money into an HSA” implies that you’ve got money to begin with, and it’s nice that it’s tax-deductible but if your income is so low that you aren’t paying taxes then tax deductions don’t really do anything for you.
The rest of the article is dumb. Lasik isn’t less-expensive because the prices are known, it’s less-expensive because it’s optional, there’s competition in the form of eyeglasses. Statements are made in the article regarding statistics without linking to the sources, or even providing numbers (costs “skyrocketed”, savings were “massive”, health outcomes were “not statistically significant”–really? what’s the p-value?) The article approvingly claims that the Indiana state government offers a “deductible security plan” about which I can find nothing on the Indiana state government website; none of the plans appears to “cover the premium”, as the article claims, and none of them show an employer contribution of $2850 or “equal to the deductible”. (The article also claims that employees using the plan “were going in for mammograms, annual check ups, and other forms or preventive medicine at the same rate as when they were enrolled in traditional insurance” which is hardly surprising when all of the plans described on the Indiana government website cover these services at 100%.)
I mean, the “reform” that’s needed in American healthcare is philosophical, and it’s on the part of patients regarding what they can expect to get and on the part of providers regarding how much they can expect to be paid for giving it, but acting like people are idiots for wanting to see the doctor isn’t going to fix anything.Report
In the particular, healthcare need is wildly unpredictable; You have no idea if you will get cancer tomorrow, or be hit by a bus.
But in the aggregate, it is amazingly predictable.
The average person will consume very little if any healthcare in their 20s and 30s, but then slowly consume more and more, then in their final decade consume a massive amount, and in their final year of life consume more than in their entire preceding lifetime.
That’s just how life is. Lifestyle habits help bend the curve up or down but the basic pattern is the same.
And healthcare marketplace is the one that no one chooses to enter, and is unable to exit.
And in a Kafkaesque twist, the need for healthcare almost always coincides with the inability to generate income to pay for it, meaning the very fact of entering the healthcare marketplace means you are categorically excluded from the marketplace.Report
My employer partly funds my HSA. Afaict the money I put into it myself comes out before all taxes, including those that start with the first dollar.
Yes. 3rd party pays is poisonous in terms of containing costs because demand rises to infinity. We instantly need to add onto that “justified costs” which instantly requires a vast bureaucracy to define and police what “justified” means, which instantly builds rival bureaucracies to fight that.
On the other hand with an HSA, if you have money left over at the end of the year you can keep it.
I’d much rather have them argue on the size of the gov’s donation into a HSA than the ins and outs of 3rd party pays.
I’ve no clue which plan they’re talking about, but at one per organization/business we don’t have enough information to use the internet to find it.Report
Interesting. I hadn’t realized some governments had experimented with that list of suggestions I put up. The two big reforms are published prices and one-price-for-all.
Nor am I suprised that they think 75% of our medical costs are overhead. Cut that and we have enough money to provide healthcare for everyone. Not blank checks, consumers need to have skin in the game but whatever.
The hard part of this isn’t the economics (although that’s not easy), the hard part is the politics… but maybe if Indiania is for real and really successful, other states will copy it and prove it out.Report